Blog

Fear of Hospitals

The past month has been a crash course for me in telemedicine, as my geriatric cardiology practice went from fully in-person to fully “virtual” in light of the COVID-19 pandemic. Despite the abrupt startup and inevitable bumps along the way, many of my older patients have successfully transitioned to video encounters for the time being. And I’ve noticed a recurring theme during many of these video conversations: people tell me that they’re terrified of coming to the hospital, even in an emergency.

ambulance architecture building business

This fear has been reported in both the scientific literature and the lay press – with a precipitous drop in hospitalizations for emergent conditions ranging from acute coronary syndrome (ACS) to stroke. For example, Metzler et al. reported that in Austria, from the beginning to the end of March 2020, ACS hospitalizations decreased by nearly 40% – far outside the range of normal variation. The authors hypothesized that “the strict instructions to stay at home as well as the fear of infection in a medical facility may have…prevented patients with an ACS from going to a hospital.” Similarly, a study in the U.S. of several high-volume cardiac catheterization laboratories found a 38% reduction in emergent activations for ACS due to ST segment elevation myocardial infarction after March 1. In the setting of ACS, failure to present due to fear of hospitals may lead to multiple consequences including fatal arrhythmias, heart failure, and death. And based on the data, it’s highly likely that many patients are suffering through ACS and other emergent conditions at home.

What steps can we take? COVID-19 has created an unprecedented challenge to modern healthcare, and there’s no consensus even among experts. In my own practice, I emphasize to my patients there are certain symptoms – persistent chest pain, shortness of breath at rest, new speech difficulty – that require them to go to the emergency room; the consequences of failing to act are too great. Letting patients know about new telemedicine options (e.g. virtual “urgent care” 24 hours a day) may help them to know there are options between staying home and calling an ambulance, so that their symptoms can be appropriately triaged. Finally, as the effects of social distancing take hold and COVID-19 cases decline, fear of hospitals may decrease. But for now, the problem is very real, and can be considered as one of the many negative consequences of the pandemic.

 

By: John Dodson, MD

Managing Older Adults with COVID-19

Megan Rau HeadshotOn March 11, 2020 the World Health Organization declared COVID-19 a global pandemic. SARS-CoV-2, the virus that causes COVID-19, was initially recognized in China in December 2020 then over the course of three short months has brought the hustle and bustle of NYC to a grinding halt. Terms such as “social distancing”, “flattening the curve”, and “hydroxychloroquine”, are now spoken causally in everyday conversation. The rapid evolution and spread of the virus has been accompanied by a mounting body of experimental protocols aimed to treat those infected, a large proportion who are over the age of 65.

One such treatment protocol is the use of azithromycin and hydroxychloroquine to treat symptomatic hospitalized patients with supplemental oxygen requirements. This treatment strategy is currently off label and is based on a small French study showing decreased viral burden. Additionally, the use of hydroxychloroquine alone is based on limited data including a study showing inhibition of the virus in vitro, meaning in the laboratory. These off label treatments, based on limited evidence, are being widely used across the United States to treat patients hospitalized with COVID-19. While there is hope for benefit, there is also potential harm due to adverse drug events, especially in older adults. While large randomized trials of these medications will provide definitive evidence, they will also require more time.

In those age 65 years and older it is necessary to critically examine the potential deadly cardiac side effect commonly known to be associated with azithromycin and hydroxychloroquine, QTc prolongation. This prolongation can lead to deadly ventricular arrhythmias. The QTc is the QT interval on an ECG corrected for heart rate. Studies have shown that, as chronological age increases, so does the QTc interval. Theories for this phenomenon include increased myocardial fibrosis altering the myocardium and changes to the sympathetic and parasympathetic tone effecting myocardial repolarization. This can result in increased susceptibility to events and medications, which may further prolong the QT interval.

ECG Phases

Figure 1. ECG Phases

Recently the Canadian Heart Rhythm Society published a treatment guideline aimed to minimize the risk of drug-induced ventricular arrhythmias. The article acknowledged that the use of certain antimicrobials to treat COVID-19 has uncertain benefits but may increase the risk of QT prolongation. They proposed an algorithm that included obtaining a baseline ECG and electrolyte panel, as well as a subsequent ECG 48 hours after initiation of therapy. The guidelines recommend that QT prolonging antimicrobial agents should generally be stopped in the setting of a QTc >500. An article in press from investigators at the Mayo Clinic makes similar recommendations.

The rapid spread and deadly devastation of COVID-19 has resulted in clinical momentum to find a definitive treatment. However, combining two medications, azithromycin and hydroxychloroquine, in the off label treatment of COVID-19 and administering them to a vulnerable patient population must be performed with extreme caution, even if the risk to the general population is low. We must continue to uphold the principles of evidence-based medicine even in a time of a global pandemic.

 

By: Megan E. Rau, MD, MPH

Dr. Rau is a practicing physician at NYU Langone Health who specializes in geriatrics and palliative care & hospice. 

 

Palliative Care in the Emergency Department

Ask any older adult about their preferences foUNC Headshotr end-of-life care, and the majority of them will tell you that they would prefer to die at home rather than in a hospital. Unfortunately, this desire is often not fulfilled.

The population in the United States is aging; by 2030, 1 in 5 Americans will be over age 65. This shift in demographics has already had a significant impact on healthcare utilization, particularly in regard to emergency medical services. Not only do older adults visit the emergency department (ED) at higher rates than younger patients, but they are also more likely to be admitted and experience longer stays.

These trends are especially prominent near the end of life, with half of older adults visiting the ED within the last month of life. For those older patients who are discharged home from the ED, repeat visits are common. This often results in a vicious cycle in which older patients are repeatedly discharged home from the ED, only to return within a few months, often for the same diagnosis that brought them to the ED in the first place. Notably, there are few safeguards in place to reduce recurrent ED visits.

With the passage of the Affordable Care Act in 2010 came the Hospital Readmission Reduction Program, which allowed Medicare to reduce payments to hospitals with excessive readmission rates. As a result, hospitals created programs to reduce readmissions, such as arranging for outpatient follow-up before discharge. However, such initiatives are only available to patients who are admitted to inpatient services and do not exist for patients who are discharged home from the ED. Thus, the ED represents a pivotal point in which clinicians can intervene to improve end-of-life care and reduce recurrent ED visits among older adult patients with advanced illnesses. The question then becomes: what should those interventions be?

Utilizing the ED as a means to enroll patients in palliative care programs represents a paradigm shift that may support older adults with advanced illness and repeat ED presentations. Palliative care is a rapidly growing field that is designed to provide supplementary care to patients with serious, life-limiting illnesses by providing medical, social, and emotional support to patients and their caregivers. Importantly, palliative care does not depend on prognosis and may be delivered in conjunction with life-prolonging treatment.

Multiple studies have shown that palliative care improves quality of life among patients and their families, lessens symptom burden, reduces future ED visits, and helps patients achieve their end-of-life goals (as evidenced here and here). Further, when the American Board of Emergency Medicine officially recognized palliative medicine as a subspecialty in 2006, palliative care found a new role within the ED. As a result, there has been a surge of research regarding the benefits and feasibility of palliative care in the ED, as well as the best ways to design programs and educate providers.

Although the benefits have been well established, there are also significant barriers to implementing palliative care in the ED. Patients in the ED, particularly those in need of palliative care services, are often distressed and may not be receptive to discussions regarding end-of-life care. Additionally, some ED physicians may feel that palliative care is outside the scope of their practice. Others worry that the chaotic environment in the ED is not conducive to meaningful end-of-life care discussions, and that implementing palliative care in the ED may significantly impact wait times.

In spite of these barriers, frequent repeated ED visits are likely to become more common with the aging U.S. population, and initiating palliative care in the ED has the potential to improve care for older adults in several ways: by decreasing repeat ED visits, improving quality of life, and helping patients achieve their end-of-life goals. Future implementation science efforts may help to identify optimal strategies to deliver palliative care in the fast-moving and often disruptive ED environment.

 

By: Julia Allison Brickey
Julia Allison Brickey is a medical student at the University of North Carolina School of Medicine.

 

 

Letting Go When People Let Go of Their Lives

dodson%20headshotMy 83-year-old patient had outlived peoples’ expectations on several occasions. Faced with a critical illness three years ago, she underwent emergency surgery and spent several months in the hospital with a series of complications, including septic shock, renal failure, and hospital-acquired pneumonia.

I’d seen her in the office for a new visit soon after she was discharged. It took nearly 20 minutes to go through her history before walking into the exam room. Notes from several doctors during that hospitalization said that she might never become well enough to be discharged home. When I finally walked into the room, I expected to see someone frail, debilitated, with a caregiver answering most of my inquiries. Instead, she appeared robust, completely alert, and cheerfully answered my questions herself. “You look better than your chart,” I told her, truthfully.

Given the extent of her recent workup, we agreed to keep further testing and medication changes to a minimum. I established that we’d touch base in the office every three to four months — a typical interval at her age.

And somewhat to my surprise, over the next several years she maintained her independence, as well as her cheerful demeanor. While she did experience some setbacks — a hospitalization for pneumonia, or mild volume overload — she usually made it home within a week.

The last time I saw her in clinic was different. She had been hospitalized for nearly a month, with a series of problems including a declining ejection fraction, rising creatinine, and multiple infections. In my interview, she looked more fatigued and responded only in brief sentences. She had lost considerable weight and had difficulty walking. I knew from a growing body of research that these last two findings were very poor prognostically in her condition.

In this context, I suggested initiating home hospice. I explained that this would provide her with a visiting nurse, medications to alleviate her symptoms, and a general focus on keeping her out of the hospital. I also explained that I expected her survival to be less than six months. After a lengthy discussion with my patient and her caregiver, she agreed.

The following week, the hospice nurse visited her at home for an intake visit, and she sent them away.

This experience is not unique. Studies show that some patients with advanced illness are unwilling to use hospice. Further, even among those who initially agree, many reverse the decision when their condition worsens. A paper earlier this year by Russell and colleagues found that 30% of patients with heart failure on home hospice in New York City ultimately canceled hospice, most often because of worsening symptoms that led to an acute hospitalization. This process, termed “live discharge from hospice,” is over twice as common with heart failure compared with cancer.

The phenomenon may stem, in part, from the “peaks and valleys” characteristic of advanced heart failure, which stand in contrast to the slow progressive decline of metastatic cancer or dementia. Heart failure patients can experience dramatic improvement with a short course of intravenous diuretics — which relieve symptoms without influencing the long-term disease course.

And perhaps my patient was not ready to let go of the hope that this time, like many times in the past, she would improve. As her cardiologist, I also had to let go of my own notions about what was best in her condition. While my clinical experience informed me that her prognosis was poor, this was ultimately her decision to make.

Within one month, my patient was admitted again to the hospital with shortness of breath and was found to have progressive heart and renal failure. I was away at the time.

The inpatient team and her indefatigable primary care physician had multiple discussions with my patient and her (also indefatigable) caregiver about her condition.

They set expectations, given what was known about her disease, and she set dual goals of symptom relief and avoiding another hospitalization. After one week in the hospital, she was referred home with hospice, and this time she did not send them away when they visited. She was ready. Several days later, she passed away, supported, at home.

 

By: John Dodson, MD

This post can also be seen on KevinMD.com here

Identifying the Gaps: Sex Differences in the Care of Older Adults Presenting with Acute MI

Michael Nanna MDSex differences between younger men and women presenting with acute myocardial infarction (AMI) have been recognized for decades. Whether sex differences persist among older adults (≥75 years old) with AMI, including in their relative burden of functional impairments, has not been adequately studied in a contemporary older adult population. Given this uncertainty, we set out to assess sex-based differences in presentation characteristics, functional impairments, in-hospital treatments and complications, in older adults ≥75 years presenting with AMI from the SILVER-AMI study. We recently published our findings in Circulation: Cardiovascular Quality and Outcomes. Some key highlights:

  • Among 3041 participants in SILVER-AMI, women and men differed across many baseline and presentation characteristics. Women had lower rates of prior coronary disease and, among those with non-ST-segment-elevation MI (NSTEMI), reported chest pain as their primary symptom less often than men (50.0% vs. 58.6%).
  • Older women with AMI had higher rates of age-associated functional impairments at baseline than men, including higher rates of cognitive impairment (NSTEMI: 20.6% versus 14.3%; STEMI: 20.6% versus 12.4%), impaired functional mobility (NSTEMI: 44.5% vs. 30.7%; STEMI: 39.4% vs. 22.0%) and disability with activities of daily living (NSTEMI: 19.7% vs. 11.4%; STEMI: 14.8% vs. 6.4%).
  • Women had lower rates of obstructive coronary disease and underwent less revascularization than their male counterparts in both the ST-segment-elevation MI (STEMI) and NSTEMI groups.
  • Bleeding complications were more frequent among women with STEMI (26.2% vs. 15.6%), driven primarily by higher rates of nonmajor bleeding (20.4% vs. 11.5%) and bleeding following percutaneous coronary intervention (PCI) (22.6% vs. 14.8%) among women.

The higher rates of functional impairment among older women identified here underscore the importance of assessing all hospitalized patients for impairments associated with aging, with an especially high index of suspicion when caring for older women with AMI. Improved diagnosis can help guide interventions to optimize mobility, adherence, and prevent falls.

Higher bleeding rates seen in older adult women with STEMI suggest that bleeding prevention strategies must be emphasized in this population, especially in those undergoing PCI. This represents an important future area for quality improvement efforts.

Recognition is the first step towards closing these gaps in AMI care. While substantial efforts are being made to reduce sex differences in care across the age spectrum, some of the more geriatric-specific issues identified here must be considered as we meet these challenges going forward.

 

By: Michael Nanna, MD

Dr. Nanna is a Cardiovascular Disease Fellow at Duke University School of Medicine.