Our recent Council review paper from the American College of Cardiology Geriatric Cardiology Section Leadership Council enumerated the potential role for a multi-domain approach to caring for older adults with heart failure. As shown in the proposed Domain Management approach to heart failure, domains including medical, mind and emotion, function, and social environment should be routinely considered when caring for older adults with heart failure.
While this Domain Management approach is applicable to any type of heart failure, it is especially relevant when caring for individuals with heart failure with preserved ejection fraction (HFpEF), a subtype that comprises 50% of heart failure cases across the United States. HFpEF may be described as a geriatric syndrome, as aging processes including biological changes to the cardiovascular system and age-related comorbid conditions have been implicated in its pathogenesis. Indeed, epidemiologic studies have shown that HFpEF disproportionately affects older adults. Consequently, management of patients with HFpEF should incorporate aspects of care needed to address the unique vulnerabilities of older adults. For example, patients with HFpEF almost universally experience multimorbidity (the condition of having multiple chronic conditions) and polypharmacy (high burden of medications); frequently experience cognitive and functional impairment; and often experience changes within their social environment relating to social support, their peer network, and/or financial state. The Domain Management approach provides a framework for clinicians to address each of these four domains, promoting a holistic approach to heart failure care.
What might the application of a Domain Management approach in clinical practice for the care of patients with HFpEF look like? Our recently-established Heart Failure with Preserved Ejection Fraction Program at Weill Cornell Medicine/New York Presbyterian Hospital could offer a model for incorporating the Domain Management approach. For the medical domain, we obtain a detailed history that focuses on both cardiac and non-cardiac conditions, and also perform a thorough review of medications (with physical pill bottles when possible) that include prescription medications, over-the-counter medications, and nutritional supplements. We pay special attention to the number of medications and regimen complexity, both of which can undermine medication adherence. For the mind and emotion domain, we routinely screen for cognitive impairment (via the Mini-Cog, which takes <2 minutes to administer) and for depressive symptoms using the PHQ-2/9 (2-4 minutes), both of which can negatively impact self-care. For the function domain, we screen for frailty and mobility limitations by conducting the short physical performance battery (approximately 5 minutes) which assesses core strength, balance, and gait speed. We also inquire about orthostatic symptoms and a history of falls. Our functional assessments have particularly important implications on prognosis as well as decision-making with regard to blood pressure targets. Lastly, for the social environment domain, we take a detailed social history that includes an assessment of their social network and sources of emotional and financial support. To address potential concerns related to this domain, our HFpEF Program has a dedicated Social Worker.
While formal assessment of each domain increases the duration of the office visit, we believe that the Domain Management approach facilitates a more nuanced approach to caring for older adults with HFpEF that is comprehensive and patient-centric. Information acquired for each domain can have a significant impact on discussions relating to the potential benefits and risks of various diagnostic and therapeutic interventions. Accordingly, we believe that the Domain Management approach is critically important to facilitate shared-decision making. Whether the Domain Management approach can improve outcomes is unclear; in the future, we hope to share our experience as it relates to outcomes. Until then, it would seem that any process that can help with decision-making in a complex condition like HFpEF would be worth the extra time and effort.
By: Parag Goyal, MD
Dr. Goyal is an Assistant Professor of Medicine in the Division of General Internal Medicine and the Division of Cardiology at Weill Cornell Medical Center, and is leading a new HFpEF program at New York Presbyterian/Weill Cornell Medical Center.
I wrote a piece on the importance of conversations with our older patients (and the inability of technology to replace these) on Kevin MD last week. I’m providing a link to the article here. In an era of rapid technological change, it’s important to remember that our older patients are unique, not only in their life experiences, but also in their impairments, care preferences, and social context. While technology will play a role, it’s essential not to lose sight of the importance of investing in the future geriatric workforce. In addition, developing novel clinical programs tailored towards older adults’ needs, given our changing demographics, is vital. There’s a lot of innovative work being done in this arena which we’ll be featuring (along with other content) in the coming year.
By: John Dodson, MD, MPH
Approximately 5.7 million U.S. adults have heart failure (HF), and 1 in 5 individuals over age 40 will develop HF in their lifetimes. HF is accompanied by many symptoms – including fatigue, shortness of breath, mood changes, pain, and anorexia. Among older adults with HF, these symptoms are compounded by mobility limitations, frailty, and other co-morbidities. Palliative Care is an optimal way to address symptoms while concurrently treating with disease-modifying interventions (Figure 1).
Palliative care is defined by the World Health Organization as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual…Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life.”
Palliative care can help HF patients in several ways. First, the palliative care team can work with a patient’s cardiologist in proactively treating symptoms as they develop over the course of the illness and during times of exacerbations. While the underlying cause of these symptoms is not completely understood, hypotheses suggest that physiological changes contribute to symptom burden (Figure 2).
One of the most common symptoms with heart failure is dyspnea, and a patient’s cardiologist and palliative care clinician may work together to treat dyspnea by using diuretics to optimize fluid status, teaching breathing techniques, and (in advanced disease) administering a low dose opioid such as morphine to alleviate shortness of breath. These treatments have the unified goal of improving a patient’s quality of life.
Second, palliative care assists with effective communication between patients and clinicians in the form of advanced care planning – including establishing a health care proxy, completing advanced directives, discussing goals of care, and having end of life conversations regarding when to stop certain interventions. Advanced care planning discussions help to ensure patients’ preferences for what is most important in their care are met.
Goodlin et al provide examples of language clinicians may use to eliciting these preferences, such as “What treatment we recommend depends on your medical condition, but also on what approach to care you prefer and what is important to you at this point in your life”. This statement allows a platform for patients to express their wishes and what quality of life means to them. Their clinician is then able to recommend treatments that align with their goals and preferences.
HF is a common disease with a dynamic trajectory due to periods of exacerbation and recovery. It is imperative that cardiologists and palliative care clinicians work together to provide disease-modifying interventions while concurrently treating symptoms and developing advanced care plans with patients.
For more information on Palliative Care in Heart Failure visit the following websites:
By: Megan E. Rau, MD, MPH
Dr. Rau is a practicing physician at NYU Langone Health who specializes in geriatrics and palliative care & hospice.
Frailty (a state of increased vulnerability to physiologic stressors) is common in older adults. Frailty can be measured in several ways, including by a simple test such as walking speed or more thorough criteria. The geriatrics community has long recognized that frailty predicts hospitalization, functional decline, and death. Cardiologists are increasingly recognizing the importance of frailty as well: for example, in predicting outcomes after cardiac surgery and myocardial infarction.
Building on this work, we recently published a paper in JACC: Cardiovascular Interventions that highlighted the role of frailty in predicting bleeding among cardiac patients with myocardial infarction in the ACTION registry. While the link may not seem intuitive, there are a number of reasons frailty may confer bleeding risk, including poor vascular integrity, altered hemostatic factors, and issues related to treatments (e.g. overdosing of anticoagulants).
There were several key findings from our work: first, frailty increased bleeding risk by 50%; second, this was only seen in patients undergoing cardiac catheterization; third, the use of strategies that may reduce bleeding (radial access, and proper dosing of anticoagulant medications) was relatively low. The findings in this large cohort largely confirmed what had been shown previously in smaller studies.
I think there are several actionable steps from this work. First, frailty matters – and we should start measuring it. Our study used a combination of variables abstracted from the medical record, which may have under-detected the true prevalence of frailty. Walking speed, an alternative measure of frailty, can be easily obtained in the hospital on most patients and is easily reproducible. Second, for frail patients, bleeding avoidance strategies are critical. For example, radial access was only used in only 1 in 4 frail patients in our study. Randomized trials in older adults have used higher rates of radial access and have found less bleeding. So this seems to be one relatively straightforward way to improve outcomes in our frail patients.
By: John Dodson, MD, MPH
Last week, I had the privilege of attending the Geronotological Society of America (GSA) 2018 Annual Scientific Meeting that was held in Boston, MA this year with the theme centralized around “The Purpose of Longer Lives.” GSA is one of the oldest and largest interdisciplinary organizations that is well-attended nationally by scientists, clinicians, and students who all have one thing in common: a passion for gerontology research.
Aside from connecting with many respectable researchers in the field, I also had the opportunity to present findings from our qualitative research focusing on decisional needs among older adults with cardiovascular disease. Specifically, our study sought to investigate the perspectives of older adults on coronary interventional procedures after their hospitalization for acute myocardial infarction (otherwise known as AMI, or heart attack). In recent decades, older adults have been undergoing more coronary revascularization procedures for AMI (stent placements and coronary artery bypass surgery (CABG)); consequently, procedure-related risks are more common. Moreover, time-sensitive settings during AMI at times do not allow for easy shared decision-making (SDM) discussions with their clinicians to detail these risks. Our study therefore was interested in probing further into AMI patients’ decision-making process – and to identify what factors, exactly, that led them to decide on whether or not to undergo a coronary revascularization procedure.
Based on our preliminary research from 15 patients who had been hospitalized with AMI and discharged home, the main themes that emerged were as follows:
- Procedural risks are perceived to be minimal when compared to perceived benefits.
Perceived procedural risks – which were generally described to be stroke, bleeding, and death – were viewed minimally when compared to the benefits. When asked to list the perceived benefits, patients mentioned “living a healthy life,” “no pains,” and “prevention of future heart attacks.”
- Some respondents reported that the alternative to a procedure was death.
“I would not have come to the hospital if I wanted to commit suicide,” stated one respondent. While this may be seemingly viewed as a more extreme perception of the alternative to the procedure, this theme was seen across several respondents. For example, another said, “That [turning down the procedure] didn’t enter my mind at all. In fact, I would’ve been dead at this point.” Most participants viewed that they “had no choice,” stating that they would not have been alive without the interventional procedure, and as a result, viewed the procedure was an absolute necessity.
- Participants place a high level of trust in their cardiologists when making decisions.
A majority of respondents revealed that faith in the physician was also a major factor contributing to their decision-making process—regardless of how long they have known their cardiologist. While one participant was loyal to their outpatient cardiologist of 28 years, others put an equal amount of trust in the interventional cardiologist whom they met on the same day of the procedure. One respondent, who was unconscious during her episode, stated: “I wasn’t thinking straight, but I had total belief that the doctors were going to take care of me.”
- Receiving procedural information, before or after the procedure, could aid in a better overall satisfaction of the experience.
All participants expressed that it was very important for them to understand their heart disease and associated procedures – even if it is after the procedure was completed. This was especially predominant among participants who had an ST-elevation MI (STEMI) who underwent their procedure rapidly. Some suggestions on how this could be achieved include providing a copy of the angiogram results, providing pamphlets and brochures, and sending medical personnel to explain the procedure more in-depth immediately pre-procedure, or during early recovery.
- All participants highly value what is perceived to be SDM.
All of our respondents, regardless of whether or not they have received a procedure, expressed a desire to have a discussion with their clinicians regarding their treatment options and the risks and benefits of a procedure.
Based on our findings, SDM has the potential to better overall patient knowledge and satisfaction with care. SDM is probably most applicable in the setting of non-ST segment AMI (NSTEMI) where there is time for more informed discussions. Notably, NSTEMI is the most common AMI presentation among older adults. We believe our work supports the future utilization of SDM in clinical practice, and perhaps, a future tool designed to better expedite the SDM process in the inpatient setting.
By: Jenny Summapund, MA
The Journal of the American Geriatrics Society published 3 related articles on redesigning healthcare around patient priorities, which I’ve linked to below. This work represents the leading edge of incorporating patient priorities into decision making for older adults. The rationale (previously discussed on this blog here, here, and here) is that for many older adults, the applicability of disease-specific guidelines are unclear; many of our therapies (in cardiology and elsewhere) were studied in relatively young patients with few comorbidities. In the setting of limited evidence, the concept of patient priorities care therefore emphasizes eliciting what matters most to patients – and designing care plans around specific, actionable goals.
Patient priorities care in practice is complex since it requires training of clinicians and support staff, engagement of patients, and streamlining of health information technology, all within our current time-limited healthcare environment. Nonetheless, the pilot studies by Naik et al. and Blaum et al. demonstrate that this care model can be effectively implemented in practice. The accompanying editorial by Applegate et al., which states that “Clinical guidelines could be revised to integrate the tradeoffs between multimorbidity, functional status, and polypharmacy in making management decisions” represents a longstanding principle of geriatrics which appears to be gaining traction in other fields (including cardiology).
Naik et al., “Development of a Clinically-Feasible Process for Identifying Patient Health Priorities.”
By: John Dodson, MD, MPH
At first glance, hearing impairment and heart disease seem to have very little in common. However, the relationship has been hypothesized since the 1960’s, and more recently has been established in epidemiologic studies – with a particular emphasis on heart failure. For example, a recent study by Sterling et al. examined patients in the cross-sectional NHANES Survey aged ≥70 years with a diagnosis of heart failure. The authors described the percentage with quantifiable hearing loss based on pure-tone audiometry (considered the gold standard test).
The main findings: 74% of patients with heart failure had some degree of hearing loss, which was significantly higher than those without heart failure (63%). Further, only 16% of heart failure patients wore hearing aids. Thus there was a disconnect between the burden of hearing loss, and use of a strategy (hearing aids) with proven effectiveness.
Why does this matter? According to the authors: “since patients with HF [heart failure] are frequently in noisy hospitals and clinics where they receive myriad instructions about disease management, it seems likely that untreated hearing loss could impair patient-physician communication and ultimately HF self-care.” After my recent two weeks attending on the inpatient cardiology service, I concur. We are constantly expecting our patients to provide us an accurate history, comprehend diagnostic test results, and adhere to discharge plans, all of which may be affected by hearing impairment.
What are the solutions? The first is to increase identification of hearing impairment through screening – and with advances in technology, I’d predict this can soon be easily done at the bedside with portable electronic devices. The second is to make hearing aids more accessible, including over-the-counter purchases – and recently there has been some notable advocacy work advancing laws to increase access. Through these two simple strategies, we may be able to make meaningful improvements in the health of our older cardiac patients.
The aging hearts of our loved ones are multifaceted for sure. Kind, funny, witty, intelligent, brave, accomplished, and if we’re lucky, loving with a lifetime of experiences all wrapped up into a well-lived life. Certainly a life deserving of respect, all the best medical care, compassion, understanding, and help to navigate this final stretch of the journey.
My mother was fiercely private concerning her medical care. She did not want anyone, other than my father, to know what doctors she was seeing and why. When it became obvious to my (physician) husband and I that her condition was deteriorating, stepping in became a delicate balancing act.
My final journey with my mother began over two years ago when I noticed she was exhausted much of the time and her breathing was labored. My husband spoke to me about his concern in private, knowing to tread lightly. Whenever either of us asked her how she was doing, and expressed concern, she very firmly stated that nothing was wrong.
When she began having difficulty with memory and recall, she reluctantly agreed to see a neurologist friend of ours. After testing, he concluded she was experiencing normal progression in aging. Her energy level, however, continued to decline. She assured us again that she was fine and was seeing a cardiologist for chronic A-Fib, which my father confirmed.
A few months later she ended up in the local emergency room, the result of a fall. Although her cardiologist had an office in the same hospital, we discovered that his records were not linked to the hospital system. Consequently, the ER doctor, not having the cardiologist’s records on my mother, took her off blood thinners because she felt the risk of injury from fall was greater than the benefit of my mother remaining on her medication. This likely contributed to the further significant decline of my mother’s condition. When my husband discovered her medication had been stopped he had my father call their cardiologist immediately to correct. We encouraged my father from that point on to keep a physical copy of their medical records with him for every future trip to the hospital and doctor’s office. Unfortunately, not every patient has the luxury of having a physician in the family.
Sadly the other effect (we assumed of the fall) was significant cognitive impairment. When re-examined by her neurologist, she had declined drastically. He secured and poured through all of her medical records. He found she had been diagnosed with mitral stenosis and severe pulmonary hypertension years before which were contributing to her confusion.
Together, my father and I decided that I would be included in Mother’s next cardiologist appointment. Given her condition I stated at that visit that we would like her to see an Interventional Cardiologist. I’ll admit I was a bit skeptical before meeting this new doctor, as all we were offered to this point was monitoring. When Dr. K walked in, he was extremely welcoming and respectful and had actually taken the time to read Mother’s chart before meeting with us—this was a first! He was very kind and honest from the start. He told us she actually had Rheumatic Mitral Stenosis and that he could offer a procedure called valvoplasty. This procedure could potentially give my mother great quality of life for her remaining years.
Being a teacher, I appreciated his unique ability to explain this complex diagnosis and procedure in terms my parents and I could understand. And, he took as much time as we needed to feel comfortable with the next step. Dr. K had given us so many gifts that first day. His world-renowned expertise, his genuine kindness and caring, gave us hope for the first time in years. He also gave us his cell phone number in case we had any questions or concerns.
Although blood clots ultimately prevented my mother from receiving this procedure, Dr. K’s care did not end there. He took time out of his busy schedule to meet with our family and discuss how best to care for Mother. He set into action Home Healthcare, having a nurse perform home visits and enabling him to monitor her INR. He even discussed (in person, by phone, or by text) when to get Hospice involved, end-of-life decisions, and what my father could expect every step of the way.
Everything Dr. K did enabled my mother to have the best quality of life possible, to live out her final days as she wanted to. My mother was a woman of deep faith. She was not afraid of dying. Quite the opposite, she knew Heaven was her ultimate destination. It was her wish to remain in her home, and she did. She was able to live out her final days in the home she loved, with the people she loved, and in her words, “with the best husband I ever could have asked for” for all but her final six hours.
When Dr. K learned of my mother’s passing, he asked to meet with my father and myself. When we met we were yet again amazed. His mission was to share a cappuccino and make sure we were doing all right. Talk about a lesson in compassion… I feel it is worth mentioning that although Dr. K was the newest cardiologist on my mother’s case, he was the only doctor to follow us through her death.
Lessons learned on the journey:
- The best way to preserve a loved one’s dignity is to be their advocate.
- Always be respectful but get involved as needed. Get referrals, go to appointments, ask the difficult questions so your loved one has all the information necessary to make their decision.
- I always knew and respected the fact that the final medical care decision would be my mother’s and father’s to make. Even if the decision was no further procedure.
- My role was to connect my loved ones to the best possible medical specialists.
- There simply are no words to adequately thank someone for giving you more quality time with your loved one. I am eternally grateful to Dr. K and the other doctors on my journey who truly care for their patients and families.
By: Cheryl Csorba
I recently was interviewed by Dr. Thomas Elwood for the NYU Langone Rusk Podcast Series, available here. I’d encourage people to listen to both sessions; Dr. Elwood asked a wide range of detailed questions relating to Geriatric Cardiology both locally and nationally. Here are a few key points:
- Geriatric cardiology is a growing field. Geriatric cardiology has emerged in response to an aging population coupled with advances in cardiovascular therapies. Several programs have been started in the U.S. in the past several years, most combining both patient care and research components.
- Frailty is a strong predictor of adverse outcomes in myocardial infarction. Multiple studies have shown frailty, a state of increased vulnerability to physiologic stressors, to be associated with both immediate consequences (procedure-related complications) and long-term sequelae (recurrent myocardial infarction, mortality). The optimal management of frail myocardial infarction patients remains unclear.
- Older adults are frequently excluded from clinical trials. While this is improving, thanks to the efforts of funding agencies, patient advocates, and the research community, we’re still largely operating in the dark when it comes to applying evidence-based therapies to patients in their 80’s and 90’s.
- Family caregiving is more critical than ever for recovery. As we move towards shorter hospital stays and lower use of skilled nursing facilities, we are asking a lot more of family members than we used to during the early recovery phase. This can lead to both physical and emotional burdens on these caregivers, which the healthcare system is currently under-equipped to address.
- There are multiple barriers to cardiac rehabilitation in older adults. These include transportation, cost, and lack of available facilities. Mobile health (mHealth) strategies may provide a means to increase access, but the efficacy of these programs in older adults remains poorly understood.
By: John Dodson, MD, MPH