aginghearts Latest, Research, Shared Decision Making

Heart, Mind, and Body: The Impact of Cardiovascular Disease on Older Adults 

(Photo Credit: Allec Gomes @Pexels)

By 2035 the number of people over age 65 in the U.S. will outnumber children under age 18 for the first time. Among this growing older adult population, nearly 4 out of 5 individuals will have one or more forms of cardiovascular disease (CVD).

Given our aging population, a key area of research has been to understand the effects of CVD on “healthspan,” which is defined as aging without major physical or cognitive limitations. Plausibly, CVD leads to accelerated vascular aging through pathways that include chronic inflammation and oxidative stress. While studies to date have broadly suggested an association between CVD and physical and cognitive impairment, we don’t know which CVD subtypes (e.g., stroke or heart failure) have the most influence. We also do not know whether having a new CVD event earlier or later in life leads to greater impairment. 

To help answer this question, we used data from the Health and Retirement Study (HRS) which is a large, well-characterized U.S. cohort study that includes over 42,000 participants enrolled between 1992 – 2018. In order to better understand the relationship between new-onset CVD and subsequent impairments, we studied 16,679 HRS participants who were age ≥65 years at study entry and looked at physical impairment using activities of daily living, and cognitive impairment using the Langa-Weir Classification of dementia. We then analyzed effects by four major CVD subtypes (atrial fibrillation, congestive heart failure, ischemic heart disease, stroke) as well as age at CVD diagnosis (65-74, 75-84, ≥85). 

There were two key findings: first, among CVD subtypes the diagnosis of stroke consistently (and expectedly) demonstrated the greatest odds of subsequent physical and cognitive impairment. However other conditions that may intuitively have less influence on these outcomes – for example, congestive heart failure – were also associated with them. Second, we found that the oldest (≥85) age-at-diagnosis subgroup had the highest risk of both physical and cognitive impairment.

In addition to better understanding the epidemiology between CVD onset and subsequent impairments, our findings may help inform practice guidelines for the oldest adults. Using statin therapy for primary prevention as an example, the 2018 American College of Cardiology (ACC) / American Heart Association (AHA) guidelines weigh heavily on patient-clinician discussions given the limitations of many clinical trials. The findings from our study can help inform these discussions by showing that CVD events have a major impact on functional status, highlighting the additional benefits of prevention over more traditional outcomes (e.g., recurrent myocardial infarction), especially for the “oldest old.” 

Our results were presented at the recent American Geriatrics Society Annual Meeting and are now published in the Journal of Gerontology: Series A.

Katherine Stone is a Medical Student at NYU Grossman School of Medicine.

aginghearts Latest, Patient Priorities Care

The Work of Being a Patient

(Photo credit: Dana Tentis @Pexels)

I recently published a piece on the many tasks we require of our patients. This is something I’ve thought about a lot recently in my own clinical practice, as I’ve watched how many of my older patients struggle with the healthcare system. To summarize:

  • The “work” of being a patient (known as treatment burden) is different from the burden of a disease itself. Treatment burden includes traveling to medical visits, undergoing testing, dealing with insurance companies, reconciling different specialist recommendations, adhering to dietary restrictions, etc.;
  • Treatment burden is highest among older patients with multiple medical problems, who paradoxically have some of the greatest challenges to completing these tasks;
  • The concept of minimally disruptive medicine aims to minimize treatment burden while maximizing health outcomes that matter to patients. Telemedicine is one component of minimally disruptive medicine, but for many older patients it’s far from a panacea;
  • There is currently no way to incentivize doctors for minimizing treatment burden, although intuitively it’s a laudable goal.

The high treatment burden in our older patients is a problem without a straightforward fix, but I think the first step is raising awareness about the issue. And as I become more aware of treatment burden, I take small steps to minimize it in my own practice, whether that means coordinating patients’ testing on the same day they see me, or reaching out to other specialists so we’re all on the same page about the care plan. This is far from a solution, but at least it’s a start.

John Dodson is a Cardiologist and Associate Professor at NYU Grossman School of Medicine.

aginghearts Acute Myocardial Infarction, Coronary Intervention, Latest, Shared Decision Making

NSTEMI Decide: A Decision Aid for Older Adults

Many patients hospitalized with non ST-elevation myocardial infarction (NSTEMI) are over age 75. This condition requires major management decisions – most importantly, whether to pursue invasive coronary angiography. However there is limited evidence about the absolute benefits of this procedure for NSTEMI in older adults; available data indicate certain advantages (reduced risk of another MI) but also risks (bleeding, acute kidney injury). Until ongoing trials provide better evidence, patients and clinicians are left with uncertainty around whether invasive coronary angiography is worth pursuing.

Our previous qualitative research revealed that for many older adults hospitalized with NSTEMI, they expressed a desire to be better informed about their options. In the same study, cardiologists asked for a tool that would help them facilitate discussions with these patients. And both groups endorsed the process of shared decision making, which involves the active participation of patients in health care decisions that have multiple acceptable choices.

In this context, we undertook an iterative process to develop a decision aid for invasive coronary angiography in older adults with NSTEMI. We convened both clinical experts (cardiologists, geriatricians, internists, nurses) and patients, in order to review serial drafts of this decision aid for accuracy and comprehension. Our development methods are now published and freely available on medRxiv.

We adapted the final decision aid, NSTEMI Decide, to a mobile health app to maximize ease of use in clinical settings. This can currently be found in Apple’s App Store and downloaded for use on iPhone or iPad (an Android version is also under development). The app is eleven pages long and can be used in English or Spanish. We used data from available trials to provide estimates of the benefits and risks of cardiac catheterization, and created visual representations (with patient input) to help make the provided estimates understandable.

Sample screenshots from NSTEMI Decide.

To our knowledge, this is the first decision aid developed for NSTEMI in older adults. We are currently studying this decision aid prospectively to evaluate feasibility of use in practice, and how it influences patients’ medical knowledge and feelings of self-efficacy. Our hope is that NSTEMI Decide may eventually be widely disseminated to help patients and clinicians better navigate care decisions together.

Sophie Montgomery is a 2nd year medical student at NYU Grossman School of Medicine.

John Dodson is a Cardiologist and Associate Professor at NYU Grossman School of Medicine.

 

aginghearts Latest, Patient Priorities Care

Patient Priorities Care: State of the Art

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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).

Links below:
Naik et al., “Development of a Clinically-Feasible Process for Identifying Patient Health Priorities.”

Blaum et al., “Feasibility of Implementing Patient Priorities Care for Patients with Multiple Chronic Conditions.”

Applegate et al. “Implementing ‘Patient-Centered Care’: A Revolutionary Change in Health Care Delivery.”

 

By: John Dodson, MD, MPH

aginghearts heart failure, Latest, Research

Hearing Loss and Heart Failure

hearing-loss-signs-aids-
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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.