A Framework for Prevention in Older Adults

pills-1885550_960_720A recent article by Lee and Kim highlights a pragmatic approach to individualize prevention for older adults. While individualizing prevention may seem like an intuitive concept, historically many specialty society guidelines (including within cardiology) have taken a population-level approach with blanket recommendations. Anyone in practice for a few years realizes that this “one size fits all” approach falls well short in older adults, particularly when considering treatments in the setting of limited trial evidence, comorbid medical conditions, and the potential for harm.

In this context, Lee and Kim propose a simple framework to implement, based on life expectancy (LE) versus time to benefit (TTB). In their model, the intervention should be encouraged if LE > TTB, should be avoided if LE < TTB, and if LE = TTB then they advise that “the individual’s values and preferences should be the major determinant of the decision.” As a concrete example within cardiology, many trials of statins for primary prevention (the topic of a prior blog post here) have shown at least 2 years until TTB, and statins would therefore be avoided in a patient with LE < 1 year.

While predicting LE can be notoriously difficult, several risk calculators have been developed. Lee and Kim propose using ePrognosis.com, which includes risk estimates based on site of care (e.g. living at home, admitted to the hospital, living in a nursing home) and a wide range of comorbid medical conditions.

A major limitation of LE and TTB is that they are not always clear. TTB, for example, may vary widely in different clinical trials based on factors including population studied, medication adherence rates (with drug trials), and competing risks. Lee and Kim acknowledge the importance of communicating this uncertainty, as well as incorporating individual patient preferences into the treatment plan. I still find this framework incredibly useful and anticipate that risk calculators, as well as visual aids to facilitate communication with patients, will continue to be developed and improved.

 

By: John Dodson, MD, MPH

Days Spent at Home

 

homeAn incredible amount of effort has been spent over the past decade in attempting to reduce the number of older patients who are readmitted to the hospital within 30 days. The argument is straightforward – readmissions are costly, disruptive for patients, and may represent insufficient coordination of care. While the proportion of readmissions that are truly preventable remains an area of active debate, readmissions are nonetheless a prime metric by which health systems are currently judged. Accordingly, many researchers (myself included) have published on factors associated with 30-day readmissions among older adults.

Recently however, the concept of “days spent at home” has emerged as a potentially more patient-centered goal. In an article in the New England Journal of Medicine, Drs. Groff and colleagues argue that this metric (initially inspired by the family member of a patient) may represent a closer ideal of what matters most to patients. This perspective makes sense to many of us in practice: while I’ve rarely had a patient tell me that what matters most to them is not being readmitted to the hospital within 30 days, they frequently tell me that what matters is spending time with loved ones, in a familiar environment. While the two concepts are related, “days at home” incorporates events beyond the hospital such as extended stays in skilled nursing facilities. It also provides important granularity – it is a continuous measure – rather than the simple “readmitted or not” paradigm that we have grown accustomed to.

Groff et al. conclude that “Outcome measures that reflect what truly matters to patients can define performance in ways that increase the engagement of patients, clinicians, and provider organizations in the redesign of care,” and I couldn’t agree more. A next critical step will be eliciting actual care preferences from patients in a formalized manner, and tailoring care plans towards these preferences. To date, studies have shown that many of these patients will likely prioritize spending days at home.

 

By: John Dodson, MD, MPH

Statins for Primary Prevention

dodson%20headshotA recent review article in JACC highlights the conundrum of primary cardiovascular disease prevention with statins among older adults. We often face this dilemma in our outpatient practices: specifically, whether patients age ≥75 without overt cardiovascular disease should be prescribed a medication to reduce their future risk, where the benefits of prevention may not accrue for several years. We are operating in a field with scant data: patients in this age group have been underrepresented in clinical trials showing benefit, and recommendations therefore need to be extrapolated from younger individuals. Accordingly there is a discrepancy in guidelines – while the UK NICE guidelines provide a strong recommendation for primary prevention statin therapy in this age group, other societies (ACC/AHA in the U.S., ESC/EAS in Europe) provide a weak recommendation, and the USPSTF in the U.S. provides no recommendation.

The authors highlight several issues to take into consideration when prescribing statins for primary prevention in this age group, including frailty, comorbidities, and polypharmacy (all of which may increase the risk of adverse drug effects), as well as limited life expectancy (which may prevent long-term benefits from accruing). They also discuss the importance of shared decision making with patients, taking into account their values and goals. Notably, statin decision aids already exist which may facilitate this process.

Several years ago we had written a piece on primary prevention for ACC.org which stated “statins are probably both under- and over-utilized in older adults,” and in my opinion this statement remains accurate. For an older patient who is functionally independent, with few life-limiting comorbidities and a strong desire to reduce their cardiovascular risk, a low to intermediate dose statin makes sense. For a patient with a major life-limiting illness, who wants to reduce their medication burden, it’s reasonable to not prescribe or even “de-prescribe” statins. Ultimately, the variation in guidelines described by Mortensen and Falk in their JACC article highlights that in the absence of consensus, care needs to be individualized – which is a central principle of geriatric cardiology.

 

By: John Dodson, MD, MPH