Tailored risk for older adults: SILVER-AMI

dodson%20headshotWe recently published a paper on predicting 30-day readmission for older adults with acute myocardial infarction (AMI) in Circulation: Cardiovascular Quality and Outcomes. Our purpose was to evaluate whether aging-related functional impairments in mobility, cognition, and sensory domains would help to predict whether AMI patients would be readmitted to the hospital within 30 days of discharge, which has been subject of increasing focus by payors and health systems over the past decade. We analyzed data from the SILVER-AMI study, which exclusively enrolled participants aged ≥75 years, and included a detailed assessment of functional impairments.

What we found:

  • Among 3006 study participants with AMI (mean age 81.5 years), 547 (18.2%) were readmitted within 30 days.
  • Readmitted participants were older, with more comorbidities, and had a higher prevalence of functional impairments including disability in activities of daily living (17.0% vs. 13.0%), impaired functional mobility (72.5% vs. 53.6%) and weak grip strength (64.4% versus 59.2%).
  • After statistical modeling, our final risk model included 8 variables: functional mobility, ejection fraction, chronic obstructive pulmonary disease, arrhythmia, acute kidney injury, first diastolic blood pressure, P2Y12 inhibitor use, and general health status. While functional mobility was the only aging-related functional impairment retained in this model, it was also the strongest individual predictor.

Our risk model was well calibrated across categories of risk but had only modest discrimination – meaning there were other factors contributing to readmission risk (for example, related to the care environment or health system), that were not captured in SILVER-AMI.

Our hope is that our score can be used in a practical setting – for example, identifying patients for more intensive post-discharge care. Accordingly, our calculator is freely available at silverscore.org, or in the App Store here.

 

By: John Dodson, MD, MPH

 

There’s an App for That: mHealth and older adults with heart disease

searcyPerfect pairings:  Peanut butter and jelly.  Grilled cheese and tomato soup.  Smartphones and geriatric patients?

While most people probably don’t picture their older adult relatives Facetiming their doctor on their iPhone or sporting a Fitbit to the gym, this could very well be the future of preventive medicine. According to a 2016 Pew Research Center poll, 42% of adults over age 65 owned smartphones, up from 11% in 2011. With this rise in mobile technology ownership, there is new opportunity for patient engagement and management beyond the traditional face-to-face encounter. Older adults, especially those with cardiovascular disease, seem well-positioned to gain considerable benefit from mobile health (mHealth) technology. Their propensity for multimorbid disease, mobility impairment, social isolation, and transportation issues means that older adults have both elevated clinical needs and substantial barriers to traditional care strategies. In order to better understand the relative utility of mHealth technologies in older adult patients, we conducted a narrative literature review recently published in Current Geriatrics Reports.

What did we find?

  • There is a wealth of mHealth apps and wearable devices designed to aid in the monitoring of older adult patients with cardiovascular disease.
  • Adoption of mHealth technology by older adults is impeded by well-documented barriers that are physical, cognitive, and motivational in nature.
  • The physical and cognitive challenges can be partially alleviated with engineered solutions that make the mobile interface easier to use.
  • However, motivational barriers require personalized coaching and social support, which are unlikely to be overcome by engineered solutions alone.
  • Studies to date have shown mixed results when mHealth interventions are adopted. More research is needed to prove their usefulness in the home setting.

What does this mean?

In short, there are still barriers to mHealth becoming standard in the treatment of cardiovascular disease in older adults. That being said, several trials have demonstrated significant improvement in blood pressure monitoring, heart failure management, arrhythmia monitoring, medication adherence, and feelings of social isolation. While it is important to keep in mind that results have been mixed with regard to the efficacy of specific mHealth intervention strategies, it makes logical sense that using smartphones and other devices to gather more patient data points between office visits would facilitate more informed care. It is critical to ensure that these strategies 1) produce trustworthy and reliable information and 2) are cost-effective.

Where do we go from here?

Moving forward, it is essential that mHealth developers incorporate the specific engineering solutions to aging-related problems outlined both in our review article and elsewhere to facilitate use with older adults. We must also continue to investigate whether mHealth interventions can be an effective and appropriate supplement to existing care paradigms in the treatment of cardiovascular disease. Though it is still too early to be certain, we believe there is great potential in mHealth interventions for older adults, and we are excited to see the ways in which technology is incorporated into patient care.

By: Ryan Searcy

Ryan is a 2nd-year medical student at the University of North Carolina-Chapel Hill School of Medicine. Ryan was also a Medical Student Training in Aging Research (MSTAR) Program scholar at NYU School of Medicine, where he participated in aging-related research and geriatrics.

CoMPAdRE: A Connecting Point for Aging Researchers

Ruth Masterson CreberWhat is the CoMPAdRE program?
The CoMPAdRE program is an interprofessional, early career mentorship program for faculty who are interested in patient-centered aging research. The acronym CoMPAdRE stands for Columbia University Mentor Peer Aging Research. Compadre also means “friend or companion,” representing the purpose of this program—to build a network of peer relationships that can be sustained over the course of a career.

Many traditional mentoring programs are structured as dyadic relationships between a senior mentor and junior mentee. However, this traditional dyadic model can put undue pressure on both the mentor and mentee.  Moreover, mentees may have trouble identifying senior mentors who are available and willing to invest the time needed to develop a productive dyadic relationship. This issue is particularly problematic for women and racial and ethnic minorities who traditionally have had less access to professional networks (additional information here) with potential senior mentors. There is a large body of research demonstrating the benefits of mentorship, such as access to career development opportunities; therefore, individuals who are excluded from mentorship opportunities are often disadvantaged with regard to career development. CoMPAdRE seeks to address shortcomings of traditional mentoring programs by offering a new model: a hybrid of a dyadic and peer mentorship model, known as facilitated peer mentorship. The program is led by a senior mentor, Mathew Maurer MD, but the focus is on building a strong, interprofessional peer network.

Why is this program interprofessional?
Over the past decade, the care of older adults has become much more clinically complex and fragmented. As patients live longer with multiple comorbid conditions, they are receiving care from a number of specialized providers, creating greater possibilities for fragmentation in care. Collaborative mentorship teams facilitate sharing of ideas and learning opportunities across disciplines. For example, when caring for older adults with heart failure, programs such as the Heart Failure with Preserved Ejection Fraction Program at Weill Cornell Medicine include physicians, nurses, and social workers. Both holistic patient care and thought leadership require an interprofessional team that bring together specific domain expertise. By bringing together a diverse cohort of health professionals from across the country, CoMPAdRE has facilitated a unique learning experience for sharing ideas, developing skills, and building relationships.

How does CoMPAdRE impact patients?
The value of mentorship goes back to the underlying importance of reducing clinician burnout and supporting sustainability. When healthcare providers feel connected through a common mission, they have more capacity to fully engage with the needs of their patients, and conduct high-impact research focused on improving patient outcomes. Clinicians and researchers thrive most when they feel their work is valued.

What will you take away from this program?
Mentorship and giving back to the community takes place at every career stage. CoMPAdRE has hosted many global leaders in aging including Drs. Luigi Ferrucci, Linda Fried, Stephanie Studenski, Terry Fulmer, Mary Tinetti, and Mark Supiano, among others. Each speaker not only shared their career highlights, but the accompanying personal stories that paralleled the highs and lows of their careers. As a group, we learned how to manage time, stay focused, and most of all, value and cultivate relationships. A major theme of discussion throughout the program was that, over the course of clinical training, skills in management, leadership, and administration are not taught, and yet are expected as part of the job. One of the benefits of this program is that it provides the mentees with a structured opportunity to learn more about these skills with direct application into our clinical practices and programs of research.

Despite being a program for “early career” faculty, we were all encouraged to not only seek out mentorship and support, but to also serve as mentor to others. A critical takeaway point from this program was the necessity of mentoring at all career levels; it is never too early or too late to support others through mentorship.

How can we find out more about the program?
If you are interested in finding out more information about this CoMPAdRE program, you can read more details about this program in the Journal of the American Geriatrics Society.

 

By: Ruth Masterson Creber, PhD, MSc, RN

Ruth Masterson Creber is an Assistant Professor of the Department of Healthcare Policy and Research at Weill Cornell Medicine. 

Frailty Matters

dodson%20headshotFrailty (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


For more information on frailty, a frailty infographic is posted on our “Infographics” page. 

Hearing Loss and Heart Failure

hearing-loss-signs-aids-
Photo credit: Shutterstock

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.