Older Adults and Telehealth

A recent piece in JAMA Internal Medicine by Roberts and Mehrotra underscores that even in our connected age, many older adults have difficulty accessing technology. While telemedicine has been widely deployed in the setting of COVID-19, these individuals are therefore unable to achieve many of its benefits. Their main findings, in a survey of 638,830 Medicare beneficiaries, were the following:

– Over 40% lacked access to a desktop or laptop computer with high-speed internet;
– Similarly, over 40% lacked a smartphone with wireless data plan;
– Over 1 in 4 people (26%) lacked both (no computer or smartphone);
– Digital access was lower among people age 85 or older, and among those who were widowed, had lower education, were Black or Hispanic, received Medicaid, or had a disability.

macbook pro iphone cup desk

Their findings are in line with my own clinical experience over recent months – while telemedicine has provided a critical way to maintain care for some patients, others are simply unable to engage. Related to the work by Roberts and Mehrotra, we published a recent piece in JAMA Health Forum outlining how “digital health” may actually worsen health disparities – if adopted by younger populations who are already reasonably healthy. Both articles underscore that patients most at risk for poor health outcomes are also the least likely to have access to the new era of digital medicine. While improving digital access among these populations is challenging, it is also essential.

 

By: John Dodson, MD

“I didn’t have a choice” – Shared Decision Making in Older Adults with Acute MI

In our article recently published in Medical Decision Making, we qualitatively explored the experience of shared-decision making (SDM) in the setting of acute myocardial infarction (AMI), from the point of view of both cardiologists and patients. We conducted 20 interviews with older adults (age ≥70) who had been hospitalized with AMI, and 20 interviews with cardiologists. Six major themes emerged from our analysis:

1) patients felt their only choice was to undergo an invasive procedure;
2) patients placed a high level of trust and gratitude toward physicians;
3) patients wanted to be more informed about the procedures they underwent;
4) for cardiologists, age was not a major contraindication to intervention, while cognitive impairment and functional limitation were;
5) while cardiologists intuitively understood the concept of SDM, interpretations varied;
6) cardiologists considered SDM to be useful in the setting of non-ST elevated myocardial infarction (NSTEMI) but not ST-elevated myocardial infarction (STEMI).

Our most salient finding was that patients felt they had no choice but to undergo intervention, whereas cardiologists stated there was a need for deliberate shared decision making about intervention in older adults with NSTEMI because of the increased risks involved with catheterization in older patients who present with greater comorbidities.

This discrepancy suggests that, from the patient perspective, conversations in practice were often inadequate to be fully informational. Solutions to this shortfall are complex, especially in light of time constraints in current inpatient settings. However, we suggest in our article that a decision aid may help to provide standardized information to patients, as well as individualized risk prediction (e.g., for risk of contrast-related acute kidney injury). This may alleviate some of the stress and uncertainty involved in discussing evidence-based risks for physicians, and it could increase patients’ awareness of a choice.

Our study had several limitations, including the typical bias in research studies of enrolling “healthier” participants (e.g. cognitively intact) who may have had the most to gain from an intervention. Moreover nearly all patients interviewed underwent invasive coronary angiography (rather than conservative management with medications alone), which omits the decisional needs of patients who chose to decline the procedure. This finding likely reflects a combination of institutional practice, national trends toward more invasive procedures in older adults, and selection bias.

Despite these limitations, to our knowledge this is the first study of SDM in the setting of AMI that incorporates both patient and cardiologist perspectives. We hope (1) it highlights the importance of capturing this dual perspective when discussing SDM and (2) SDM can be made more effective for older adults with NSTEMI with the implementation of a decision aid to help physicians faced with a lack of clear evidence for this older population, and patients who may benefit from being more informed.

Eleanore Grant

By Eleonore Grant, MD Candidate 2022
Perelman School of Medicine at the University of Pennsylvania

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. 

 

Glucose Monitoring in Older Adults: How Much Is Too Much?

Wilcox_TanyaMy 90-year-old grandfather was the first person to teach me how to use a glucometer. He developed diabetes thirty years after his 3-vessel CABG, and the necessity of daily blood glucose checks seemed like an inevitable aspect of managing his new disease. As a diligent patient, he underwent the painful experience of pricking his finger and recording his measurements daily, and taught me how to help him as he lost dexterity with age. The experience left me questioning whether glucose monitoring is necessary for all patients with diabetes, especially older patients with late-onset, stable disease like my grandfather.

Diabetes mellitus is common disease among older adults; in the U.S., 1 in 4 persons over age 65 are affected. Cardiologists recognize diabetes management as integral to overall cardiovascular health. However in older adults, aggressive glycemic control can be burdensome and at times dangerous. Evidence from large randomized control trials including ADVANCE, ACCORD and VADT suggests that avoiding dangerously low blood sugars (hypoglycemia) may be more beneficial than achieving aggressively low hemoglobin a1c (HbA1c) targets. Based on available evidence, the American Geriatrics Society recommends higher Hba1c targets for older adults –  between 7-8.5% depending on comorbidity burden and prognosis. There remains, however, a lack of strong evidence on the optimal frequency of home glucose monitoring in this group of patients. An individualized discussion the benefits, risks and alternatives provides a framework for this discussion.

There is a clear need to avoid hypoglycemia, and self-glucose monitoring may provide a mechanism to screen for low blood sugars. Accordingly, the Endocrine Society indicates that glucose monitoring may benefit type 2 diabetics taking medications that put them at risk for hypoglycemia, including insulin or sulfonylureas. This may be especially important during medication initiation or uptitration. However, in patients with stable disease with no clear risk for hypoglycemia, the Endocrine Society and the Society of General Internal Medicine both recommend against routine multiple daily self-glucose monitoring. Home monitoring is nonetheless overprescribed; CDC health behavior data indicate that a majority (63%) of non-insulin dependent diabetics are checking finger sticks at home at least daily, and Veterans Affairs data found that test strips were prescribed to a large number of patients with stable non-insulin type-2 diabetes. Potential harms associated with daily self-monitoring of blood glucose monitoring include pain of needle sticks, cost, and general therapeutic burden, all of which can adversely influence quality of life. While needle-free glucose monitors are a potentially promising alternative, they remain under development.

In summary, in the absence of clear guidelines, decisions about initiation, frequency and discontinuation of self-monitoring of blood glucose in older adults with type 2 non-insulin dependent diabetes requires an informed discussion between clinician and patient, with particular attention to patient goals. For most older patients with cardiovascular disease, in whom sulfonylureas should be avoided, routine glucose monitoring is reasonable for a brief period during medication titration, and subsequent intermittent monitoring may be helpful to determine whether symptoms of hypoglycemia correlate with low blood glucose. However, for most patients with stable disease on oral agents, discontinuing routine (daily) home glucose checks can improve quality of life and reduce health care costs.

 

By: Tanya Wilcox, MD