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.

The Domain Management Approach for Holistic and Patient-Centered Care of Older Adults with HFpEF

parag_officialOur 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.

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. 

“I Had No Choice”: Perspectives from Heart Attack Patients on Coronary Interventional Procedures

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Photo taken at Boston Public Garden

Last week, I had the privilege of attending the Gerontological 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:

  1. 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.”

  1. 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.

  1. 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.”

  1. 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.

  1. 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

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Patient Priorities Care: State of the Art

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Photo credit: Shutterstock

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