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.

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. 

Compassion in Medicine

cherylThe aging hearts of our loved ones are multifaceted for sure. Kind, funny, witty, intelligent, brave, accomplished, and if we’re lucky, loving with a lifetime of experiences all wrapped up into a well-lived life. Certainly a life deserving of respect, all the best medical care, compassion, understanding, and help to navigate this final stretch of the journey.

My mother was fiercely private concerning her medical care.  She did not want anyone, other than my father, to know what doctors she was seeing and why.  When it became obvious to my (physician) husband and I that her condition was deteriorating, stepping in became a delicate balancing act.

My final journey with my mother began over two years ago when I noticed she was exhausted much of the time and her breathing was labored.  My husband spoke to me about his concern in private, knowing to tread lightly.  Whenever either of us asked her how she was doing, and expressed concern, she very firmly stated that nothing was wrong.

When she began having difficulty with memory and recall, she reluctantly agreed to see a neurologist friend of ours.  After testing, he concluded she was experiencing normal progression in aging. Her energy level, however, continued to decline.  She assured us again that she was fine and was seeing a cardiologist for chronic A-Fib, which my father confirmed.

A few months later she ended up in the local emergency room, the result of a fall. Although her cardiologist had an office in the same hospital, we discovered that his records were not linked to the hospital system.  Consequently, the ER doctor, not having the cardiologist’s records on my mother, took her off blood thinners because she felt the risk of injury from fall was greater than the benefit of my mother remaining on her medication.  This likely contributed to the further significant decline of my mother’s condition.  When my husband discovered her medication had been stopped he had my father call their cardiologist immediately to correct. We encouraged my father from that point on to keep a physical copy of their medical records with him for every future trip to the hospital and doctor’s office.  Unfortunately, not every patient has the luxury of having a physician in the family.

Sadly the other effect (we assumed of the fall) was significant cognitive impairment. When re-examined by her neurologist, she had declined drastically. He secured and poured through all of her medical records.  He found she had been diagnosed with mitral stenosis and severe pulmonary hypertension years before which were contributing to her confusion.

Together, my father and I decided that I would be included in Mother’s next cardiologist appointment.  Given her condition I stated at that visit that we would like her to see an Interventional Cardiologist.  I’ll admit I was a bit skeptical before meeting this new doctor, as all we were offered to this point was monitoring.  When Dr. K walked in, he was extremely welcoming and respectful and had actually taken the time to read Mother’s chart before meeting with us—this was a first!  He was very kind and honest from the start.  He told us she actually had Rheumatic Mitral Stenosis and that he could offer a procedure called valvoplasty.  This procedure could potentially give my mother great quality of life for her remaining years.

Being a teacher, I appreciated his unique ability to explain this complex diagnosis and procedure in terms my parents and I could understand.  And, he took as much time as we needed to feel comfortable with the next step.  Dr. K had given us so many gifts that first day.  His world-renowned expertise, his genuine kindness and caring, gave us hope for the first time in years.  He also gave us his cell phone number in case we had any questions or concerns.

Although blood clots ultimately prevented my mother from receiving this procedure, Dr. K’s care did not end there. He took time out of his busy schedule to meet with our family and discuss how best to care for Mother. He set into action Home Healthcare, having a nurse perform home visits and enabling him to monitor her INR. He even discussed (in person, by phone, or by text) when to get Hospice involved, end-of-life decisions, and what my father could expect every step of the way.

Everything Dr. K did enabled my mother to have the best quality of life possible, to live out her final days as she wanted to.  My mother was a woman of deep faith. She was not afraid of dying. Quite the opposite, she knew Heaven was her ultimate destination. It was her wish to remain in her home, and she did.  She was able to live out her final days in the home she loved, with the people she loved, and in her words, “with the best husband I ever could have asked for” for all but her final six hours.

When Dr. K learned of my mother’s passing, he asked to meet with my father and myself.  When we met we were yet again amazed. His mission was to share a cappuccino and make sure we were doing all right.  Talk about a lesson in compassion… I feel it is worth mentioning that although Dr. K was the newest cardiologist on my mother’s case, he was the only doctor to follow us through her death.

Lessons learned on the journey:

  1.  The best way to preserve a loved one’s dignity is to be their advocate.
  2.  Always be respectful but get involved as needed.  Get referrals, go to appointments, ask the difficult questions so your loved one has all the information necessary to make their decision.
  3.  I always knew and respected the fact that the final medical care decision would be my mother’s and father’s to make.  Even if the decision was no further procedure.
  4. My role was to connect my loved ones to the best possible medical specialists.
  5.  There simply are no words to adequately thank someone for giving you more quality time with your loved one.  I am eternally grateful to Dr. K and the other doctors on my journey who truly care for their patients and families.

 

By: Cheryl Csorba

 

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