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Care of older adults

Susan P Bell, Nileshkumar Patel, Nish Patel, Rajesh Sonani, Apurva Badheka, Daniel E Forman Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, School of Medicine, Nashville, TN, USA Department of Cardiology, University of Miami Miller School of Medicine, Miami, FL, USA Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA, USA Department of Cardiology, the Everett Clinic, Everett, WA, USA Section of Geriatric Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA


Background 
In the United States, approximately 40 million adults over the age 65 are affected by one or more forms of cardiovascular disease and it remains the leading cause of morbidity and mortality in this population. [1,2] Among older adults, therapeutic goals for cardiovascular diseases (CVD) are often confounded by comorbid diseases and/or conditions that dominate their overall sense of health and well-being. [1,2] Thus, even while CVD is usually considered a principal concern, management is often complicated by concomitant medical challenges. Whereas, evidence-based care is often premised primarily on goals to increase longevity, the circumstances associated with multimorbidities [e.g., cancer, chronic obstructive pulmonary disease (COPD), Parkinson disease, dementia, and chronic kidney disease] may undercut the perceived value of prolonging life. Thus, in addition to mortality benefit, other effects of cardiovascular (CV) therapy and/or management processes are important as well.
In addition to life prolongation, goals to preserve functional capacity (including cognitive and physical function), maintain independence and quality of life, reduce hospitalization, reduce pain, and moderate personal costs may all be just as or even more important from the patient's perspective. Therefore, decisions regarding cardiovascular treatment in older adults need to be individualized to each pa-of daily living (IADLs) are critical for independent functioning. A change in these activities should warrant further investigations by the treating physician including assessment for cardiovascular [coronary artery disease (CAD), structural heart disease, etc.], neurological [dementia, cardiovascular accidents (CVA), transient ischemic attacks (TIA)], and psychiatric causes (depression, stress). (5) Falls in the elderly population can result in significant morbidity, mortality and functional decline. Identifying and addressing treatable/reversible causes of the falls should be undertaken as soon as the incident has occurred. (6) Vulnerable elders and their caregivers may benefit from referral to a geriatrician and/or an interdisciplinary geriatric team in the inpatient and outpatient settings. A geriatric assessment responds to the broad context of clinical complexity in older adults, and can often increase the potential to live more safely and independently despite the risks associated with disease and age.

Altered presentation of diseases
While chest pain remains the most common and important symptom of CAD, dyspnea in the absence of chest pain is a commonly reported symptom, particularly in older adults, women, and those with multiple comorbidities. [5,6] CAD symptoms may also include nonspecific problems, including fatigue, weakness, and decline in physical activity or function, so it is important to maintain a high-index of suspicion in those at risk.
The concept of altered presentation of disease among older adults applies to a number of conditions, including CAD. A lack of understanding of this phenomenon can lead to delays in diagnosis and treatment, and result in worse outcomes for older adults. [5,6] While chest pain remains a common and important symptom of heart disease, dyspnea in the absence of chest pain is even more commonly reported in older adults. In the Global Registry of Acute Coronary Events (GRACE) registry, dyspnea was the primary presenting complaint of CAD in nearly 50% of the participants ages > 85 years. [6] Any medical illness may present nonspecifically and be multifactorial among older adults, particularly those in frail health. Nonspecific symptoms related to an underlying medical illness include changes in cognition, difficulty with balance and falls, new urinary incontinence, or a general change in functional ability. Older adults may also be less likely to report significant symptoms due to pre-existing conditions, cognitive impairment, or a desire to minimize symptoms. Likewise, health care providers may minimize complaints among older adults with complex medical illness or frail health. [2] 3 Multimorbidity Cellular senescence, inflammation, oxidative stress, telomere attrition, telomerase activity, and apoptosis are biological factors underlying aging and the development and progression of CVD and can also provoke the development of other disease states over time. [7][8][9] The accumulation of chronic conditions as a result of genetics, lifestyle choices, environmental factors, treatment of prior conditions (e.g., CVA as a complication of coronary artery bypass grafting) and aging itself culminates in a vastly heterogenic older population of adults with multiple medical problems. [2] The prevalence of multimorbidity (the coexistence of 2 or more chronic conditions) rapidly increases with age such that it occurs in over 70% of 75 or older. [2,10] In older adults with heart failure the burden of multimorbidity is significant with over 50% having 5 or more coexisting chronic conditions. [11,12] Clustering of multimorbidity occurs both at a CVD level, where heart failure frequently exists with ischemic heart disease, hypertension, hyperlipidemia, and atrial fibrillation and at the non-CVD level where heart failure is commonly associated with diabetes mellitus, arthritis, depression and frailty. [12,13] The impact of multimorbidity is particularly evident in the management of heart failure where increasing non-cardiac comorbid conditions is associated with an increase in re-hospitalization and mortality. [14] In addition, the societal cost of multimorbidity is substantial with increasing costs per number of chronic conditions such that individuals with 6 or more chronic conditions on average have over three times the spending compared to average per capita Medicare spending. [15] 4 Geriatric syndromes Geriatric syndromes represent clinical conditions common in older adults that share underlying causative factors and involve multiple organ systems. Unlike traditional medical syndromes, they do not fit a discrete metabolic, pathological or genetic disease category. [16,17] Examples of geriatric syndromes include incontinence, cognitive impairment, delirium, falls, pressure ulcers, pain, weight loss, anorexia, functional decline, depression, and multi-morbidity.

Delirium
Delirium affects over two million hospitalized persons each year and is estimated to affect between 25% and 60% hospitalized older adults. The hallmark of delirium is characterized by its acuity, fluctuating course, alteration in global cognitive function and reversibility. In addition, a http://www.jgc301.com; jgc@mail.sciencep.com | Journal of Geriatric Cardiology common feature relates to an altered level of consciousness resulting in both the familiar hyperactive and agitated form and more frequently (over 60% of cases) a more hypoactive and under-recognized phenotype. [18] Dementia and mild cognitive impairment, in contrast to delirium, feature a more chronic progressive course and may affect a more specific cognitive domain pattern. While patients with dementia are more at risk of developing delirium, it is frequently underrecognized and not adequately managed within that population. Delirium is associated with prolonged hospital stay, increased costs, increased readmission rate to the hospital (12%65% at 6 months), and higher in-hospital and 1-year mortality.
The Confusion Assessment Method (CAM) offers a validated screening tool to diagnose delirium. [19] Per the CAM, delirium is likely present if the patient has both an acute onset with fluctuating course, inattention, and either disorganized thinking or altered level of consciousness. [19] Key risk factors for delirium include older age, cognitive impairment, surgery, polypharmacy (especially medications with anticholinergic properties), infection, sensory impairment, psychoactive drugs, comorbid illness, and functional decline. Precipitating factors during an acute illness include hypoxia, electrolyte abnormalities, dehydration, malnutrition, medications, and alcohol withdrawal. Environmental factors also contribute to problems, including tethers such as catheters and IVs that contribute to risk of falls, noisy wards, and frequent tests and procedures that further disrupt diurnal rhythms and sleep. [20,21] Key points: Delirium is a common complication of hospitalization and surgery among older adults. Assessing risk for delirium and implementing a multimodal intervention can prevent its onset. Identification of other potential hazards of hospitalization for older adults, including sleep disruption, dehydration, malnutrition, and immobility, can improve outcomes. [22]

Dementia
Dementia is prevalent in approximately 13% of community dwelling older adults over the age of 65 and increases to approximately 40% by the age of 80. [23] In adults over the age of 65 with a diagnosis of advanced heart failure these estimates can reach 30%60%. [24] These figures likely underestimate the prevalence due to reduced patient and provider recognition of the disease, particularly in the early stages. The most common causes of dementia globally are Alzheimer's disease (AD) and vascular dementia which can also co-exist and result in a more progressive trajectory. [25] The presence of dementia significantly increases the financial cost, management complexity and mortality rates for an older adult. In older adults who are classified as frail the prevalence of cognitive impairment is five times greater than those who are not frail. Moreover, the combination of these factors causes a more rapid decline in cognition and disability. [26] Hypertension and frailty also lead to a combined effect, with increased risks for the development of mild cognitive impairment, a prodromal phase of Alzheimer's type dementia. For an individual that has both HTN and mild cognitive impairment, institutionalization and mortality rates are similar to those with dementia and significantly higher than those with HTN alone. [27] Executive function, specifically, appears to be impaired in older adults with CVD and can dramatically reduce their capabilities to initiate and participate in their disease management. [28] High rates of unidentified cognitive impairment in older adults suggest that periodic screening is necessary to accurately establish future risk and determine benefits of simplification of treatment strategies.

Frailty
Frailty encompasses a biological decline across multiple interrelated organ systems and a subsequent loss of reserve in response to stressors, such as acute illness, and can result in a poor tolerance CVD and/or to CVD therapy. [29] Frailty is an independent predictor of a wide range of CVD including subclinical CVD, coronary artery disease, congestive heart failure and CVD mortality. Objective frailty, in the most part, refers to a phenotype that includes weight loss, exhaustion, weakness, slowness, and low levels of activity. In addition, cognitive impairment now appears to be a common and significant component of frailty and should be assessed for in combination with objective tools. [30] Currently, there is no widespread standard for assessment of frailty in the CV setting despite the recognition as a significant factor in the evaluation of an older adult with CVD. Many parameters can be used to assess frailty. [30] Despite the recognition of frailty as a significant factor in the evaluation of an older adult with CVD, there is no widespread standardized tool utilized for the assessment of frailty although numerous methods have been used. [30] Grip strength and gait speed are sensitive and frequently used physical functional measures, but faltering cognition, ADLs, and other deficits are also sometimes used to define frailty. [30,31] Gait speed (defined as ≥ 6 s to walk 5 m in one notable study of older surgical patients) is probably the most commonly used frailty parameter, particularly due to its convenience. [32] Slow gait speed, is independently associated with mortality risk over time in patients with CVD, but the particular speed cut-points may vary with the specific populations. [33] Journal of Geriatric Cardiology | jgc@jgc301.com; http://www.jgc301.com Frailty is relevant to all aspects of CVD management, including patients with aortic valve disease, heart failure, atrial fibrillation, and CAD. It is possible that patients categorized as frail may benefit from added precautions and/or cardiac rehabilitation, but these concepts remain to be proven.

Sensory impairments (hearing and vision loss)
Hearing and vision loss are very common in the geriatric population, with more than 40% reporting difficulties with hearing, and more than 13% having visual impairment after the age of 65 years. [34] Age-related hearing loss or presbycusis, the most common type of hearing loss in older adults, is a multifactorial high frequency sensorineural hearing loss that commonly results ina component of impaired speech discrimination. [35] Cerumen impaction and chronic otitis media leading to conductive hearing loss may be present in up to 30% of elderly patients with hearing loss, and can be treated by the primary care clinician.
Patients, clinicians, and health care staff often do not recognize hearing loss, particularly in its early stages. Older adults may not volunteer difficulties associated with the hearing loss through a fear of social embarrassment. Implications include increased susceptibility to delirium, poor health literacy, and misdiagnosis of depression and/or dementia.
Screening is endorsed by most professional organizations, including the US Preventive Services Task Force. Despite the paucity of data evaluating routine screening for improving patient outcomes the role of any provider, commonly evaluating older adults for hearing changes has the potential to trigger appropriate evaluation.

Falls
Falls in the elderly population can result significant morbidity, mortality and functional decline. Defining the context of the fall and addressing treatable and reversible causes of falls should be undertaken as soon as the incident has occurred, however, the cause of falls in older adults tends to be multifactorial in nature and requires considerable time to unearth predominate driving factors for each event. [36] Older adults with CVD are particularly at risk of falling through the signs and symptoms associated with the disease process. Physiological changes in the aging cardiovascular system result in impaired reflexes, orthostatic hypotension, bradycardia, and impaired tolerance to activity. In addition, common CV conditions such as aortic stenosis, arrhythmias, and heart failure feature symptoms (i.e., dizziness, loss of consciousness, blood pressure drop) that may also result in increased risk. [37] Falls occur frequently, and are dramatically more common in those with a prior history of falling. They can result in soft tissue injury, head injuries, fractures, including the most feared complication of a hip fracture, which occurs in 3%5%. [38] In addition, far reaching repercussions can include reduced physical activity, reduced social engagement and social isolation through a fear for further falls. Fall prevention, especially in the home, can be challenging but risks (i.e., polypharmacy, hypotension, unrecognized sensory impairments) can be moderated with a coordinated care approach. Within a more structured environment of long-term and skilled care, Jensen et al. found that an interdisciplinary and multifactorial prevention program targeting nursing home residents, staff, and the environment can reduce falls and femoral fractures by approximately 12% suggesting fall reduction is possible and a multifaceted intervention approach may produce benefit. [39,40] 6 Geriatric review of systems All clinicians, including cardiologists, need to understand the prevalence and impact of the various health problems in older adults. The so-called "geriatric syndromes" represent the most commonly occurring, but overlooked problems in the older patient. [41][42][43] The following is a brief screen, which identifies potentially preventable or treatable conditions, and can be obtained from the medical record, the patient, or the caregiver. Identifying the myriad of symptoms and problems often present in older adults can seem far beyond the scope of a cardiologist. However, geriatric syndromes often affect and in some cases are crucial to the management of heart disease. For example, certain cardiovascular medications increase problems with gait and balance (antihypertensive medication and orthostatic hypotension) and incontinence (loop diuretics). The cardiologist will also want to assess the patient's cognitive function, and their capacity for understanding treatment options and adhering to a treatment plan. [2] Coordinated care between the cardiologist, primary provider, and other sub-specialists is critical for optimal care. [2] In addition, referral to a geriatric care assessment for a comprehensive assessment performed by an interdisciplinary team of providers can provide the expertise and care planning needed to navigate the typical difficulties of late life, and to best maintain independence.
A comprehensive geriatric assessment can be triggered by a cardiovascular provider for patients whose management is particularly encumbered by age-related complexity. It provides a multidimensional, interdisciplinary, diagnostic process to assess medical, psychological, and functional capabilities of older adults which can be applied as a means to develop a coordinated and integrated plan of treatment and long-term follow-up.

Disability, social support and processes of care
ADLs encompass activities required for successful independent living on a daily basis these tasks include bathing, grooming, transferring, toileting, eating and dressing. IADLs include relatively more advanced activities required on a more infrequent basis but still instrumental to remaining independent such as handling finances, shopping, preparing food, answering the telephone and transport. [44] Disability and underlying physical, cognitive, and sensory limitations are not inevitable consequences of aging. Yet, approximately 20% of older US adults have chronic disabilities, 7%8% have severe cognitive impairments, roughly one-third have mobility limitations, 20% have vision problems, and 33% have hearing impairments. [45] Women, minorities, and persons of low socioeconomic status are especially vulnerable. Routine screening for the ADLs and IADLs provides important opportunity to anticipate (and take steps to possibly modify) advancing disability and frailty.
Up to a third of hospitalized older adults experience a decline in their ability to perform ADLs in the course of their hospitalization. [46] Patients who experience declines in function during hospitalization have higher rates of rehospi-talization, prolonged institutionalization, and mortality after discharge, and many (41%) never return to their preadmission level of function. The Assessing the Care of the Vulnerable Elderly (ACOVE) project has published specific quality measures to optimize outcomes in hospitalized older adults. [47] Many older adults are burdened by sensory and/or cognitive limitation that limit their ability to hear, see, understand their medical circumstances, or access of health care services. Extra efforts to convey information in a manner that is accessible to each patient, overcome logistic constraints, and which facilitate patient-centered choices, in spite of intrinsic age-related limitations, are important aspect of care of older CVD patients. [2] Patient-centered goals of care in the elderly are critical to the personalized treatment approach for each patient. Older patients do not necessarily desire longevity as their sole outcome but may also have expectations about modifying pain, independent life or increasing function. Goals of care are different for each patient and depend on the patient condition and his/her expectations from life. [2,48] Older adults with CVD and multimorbidity can become more dependent over time, frequently relying on family members to support these deficits. Primarily a spouse or adult child will become burdened with resulting social, physical and financial strains whilst negotiating a confusing and complex health care system on behalf of their loved one. Insufficient financial means, living far away, employment restrictions (caregiver) and different perceptions of the appropriate goals of care can result in significant stress among caregivers and in turn affect their ability to provide the required support and have a detrimental effect on their own health. Stress can complicate all aspects of life for frail older adults and their caregivers. [49] Key risk factors for caregiver stress include: (1) a caregiver who is also frail; (2) a patient with cognitive impairment, emotional disturbance, substance abuse, sleep disruption, or behavioral problems; (3) low income or financial strain; and (4) acute illness or hospitalization. [50] Caregiver stress is an important contributing factor to increased morbidity and mortality, and should prompt referral to team and community resources. Occasionally, these immense expectations and levels of stress can lead to neglect or abuse by their caregivers, especially when complicated changes in personality and behavioral issues seen in individuals with dementia. [51] Physicians should be attuned to both caregiver burden and burnout and consider the possibility of patient abuse by caregiver if circumstances and physical findings suggest it and should consider referral of the patient to a social worker, patient resource manager, or geriatric assessment team with the goal of helping the patient and the caregiver.