AHA: Geriatric syndromes affect care of older patients in cardiac ICU
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Despite older patients receiving the care they need in cardiac ICUs, they may experience worsening of geriatric conditions such as cognitive impairments and frailty, according to a American Heart Association scientific statement published in Circulation.
“These issues are difficult to address for cardiologists in practice, but they are encountered every day,” Abdulla A. Damluji, MD, MPH, FAHA, interventional cardiologist at Inova Heart and Vascular Institute in Falls Church, Virginia, assistant professor of medicine at Johns Hopkins University School of Medicine and chair of the writing group, told Healio. “As a cardiovascular community, we have to face and manage these complexities. We don’t have a choice. The population of older adults is expanding rapidly, and this paper will expose these intricacies so that clinicians can think differently about the management of older adults with acute cardiovascular disease.”
Geriatric syndromes
As patients get older, they are more prone to developing geriatric syndromes such as delirium and cognitive dysfunction, which is common in the cardiac ICU due to the environment itself and stress associated with their CVD. Although the care paradigm within cardiac ICUs may elicit delirium, new measures and therapies are needed to prevent and treat the condition, according to the statement.
Frailty is also connected with CVD, as it can also increase a patient’s risk. It can also lead to poor outcomes. More research is needed to better integrate tools to prevent, treat and possibly reverse frailty within the cardiac ICU.
Multimorbidity can also lead to clinical decline in older adults with CVD, although more efforts are needed to understand how it can affect care obtained in the cardiac ICU. Novel therapeutic approaches for this specific geriatric syndrome are also needed in this area, according to the scientific statement.
Polypharmacy can lead to more adverse events in older patients due to organ dysfunction, age-related physiological changes, metabolism or excretion. Drug-disease and drug-drug interactions can also negatively play a role in older patients.
The cardiac ICU itself can also be a mechanism in the risk seen in older patients with CVD. This can be seen through situations such as immobility, bed rest, caloric insufficiency, physiological and psychological stress, disruption and the feeling of being overwhelmed.
Challenges in care
A challenge remains in trying to determine the best way to conveniently and reliably assess older patients to improve the anticipation and response to these critical needs, according to the scientific statement. Another question that arises is how to apply these assessment tools when the cardiac ICU can lead to acute medical instability. Structured questionnaires may play a role in this, but sometimes they can be impractical in this specific setting.
Aging can play a role in the development of CVD including MI, acute decompensated HF, acute valvular heart disease, acute aortic syndrome and pulmonary embolism.
“Aging itself is a risk factor for cardiovascular pathophysiology that makes older patients vulnerable to acute cardiac illness,” Damluji and colleagues wrote. “Aging is also associated with important changes in organs outside the cardiovascular system including kidney function, pulmonary reserve and hemostasis.”
These conditions can be difficult to treat in older patients, and more research is needed to integrate the clinical standards of cardiac ICUs and complexities common in older patients, according to the statement.
“These geriatric syndromes complicate the care of these patients,” Damluji told Healio. “Sometimes we try to extrapolate the treatments from the younger cohorts and apply to the older cohorts and they don’t do as well.”
Not only does patient-centered care play an important role, but also a team-based approach, shared decision-making, palliative care and end-of-life care, according to the statement.
“As the U.S. older adult population expands, the influence of these geriatric syndromes on the health care system will be magnified in the years come,” Damluji and colleagues wrote. “As part of the American Heart Association initiative to improve cardiac care for older adult populations, we highlight areas where future investigations are needed to integrate geriatric syndromes into the overall [cardiac] ICU models of care.” – by Darlene Dobkowski
For more information:
Abdulla A. Damluji, MD, MPH, FAHA, can be reached at abdulla.damluji@jhu.edu; Twitter: @drdamluji.
Disclosures: Damluji reports no relevant financial disclosures. Please see the scientific statement for all other authors’ relevant financial disclosures.
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