Transcript Heart Failure in the Aged

Cardiovascular Syndromes in
Older Adults
Greater New York Geriatric Cardiology Consortium
October 18 and 19, 2011
Mat Maurer, MD
Columbia University Medical Center
Disclosures
None
Goals of GNYGCC
AIM #1
AIM # 2
Seminar Series
Develop membership
Build enthusiasm
Educate
Build Camaraderie
Brainstorm Ideas
Research
Innovative
Investigator Initiated
Multi-center
Multi-disciplinary
Leads to
GNYGCC
Participating Sites
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Allen Hospital
Columbia
Weil Cornell
Einstein/Montefiore
Mount Sinai
Maimonides
University of Michigan
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New York University
St. Luke’s Hospital
Roosevelt Hospital
SUNY Downstate
Vanderbilt
Yale University
Woodhull
Objectives
1. Define disability, frailty and co-morbidity
2. Enumerate criteria for defining “geriatric syndromes”
3. Understand the added value added for Geriatric Cardiology in
moving away from a “disease based model” to a more
complex paradigm involving syndromes.
4. Delineate common “geriatric cardiovascular syndromes” and
identify shared risk factors among “geriatric syndromes”
5. Highlight the prevalence of “geriatric syndromes” in older
adults with cardiovascular disease and their independent
association with outcomes.
An Aging Society:
Important Tenants for Clinical Care
Aging:
1. A process of gradual and
spontaneous change, resulting in
maturation.
2. To acquire a desirable quality by
standing undisturbed for some time
3. To bring to a state fit for use or to
maturity
Selective
Heterogeneous
Homeostenosis
Co-Morbidity, Frailty and Disability
• Co-morbidity
– Concurrent presence of two or more medically
diagnosed diseases in the same individual
Multiple, Chronic and Therefore Multifactorial
Co-Morbidity, Frailty and Disability
• Co-morbidity
– Concurrent presence of two or more medically
diagnosed diseases in the same individual
• Frailty
8%
60%
– A physiologic state of increased vulnerability to
stressors that results from decreased physiologic
reserves causing homeostenosis.
• Disability
– Difficulty or dependency
in carrying out activities
7%
essential to independent living
(e.g. Loss of ADLs and IADLs).
Embracing Complexity
…at
best out of date and at worst harmful
…lead
to under-treatment, overtreatment or
mistreatment
Am J Med. 2004 Feb 1;116(3):179-85.
Geriatric Cardiology:
A delicate balance
Omission
Commission
What is a Syndrome?
• Syndrome derives from
the Greek roots
– "syn“ = meaning "together“
– "dromos" = meaning "a
running“
• Refers to "a concurrence
or running together of
constant patterns of
abnormal signs or
symptoms."
What constitutes a
Geriatric Syndrome?
1. High Frequency (e.g.>10%)
– Particularly frail older adults
2. Chronic/intermittent conditions
– Not isolated episodes
3. Triggered by acute insults
4. Associated with functional decline
Geriatric Syndromes:
Clinical Perspective
• Chief Concern/Complaint
– Expressed by patient or caregiver
– Does not represent the specific pathological
condition underlying the change in health status.
• Result from impairments in multiple systems
– Not from a discrete disease
• Develop from accumulated effects of
impairments in multiple domains that ultimately
compromise compensatory ability
Common Geriatric Syndromes
•
•
•
•
Falls/Syncope
Delirium
Dizziness
Urinary
Incontinence
• Pressure Ulcers
•
•
•
•
•
•
Dementia
Weak Bones
Visual difficulties
Auditory difficulties
Weight loss
Sleep disorders
Anergia:
A Neglected Geriatric Syndrome
•
Anergia (an·er·gia) (an-ər´je-ə):
– 1. characterized by abnormal inactivity; inactive.
– 2. marked by lack of energy.
– 3. lack of mental energy, debility; passivity
•
•
Analogous to fatigue (~20% of the population)
but not strictly a post-exertional construct.
The prevalence and clinical significance is not
well characterized in the elderly population.
The Journals of Gerontology; Medical
Sciences: 2008; 63A, 707-714
Anergia Criteria
Specific Criteria
Recently not enough energy
Felt slowed physically in month
Sits around a lot for lack of energy
Wakes up feeling tired
Any slowness is worse in morning
Doing less than usual in month
Naps during the day (>2 hours)
The Journals of Gerontology; Medical
Sciences: 2008; 63A, 707-714
Prevalence
46.4%
41.8%
21.7%
21.4%
19.5%
18.1%
8.9%
Severity of Anergia
Percentage of Subjects
40%
30.9%
30%
16.8%
20%
14.4%
10.4%
9.8%
10%
6.7%
2.2%
0.3%
0%
0
1
2
3
4
Degrees of Anergia
The Journals of Gerontology; Medical
Sciences: 2008; 63A, 707-714
5
6
7
Percentage of Subjects
Severity of Anergia
40% None
30.9%
Mild
30%
16.8%
20%
Severe
14.4%
10.4%
9.8%
10%
6.7%
2.2%
0.3%
0%
0
1
2
3
4
Degrees of Anergia
The Journals of Gerontology; Medical
Sciences: 2008; 63A, 707-714
5
6
7
Anergia: Source of Presentation and
Association with Somatic Symptoms and Disease
Parameter
Arthritis
Arthritis/Rheumatism
Joint pain, stiff or swelling
Often takes meds for pain
Odd’s Ratio
Parameter
Odd’s Ratio
2.38 (1.96-2.88)
3.39 (2.75-4.17)
3.78 (2.83-5.05)
Mobility
Falls
Assist device to ambulate
Ever had a fracture
2.77 (2.20-3.49)
5.42 (3.81-7.70)
1.52 (1.20-1.92)
Incontinence
3.83 (2.63-5.57)
Depression
5.80 (3.97-8.46)
Sensory Deficits
Hearing Difficulty
Trouble seeing
2.24 (1.78-2.82)
2.52 (1.90-3.33)
Neurology
Ever had stroke
Dementia
Parkinsons’ Disease
2.41 (1.57-3.70)
1.91 (1.37-2.64)
1.55 (0.61-3.92)
Respiratory
Shortness of breath
Breathless all the time
Other lung conditions
7.10 (5.18-9.73)
9.6 (1.31-70.58)
2.10 (1.38-3.22)
Cardiovascular
Every had heart trouble
Felt dizzy or weak
Exertional chest pain
Ever had high blood pressure
2.04 (1.63-2.55)
6.42 (4.86-8.49)
4.94 (3.40-7.19)
2.98 (1.90-4.68)
Sleep Disorder
Trouble falling asleep
Medication for sleep
3.67 (2.90-4.64)
2.68 (1.90-3.78)
Anergia Is Associated
with Mortality
Total
No Anergia
Anergia
Odd’s Ratio
18 months
158 (8.1)
39 (5.9)
119 (9.2)
6 years
453 (23.2)
119 (18.1)
334 (25.9)
1.61
(1.11-2.35)
1.58
(1.25-2.00)
Time
Anergia Is Associated with
Health Service Utilizations
No Anergia (%)
Anergia (%)
No Anergia (%)
Anergia (%)
# Days Hopsitalized
Percentage of Subjects
30%
25%
20%
15%
10%
5%
0%
Hospitalized
ER visit
Meals on
wheels
Homecare
service
0
The Journals of Gerontology; Medical
Sciences: 2008; 63A, 707-714
1
2
3
Number of Days
4
5
Factors Associated with
Anergia: Multivariate Analyses
Adjusted OR *
(95% CI)
Depression
2.01 (1.29-3.13)
Trouble sleep
2.01 (1.52-2.65)
Falls
1.69 (1.23-2.23)
Respiratory syndrome
1.63 (1.41-1.88)
Female
1.33 (1.01-1.74)
Isolation
1.26 (1.12-1.42)
Activity limitations
1.26 (1.15-1.38)
Pain syndrome
1.20 (1.13-1.28)
*The adjusted confounders included age, gender, married status, education, income, selfrated health, physical function, social function, somatic symptoms, medications, co-existing
diseases
Anergia: A New Geriatric
Syndrome?
1. Anergia may be a prevalent concern and of
sufficient magnitude and duration to warrant
clinical attention.
Anergia is common among multi-ethnic communitydwelling older persons.
2. Anergia may be linked to many etiologic factors
and/or multiple functional, cognitive or affective
disorders
Anergia is associated with many clinical symptoms and
multiple co-existing diseases
Anergia: A New Geriatric
Syndrome?
3. Anergia may be associated with increased health
care utilization and adverse outcomes in elderly
persons.
Anergia is associated with extensive health services
use and poor outcomes including mortality
4. Anergia may be potentially susceptible to targeted
interventions that reduce the morbidity and
mortality in anergic older individuals.
Multivariate analyses suggests that several
factors/diagnoses are independent of
other confounders and thus, should
be investigated initially.
Geriatric Syndromes:
Shared Risk Factors
Physical
performance
(arm and leg
strength)
Sensory
Impairments
Affective
Impairments
(Anxiety)
Functional Dependence
JAMA. 1995;273:1348-1353
Geriatric Cardiovascular
Syndromes
• Systolic Hypertension
– 70% NHANES1, 90% Liftetime2
– Load lability – Hypertensive
urgency and orthostasis
– Trigger: salt, NSAIDs, stress,
etc
• HFPEF (aka DHF)
– >Half of all heart failure
– APE/AHDF/CHF - presentations
– Multiple mechanisms
1 MMWR
• Syncope/Falls
– 33-50% fall/year, syncope ↑
with age.
– Multiple triggers
– OR 3.1 for NH placement3
• Atrial Fibrillation
– >10% of octogenarians
– PAF leads to chronic afib
– ↑ risk for stroke/disability
Surveill Summ. 2011;60 Suppl:94-7, 2 Circulation.
2011 Feb 1;123(4):e18, 3 N Engl J Med. 1997;337(18):1279-84.
Added Value?
Syndromes over Diseases
• Under-treatment:
– Treating only the biological rather than addressing all
contributing factors results in lost opportunities to
maximize health outcomes.
• Overtreatment
– Get Away from the Guidelines (GAFTG)
• Mistreatment
– Clinical decision making based on disease-specific
outcomes rather than on patient preferences
Am J Med. 2004;116:179 –185
Changes in Models of Care
Am J Med. 2004;116:179 –185
A New Model of Care for Older Adults
with Cardiovascular Disease
Traditional Cardiology
Geriatric Cardiology
Treatment focused on the heart
Treatment considers the host
Few comorbidities
Multiple comorbidities
Treatment yields expected outcomes
Treatment may result in complex effects
Large simple trials apply
Large simple trials have limited
generalizability
Evidence-based medicine
Patient-centered evidence-based medicine
Cardiovascular reserve usually
preserved
Cardiovascular reserve usually
compromised
Outcomes: death, MI, revascularization
Outcomes: morbidity, function,
independence, cognition
J Am Coll Cardiol. 2011;57(18):1801-10.
HFPEF: Disease or Syndrome?
Disease
Syndrome
Variable
High
Organ Focused
Often
Rarely
Mechanism(s)
Single
Multiple
Heterogeneity
No
Yes
Represents Specific
Pathologic Condition
Disconnect between
Chief complaint and
underlying pathology
Prevalence
Chief Complaint
Heart Failure:
Is there a better model for care?
• HF is principally a disease of older adults.
• HF in the setting of a preserved EF (HFPEF) is
increasing in prevalence/incidence.
• Disease model argued a single pathophysiologic
mechanism “diastolic dysfunction”
• Outcomes in HFPEF have not improved.
• Multiple “under-appreciated” targets for therapy
that confound outcomes
Heart Failure Epidemic
• 6 million patients diagnosed with symptomatic HF
• Annually there are
– 600,000 new cases of symptomatic HF diagnosed
– 15 million visits for heart failure
– 1 million hospitalizations and 6.5 million hospital days for
heart failure
– 2.6 million patients hospitalized with heart failure as a 2°
diagnosis
• ~33-50% of patients with heart failure as a discharge
diagnosis readmitted within 90 days
• $39.2 billion annually on heart failure in the US
AHA. Heart Disease and Stroke Statistics—2010 Update.
Heart Failure and Aging
• Heart failure is the most
common Medicare DRG.
• 10% of patients older
than 65 years have heart
failure
• 80% of hospitalized
patients with heart
failure are older than 65
years.
Trends in Heart Failure
N Engl J Med. 2006 Jul 20;355(3):251-9
Re-hospitalization:
Heart Failure
Leading
the
List
Reason for
Re-hospitalization
Condition
30 day Reat Index Discharge hospitalization Rate (%)
Heart Failure
Pneumonia
COPD
37%26.9
20.1
22.6
63%
Psychosis
24.6
GI Problems
19.2
Heart Failure
Non Heart Faiure
N Engl J Med 2009;360:1418-28.
HFPEF: Effective therapy?
J Am Coll Cardiol 2011;57:1676–86
HFPEF: Effective therapy?
J Am Coll Cardiol 2011;57:1676–86
HFPEF: Effective therapy?
J Am Coll Cardiol 2011;57:1676–86
HFPEF
Heterogeneous Disorder with a Single
Pathophysiologic Mechanism?
• Although heart failure with a preserved ejection fraction
(HFPEF) is a heterogeneous clinical entity, a single
mechanism, diastolic dysfunction, is ascribed to explain
the pathophysiology of this condition.
HFPEF: Embrace Complexity
Atrial
Fibrillation
Anemia
Salt
Sensitivity
Arterial
Stiffening
Sarcopenia
HFPEF
Chronotropic
Incompetence
Endothelial
Dysfunction
Volume
Overload
Diastolic
Dysfunction
Pulmonary
HTN
Heart Failure and Geriatrics:
More Common than Different
Heart Failure Geriatrics
Patient population
Disease vs.
syndrome
So
why
Generally older
Exclusively
adults
older adults
Syndrome
Syndrome(s)
we collaborate
and
don’t
develop a new model
Multidisciplinary
Yes of care Yes
employing geriatric principles?
Integrated/Tailored Management
Yes
Yes
Palliation
Yes
Yes
Definitely
Definitely
Complex Cases
How to Treat HFPEF?
JAMA. 2008 Jul 23;300(4):431-3.
Co-Morbidities/Geriatric Syndromes
in Older Adults with Heart Failure
Condition Prevalence
Renal
Dysfunction
Assessment
Technique
Worsens symptoms,
•Cockroft-Gault
prognosis; exacerbated by
Formula
diuretics, ACE inhibitors and •MDRD Formula
ARBs.
Worsens symptoms;
•Pulmonary
prognosis; Contributes to
Function Tests
uncertainty about diagnosis,
exacerbates right heart
function
Dementia – 8.5%
Increases chance of non•MMSE
Cognitive impairment adherence with meds, diet
•Mini-Cog
Mild – 28%
and non-pharmacologic
Mod/Severe – 19% interventions.
16%- GFR < 30
mL/min
40% - GFR 30 to 59
mL/min
Chronic Lung 20% to 32%
Disease
Cognitive
Impairment
Potential
Consequences
Co-Morbidities/Geriatric Syndromes
in Older Adults with Heart Failure
Condition
Prevalence
Delirium
30-50% of
hospitalized
patients
36.8% (range, 0%
to 73.5% in post-op
patients
>70% in ICU
Depression
8-25%
Potential
Consequences
Prolong hospital stay,
increased chance of
long term care placement,
Increased mortality
Worsens prognosis;
exacerbates symptoms
and increases chance of
non-compliance
Assessment
Technique
•Seven digit
numbering
•Confusion
Assessment
Methodology
Geriatric Depression
Scale
Co-Morbidities/Geriatric Syndromes
in Older Adults with Heart Failure
Condition
Prevalence Potential
Consequences
Diabetes
30-50%
Falls, Mobility
Difficulties
30-50%
Worsens prognosis and
increases risk associated
with polypharmacy.
Increases risk of vascular
disease, dementia,
chronic renal dysfunction
and anemia.
Exacerbated by diuretics
and vasodilators, impairs
community mobility and
interferes with ability to
follow-up routinely
Assessment
Technique
•Blood glucose
•Glycosylated
hemoglobin
•Gait speed
•Timed get up and
Go
•Tinnetti Gait and
Balance Scale
Co-Morbidities/Geriatric Syndromes
in Older Adults with Heart Failure
Condition
Prevalence Potential
Consequences
Assessment
Technique
Postural/
Postprandial
Hypotension
Postural: 10-30% Worsened by diuretics,
Postprandial: 10- vasodilators
20%
•Orthostatic/
Postprandial BP
measurements
•Tilt table testing
•Complete Blood
Count
•Blood Volume
•Bladder diary
Anemia
Urinary
Incontinence
Inpatient: 70%
Outpatient: 1020%
Women > Men
35% and 22%,
respectively
Worsens symptoms,
increases risk of
hospitalization.
Aggravated by medical
therapy including diuretics,
ACE (secondary to cough
thereby worsening stress
incontinence)
Co-Morbidities/Geriatric Syndromes
in Older Adults with Heart Failure
Condition
Sensory
Impairments
Prevalence Potential
Consequences
Interferes with
compliance, increases
chance of medication
error
Anergia/Fatigue Mild to mode – 70% Worsens symptoms,
Severe – 20%
complicates diagnosis
Polypharmacy
24% - Ocular
disorders
-Almost all.
Increases risk of nonadherence, medication
interaction and adverse
drug reaction
Assessment
Technique
•Snellen eye chart
•Contrast Sensitivity
Testing
•Auditory evaluation
•Anergia scale
•Greater than 4
medications
Non-cardiac Dysfunction
Predicts Incident Heart Failure
Circulation. 2011;124:24-30.
Geriatric Syndromes and Outcomes
in Cardiovascular Disease
Diagnosis At Admission
Arrhythmia
Syncope
5%
Other
2%
11%
Heart
failure
46%
NonSTEMI
19%
STEMI
17%
n=211
82±5 years
Range 75-95 years
LOS 7±4 days
Heart. 2011 Oct;97(19):1602-6.
Geriatric Syndromes
• Functional Status/ADLs
• Cognitive Dysfunction
• Depression
• Frailty
Geriatric Syndromes and Outcomes
in Cardiovascular Disease
Heart. 2011 Oct;97(19):1602-6.
Geriatric Syndromes and Outcomes
in Cardiovascular Disease
J Am Coll Cardiol 2010;55:309–16
Unmet Needs:
Cardiovascular Syndromes in Older Adults
• An approach to assess “homeostenosis”, frailty or vulnerability to
adverse outcomes in older adults with cardiovascular disorders.
• A definition of resiliency that predicts who can tolerate invasive
interventions with meaningful benefit.
• Method to identify basic mechanisms underlying geriatric
cardiovascular syndromes that are targets for therapy, given
underlying multifactorial complexity.
• Are there shared risk factors for geriatric cardiovascular syndromes
(isolated SBP, HFPEF, syncope/falls/dizziness, atrial fibrillation)?
• Develop models that account for multiple pathways and potential
synergisms between pathways that underlie geriatric cardiovascular
syndromes.
Summary
• Embracing the inherent complexity in caring for
older adults with cardiovascular disease may be
facilitated by a move away from a “disease
based model” to a more complete paradigm
involving “syndromes”.
• Optimizing outcomes for older adults with
cardiovascular disease will require a
collaboration between disciplines capitalizing on
their respective expertise.
THANK YOU!!!
• Submit your unmet needs online!!
• Join the GNYGCC!!
• Collaborate!!
Geriatric Assessment:
Essential Part of Routine Clinical
Cardiovascular Care?
• “I don’t know what questions to ask.”
• “I have too little time.”
• “I am not paid to do it”
• “How do I interpret the information.”
• “What do I do if I find these problems?”
• “I am not trained to manage this.”
HFNEF: Embrace Complexity
J Am Geriatr Soc 55:780–791, 2007
Geriatric Cardiology:
New Paradigm of Care
1. Emphasize patient centered approach to care
2. Screen for co-existing geriatric syndromes
and co-morbidities
3. Purposefully manage pharmacologic regimen
4. Optimize care transitions
Focus of Geriatric Cardiology
• Continue to emphasize:
– State-of-the-art technological and medical expertise,
– Appropriate application of readily advancing technologies
• Promote skills needed to:
–
–
–
–
–
Assess patient preferences,
Circumvent hazards of hospitalization,
Facilitate successful transitions
Engage in useful risk-benefit discussions,
Provide care collaboratively within a care team
• Responsive to the needs of the oldest patients.