Mat Maurer, MD Columbia University Medical Center

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

Seminar Series

Develop membership

Build enthusiasm

Educate

Build Camaraderie

Brainstorm Ideas

AIM # 2

Research

Innovative

Investigator Initiated

Multi-center

Multi-disciplinary

Leads to

GNYGCC Participating Sites

• New York University

• St. Luke’s Hospital

• Roosevelt Hospital

• SUNY Downstate

• Vanderbilt

• Yale University

• Woodhull

• Allen Hospital

• Columbia

• Weil Cornell

• Einstein/Montefiore

• Mount Sinai

• Maimonides

• University of Michigan

Objectives1. 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

Heterogeneous

Selective

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– A physiologic state of increased vulnerability to stressors that

results from decreased physiologic reserves causing homeostenosis.

• Disability– Difficulty or dependency in carrying out activities essential to

independent living (e.g. Loss of ADLs and IADLs).

60%8%

7%

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…at best out of date and at worst harmful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

Commission

Omission

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 CriteriaSpecific Criteria Prevalence

Recently not enough energy 46.4%

Felt slowed physically in month 41.8%

Sits around a lot for lack of energy 21.7%

Wakes up feeling tired 21.4%

Any slowness is worse in morning 19.5%

Doing less than usual in month 18.1%

Naps during the day (>2 hours) 8.9%


Severity of Anergia

30.9%

16.8%14.4%

10.4% 9.8%6.7%

2.2%0.3%

0%

10%

20%

30%

40%P

erce

ntag

e of

Sub

ject

s

0 1 2 3 4 5 6 7

Degrees of Anergia


Severity of Anergia

30.9%

16.8%14.4%

10.4% 9.8%6.7%

2.2%0.3%

0%

10%

20%

30%

40%P

erce

ntag

e of

Sub

ject

s

0 1 2 3 4 5 6 7

Degrees of Anergia

Mild

None

Severe


Anergia: Source of Presentation and Association with Somatic Symptoms and DiseaseParameter Odd’s RatioArthritis Arthritis/Rheumatism Joint pain, stiff or swelling Often takes meds for pain

2.38 (1.96-2.88) 3.39 (2.75-4.17)3.78 (2.83-5.05)

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)

Parameter Odd’s RatioMobility 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)

Anergia Is Associated with Mortality

Time Total No Anergia Anergia Odd’s Ratio

18 months

158 (8.1) 39 (5.9) 119 (9.2) 1.61

(1.11-2.35)

6 years

453 (23.2) 119 (18.1) 334 (25.9) 1.58

(1.25-2.00)

Anergia Is Associated with Health Service Utilizations

0%

5%

10%

15%

20%

25%

30%

Hospitalized ER visit Meals onwheels

Homecareservice

Perc

enta

ge o

f Sub

ject

s

No Anergia (%) Anergia (%)

0 1 2 3 4 5

# D

ays

Hop

sita

lized

Number of Days

No Anergia (%) Anergia (%)


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, self-rated 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 community-dwelling 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

JAMA. 1995;273:1348-1353

Falli

ng

Incontinence

Functional Dependence

Physical performance(arm and leg

strength)

Sensory Impairments

Affective Impairments

(Anxiety)

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

• 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

1 MMWR 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

Prevalence Variable High

Organ Focused Often Rarely

Mechanism(s) Single Multiple

Heterogeneity No Yes

Chief Complaint Represents Specific Pathologic Condition

Disconnect between Chief complaint and underlying pathology

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

Conditionat Index Discharge

30 day Re-hospitalization Rate (%)

Heart Failure 26.9

Pneumonia 20.1

COPD 22.6

Psychosis 24.6

GI Problems 19.2

N Engl J Med 2009;360:1418-28.

HFPEF: Effective therapy?

J Am Coll Cardiol 2011;57:1676–86

HFPEFHeterogeneous 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

Heart Failure and Geriatrics:More Common than Different

Heart Failure GeriatricsPatient population Generally older

adultsExclusively older adults

Disease vs. syndrome Syndrome Syndrome(s)

Multidisciplinary Yes Yes

Integrated/Tailored Management Yes Yes

Palliation Yes Yes

Complex Cases Definitely Definitely

So why don’t we collaborate anddevelop a new model of care

employing geriatric principles?

How to Treat HFPEF?

JAMA. 2008 Jul 23;300(4):431-3.

Condition PrevalencePotential Consequences

Assessment Technique

Renal Dysfunction

16%- GFR < 30 mL/min

40% - GFR 30 to 59 mL/min

Worsens symptoms, prognosis; exacerbated by diuretics, ACE inhibitors and ARBs.

•Cockroft-Gault Formula

•MDRD Formula

Chronic Lung Disease

20% to 32% Worsens symptoms; prognosis; Contributes to uncertainty about diagnosis, exacerbates right heart function

•Pulmonary Function Tests

Cognitive Impairment

Dementia – 8.5%Cognitive impairment Mild – 28% Mod/Severe – 19%

Increases chance of non-adherence with meds, diet and non-pharmacologic interventions.

•MMSE•Mini-Cog

Co-Morbidities/Geriatric Syndromes in Older Adults with Heart Failure

Condition PrevalencePotential Consequences


Delirium 30-50% of hospitalized

patients36.8% (range, 0% to 73.5% in post-op

patients>70% in ICU

Prolong hospital stay, increased chance oflong term care placement, Increased mortality

•Seven digit numbering•Confusion

Assessment Methodology

Depression 8-25% Worsens prognosis; exacerbates symptoms and increases chance of non-compliance

Geriatric Depression Scale


Condition Prevalence Potential Consequences


Diabetes 30-50% Worsens prognosis and increases risk associated with polypharmacy. Increases risk of vascular disease, dementia, chronic renal dysfunction and anemia.

•Blood glucose•Glycosylated hemoglobin

Falls, Mobility Difficulties

30-50% Exacerbated by diuretics and vasodilators, impairs community mobility and interferes with ability to follow-up routinely

•Gait speed•Timed get up and

Go•Tinnetti Gait and

Balance Scale




Postural/Postprandial Hypotension

Postural: 10-30%Postprandial: 10-

20%

Worsened by diuretics, vasodilators

•Orthostatic/Postprandial BP measurements

•Tilt table testingAnemia Inpatient: 70%

Outpatient: 10-20%

Worsens symptoms, increases risk of hospitalization.

•Complete Blood Count

•Blood VolumeUrinary Incontinence

Women > Men35% and 22%,

respectively

Aggravated by medical therapy including diuretics, ACE (secondary to cough thereby worsening stress incontinence)

•Bladder diary

Co-Morbidities/Geriatric Syndromes

in Older Adults with Heart Failure



Sensory Impairments

24% - Ocular disorders

Interferes with compliance, increases chance of medication error

•Snellen eye chart•Contrast Sensitivity

Testing•Auditory evaluation

Anergia/Fatigue Mild to mode – 70%Severe – 20%

Worsens symptoms, complicates diagnosis

•Anergia scale

Polypharmacy -Almost all. Increases risk of non-adherence, medication interaction and adverse drug reaction

•Greater than 4 medications


Non-cardiac Dysfunction Predicts Incident Heart Failure

Circulation. 2011;124:24-30.

Geriatric Syndromes and Outcomes in Cardiovascular Disease

Heart. 2011 Oct;97(19):1602-6.

Heart failure

46%

STEMI17%

Non-STEMI19%

Arrhythmia

11%

Syncope5%

Other 2%

Diagnosis At Admission

n=21182±5 years

Range 75-95 yearsLOS 7±4 days

Geriatric Syndromes•Functional Status/ADLs

•Cognitive Dysfunction

• Depression

• Frailty


Heart. 2011 Oct;97(19):1602-6.


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.

Mat Maurer, MD Columbia University Medical Center

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