Cardiovascular Care for Older Adults (1)

A World Health Organizations (WHO) report stated that 76.2 million Nigerians are living with hypertension, which poses the highest cardiovascular disease burden. Cardiovascular diseases (CVD) are the leading cause of deaths globally. An estimated 17.9 million people died from cardiovascular diseases in 2019, of which 85 per cent were due to heart attacks and strokes. Eliminating trans-fat is seen as an easy way to reduce the numbers. According to the report it is estimated that 70% of people over 70 years old will develop CVD and that more than two thirds will also have associated non-cardiovascular comorbidities.

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. 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 multi-morbidities [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 patients overall health context, comorbid illness, functional status, life expectancy and personal preferences. Process of care is also particularly relevant to quality of care for older adults. Many older adults are burdened by sensory and/or cognitive limitations that limit their ability to hear, see, and/or understand their medical circumstances. Extra effort should be made to convey information in a manner that is accessible to each patient. Age-related changes impact the efficacy and complexity of providing standard CV therapies as well. Changes in pharmacokinetics, pharmacodynamics, metabolism, frailty and adverse events related to medications including increased prevalence of side effects (e.g., fatigue, changes in taste, dizziness, and depression) demand therapeutic approaches that are better attuned to each patient’s particular state and physiologic capacities.

The object of this review is to highlight the added complexity of managing CVD in an older adult population; specifically regarding key non-cardiac factors that affect health care delivery, management and outcomes including coexisting chronic comorbid conditions, geriatric syndromes (i.e., falls, visual and hearing impairment, delirium and cognitive impairment) and frailty. Key points:

Care of older adults should be designed to better respond to a broader perspective of patient-centered concerns, and target not only improved longevity, but improved function, independence, and quality of life;
Optimal care of older adults’ CVD requires consideration of pertinent non-CVD aspects of care that impact CVD progression and management;
Common problems which complicate CV management of older adults include comorbid diseases as well as issues related to aging, sensory changes (vision, hearing), frailty, falls, and dementia;
Activities of daily living (ADLs) and independent activities 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);
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; and
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.