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Cardiovascular Disorders in the Adult and Geriatric Patient Essay
This week you have learned about common cardiovascular disorders in the Adult and Geriatric patient. For the purpose of this discussion select one of the following cardiovascular disorders and provide the following in your initial post: Cardiovascular Disorders in the Adult and Geriatric Patient Essay
Common Signs and smptoms seen
Screening assessment tools
Recommended diagnostic tests (if any)
Treatment plans both pharmacologic and non-pharmacologic based on current clinical practice guidelines
Demographics of Aging
Western society is aging. In 1900 only 4% of people in the USA were over 65 years old. By 2000 the proportion
had risen to14%, and by 2020 it is predicted that more than 20% will be over 65 years old(1). In Ontario it is
estimated that the number of individuals over 65 years old will double in the next 20 years. Currently 11% of
the over 60 years olds are over 80. However it is forecast that in the next 50 years 20% of the total population
will be over 80 and the number of centenarians will increase 15 fold. Associated with the marked increase in the
elderly population is an increase in life expectancy. Today a 65 year old man can expect to live 14.9 – 18.9
years, whereas the average 80 year old will survive an additional 7-9 years(2). Canadian women who are 60
years old have a 50% chance of surviving until age 80. However males aged 60 have a lower (38-48%) chance
of living until age 80 as a result of the earlier impact of atherosclerosis and its subsequent cardiovascular
complications. Cardiovascular Disorders in the Adult and Geriatric Patient Essay
Heart Disease: a disease of elderly people.
Cardiovascular disease is the leading cause of death today (36%), of which over half is attributable to ischemic
heart disease. Ischemic heart disease, congestive heart failure, and atrial fibrillation are the three most common
cardiac disorders encountered in an elderly population. Hospitalization rates for ischemic heart disease are fourfold more frequent in patients 75-84 years old, as compared to a 45-54 year old group (Hospital morbidity
database, Canadian Institute for Health Information). Congestive heart failure is very much more frequent in the
elderly, with 85% of patients with heart failure being older than 65 years(3). The prevalence of atrial fibrillation
increases 3 fold in those aged >80 compared to patients < 65 years old (ref). Heart disease has a greater impact
on the elderly than in a younger population. Mortality is greater (despite adjustment for a wide range of
variables), and a multitude of complications are more likely to result in greater morbidity and a consequent
decline in the quality of life. The impact of cardiovascular disease is compounded by reduced homeostatic
reserves, increased co-morbidity, the frequent need for polypharmacy, and complex societal issues such as
social deprivation, and devaluation of the aged. Despite the worse prognosis, the benefits of treatment are often
enhanced in an elderly population. For many elderly patients, heart disease has been their first serious medical
problem. Yet there is an attitude to link the elderly patient to disability, a deteriorating quality of life and
consider them to be less deserving of aggressive medical treatment. The impact of an aging society on patient
care resources is illustrated in Chapter 2.
Aging and the Cardiovascular System
Normal age related changes in the cardiovascular system are distinguished from age related pathology (eg
atherosclerosis) that theoretically should be preventable. Age related changes in the heart result in a progressive
loss of cardiac myocytes, hypertrophy of the remaining cells, increased accumulation of connective tissue, and
in the very old the deposition of amyloid (4). Although systolic function is usually maintained, early diastolic
function declines with age(5) resulting in higher left ventricular filling pressures at rest and during exercise, and
a greater dependence upon atrial contraction to maintain adequate diastolic filling(6). A profound reduction of
cells in the sino-atrial node and increase in fibrosis in the inter-nodal tracts and conduction system is seen with
aging even in the absence of ischemic heart disease(7). An attenuated heart rate response to stress, including
exercise and fever is observed with aging(8). Increased fibrosis and calcification of the aortic and mitral valves
if sufficiently severe may result in valvular obstruction and incompetence. A reduction of the cushioning
properties of the arterial system results from increased collagen deposition, and a loss of elastic fibres in both
central and peripheral arteries(9). This causes a widening of the arterial pulse pressure, and an increase in
systolic arterial pressure.
There is frequently an interaction between age related pathology and normal biological aging processes in the
cardiovascular system. Consequently aging modifies the clinical presentation, the response to treatment and
outcomes, such that observations from clinical trials in a younger population might not apply in the very old.
Definitions of “ Elderly” Cardiovascular Disorders in the Adult and Geriatric Patient Essay
The consensus conference needed to define what is meant by an elderly population. That the term can be used
in several ways and means different things to different people, is an indication that there is considerable
heterogeneity in an older population. Practically, there are two useful ways to characterize elderly people – on
the basis of their relative fitness and frailty, and by chronological age(10-13). Assessment of fitness and frailty
can be made rapidly using indices such as shown in table 1, and is a practical guide to clinical decision-making
in the individual patient. Chronological age, by contrast, is not a useful clinical guide in individual patients,
with an unacceptably low sensitivity and specificity. Yet chronological age is a reasonable guide to the
proportion of individuals who are relatively fit or frail, and provides information useful for population planning.
Although chronological age is currently the only characterization of outcomes in relationship to aging for
epidemiological and clinical trials, there is a serious lack of evidence for the old-old patients above the age of
75 to 80. As the interaction between natural aging and age related disease is greatest in this population it may
not be possible to extrapolate the results of clinical trials determined in younger populations. Importantly, this is
the group where the benefit of many treatments is least clear. Furthermore the old-old are the group with the
greatest increase in utilization and demand for health care resources.
The elderly population is not a homogeneous risk group, with a wide range of frailty and fitness for each
chronological age range. The chief drivers of risk in elderly people are the number of co-morbid conditions, the
extent of cognitive impairment, the degree of functional disability, and the degree of social support. Relative
fitness and frailty is much more valuable than chronological age in determining the risk for adverse
outcomes(12;14). Data from the Canadian Study of Health and Aging shows that a brief clinical measure which
includes information about exercise, cognition and function in activities of daily living (Table 1) classifies
relative fitness and frailty and relates to short and long term outcomes.(15;16). Whilst these principles apply to
a general elderly population, there is no data currently available to show how they relate specifically to elderly
cardiovascular patients. Furthermore there are no studies or guidelines which include an assessment of frailty
and fitness in decision making algorithms for any cardiological management. Yet there is need to make
decisions which take into account relative fitness and frailty, and until better data becomes available, the use of
a fitness / frailty scale such as in Table 1 may be a less arbitrary way than clinical judgment alone.
The consensus conference documents have examined the available evidence for older populations (> 65 years
old) in both epidemiological studies and clinical trials. Where possible, data has been separated to examine
outcomes in younger (65-75 years) and older (> 75-80 years) populations. Although such sub-group analyses
are clearly not conclusive, in the absence of studies directly examining the elderly, they are the only available
evidence today. Cardiovascular Disorders in the Adult and Geriatric Patient Essay
Treatment Goals in Elderly Patients
Treatment goals in elderly patients may have different priorities compared to those in younger individuals.
Improved quality of life clearly must be the first priority, with enhanced survival a secondary goal whenever
possible. Many therapeutic strategies today aim to improve survival but have little effect on the quality of life.
Examples include HMG co-reductase inhibitors (statins) for hypercholesterolemia, clopidogrel / ASA following
an acute coronary syndrome, implantable automatic defibrillators for ventricular dysfunction, and coronary
bypass surgery for three vessel coronary disease and left ventricular dysfunction (in the absence of limiting
angina). Other treatments are principally aimed at improving survival, but also may improve quality of life if
they prevent progression of the disease process eg: thrombolysis for acute ST segment elevation myocardial
infarction, and angiotensin converting enzyme inhibitors for heart failure. Selection of treatment strategies in
the elderly patient should take into account their impact on quality of life. Many treatments used to improve
survival may have a greater potential adverse impact on the quality of life in the elderly patient compared to
younger individuals, due to differences in drug metabolism and adverse events, drug interactions, wound
healing, poor tolerance of surgical procedures, and impaired cognitive and psycho-social interactions.
For many old people there are worse outcomes than dying. Stroke dementia and the loss of independent living
are justifiably feared. Unfortunately the anti-thrombotic, thrombolytic treatments as well as cardiac surgery, are
associated with an increase in neurological complications with advancing age. Informed consent for treatments
in the elderly person should include realistic estimates for the risk of non fatal complications especially stroke
and important cognitive dysfunction.
Although most elderly patients are candidates for therapeutic strategies that can improve survival, it would be
useful to assess the potential gain in life expectancy achievable. Currently there are few guidelines available to
estimate the benefit in months or years of quality life saved by a treatment strategy in the individual patient.
Boersma et al devised a simple tool to estimate the gain in life expectancy from thrombolysis(17). The model
used patient age, time of treatment, estimated infarct size, history of prior infarction, and intra-cranial bleed risk
to calculate the increase in life expectancy from thrombolysis. Although there are clear limitations from such
analysis it does show that there is a very wide range of benefit from thrombolysis varying from increased 2
years survival in a 55 year old patient with an extensive infarction treated within three hours of symptom onset
to no increase in life expectancy in the 75 year old patient with no high risk feature, other than age, (no prior
infarction, anterior infarction, inferior infarction with RV involvement, heart failure and bundle branch block),
presenting at 6-12 hours after symptom onset. Although similar tools could be developed for other treatments, it
would be also be useful to incorporate frailty indices into the decision model. Cardiovascular Disorders in the Adult and Geriatric Patient Essay
Consensus Conference Goals
The Canadian Cardiovascular Consensus Conference for 2002 has brought together a wide range of experts to
examine issues of the elderly patient with heart disease which impact both on the individual and on society. It is
recognized that heart disease in the elderly is of immense concern to health care providers and payers. The
growth of the elderly population, the high prevalence of heart disease, the limited evidence for treatment
benefit, the disproportionate use of resources and the increasing cost of treatment heightens the need for an
assessment of heart disease in the elderly population.
The Consensus Conference aims to examine the magnitude of the problem of heart disease in an elderly
population today and make projections for the future. The choice of topics, selected by the conference chairman
and discussed by the primary panel, aims to target issues that are more likely encountered in an older patient
group. It is not an all-inclusive discussion of cardiology. Consequently there are subjects, which have few
specific problems in an elderly population or are sufficiently uncommon as not to require inclusion.
Hypertension, although a major cardiovascular disease in the elderly, was not included as a specific topic in this
conference, as the Canadian Hypertension Society have recently addressed the issues of hypertension and the
older patient (ref). Cardiovascular Disorders in the Adult and Geriatric Patient Essay
The subject matter and the recommendations of the consensus conference are directed towards a wide range of
health professionals including physicians (including cardiologists, internists, geriatricians and family
practitioners), nurses, and allied health workers (eg physiotherapists, pharmacists, dieticians, occupational
therapists, and social workers). Consequently the primary and secondary includes cardiologists, geriatricians,
family practitioners, epidemiologists, and pharmacists.
The recommendations of the consensus conference will be available as an executive summary, which will assist
in the dissemination of the recommendations. Other tools which will be developed to facilitate implementation
of the recommendations include: Consensus Conference slide show, Guideline Review and implementation
courses, a Continuing Professional Development (CPD) Consensus Conference Web site, Patient education
information, drug interaction check lists and links to other relevant web sites.
Levels of Recommendation and Evidence
The grading for levels of recommendation and evidence are those used by the American Heart Association and
American College of Cardiology (Table 2).
Limitations of Consensus Recommendations
Support for the recommendations is frequently limited by a lack of clinical trials to provide direct evidence.
Trials often include patients in their mid 60’s in good health. Clinical trials rarely include the old-old >75-80
years old, who have more frailty, limited mobility, increased co-morbidity and are at risk from drug interactions
consequent to the poly-pharmacy required to manage their multiple medical problems. Not only might the
efficacy of treatment differ in the elderly, but also serious complications such as hypotension and hemorrhage
are more likely. Unfortunately clinical trials are usually funded by the pharmaceutical industry that might have
disincentives to study populations with high mortalities and adverse outcomes, as these complicate and increase
the expense of the study. Consequently it is unlikely that trials will be specifically directed at the elderly
population. Hopefully future clinical trials in the management of heart disease will include the old-old as well as
Table 1: Clinical Assessment of Fitness and Frailty
Grade Description Characteristics Cardiovascular Disorders in the Adult and Geriatric Patient Essay
1. Most fit Moderate-high exercise
2. Fit Low level exercise
3. Sedentary well Includes treated co-morbid disease
4. Isolated incontinence Chiefly isolated urinary incontinence
5. Mildly frail Minimal cognitive impairment or
impairment in complex care.
6. Moderately frail Intermediate self-care
dependence or mild dementia
7. Severely frail Dependence in personal care
More than mild dementia
Table 2: Levels of Recommendation of the Guidelines (ACC/AHA Format)
Class 1: Conditions for which there is evidence and / or general agreement that a given procedure / therapy is
useful and effective
Class II: Conditions for which there is conflicting evidence and / or a divergence of opinion about the usefulness /
efficacy of performing the procedure / therapy.
Class IIa: Weight of evidence/opinion is in favour of usefulness/efficacy.
Class IIb: Usefulness/efficacy is less well established by evidence/opinion.
Class III Conditions for which there is evidence and/or general agreement that a procedure/therapy is not
useful/effective and in some cases may be harmful.
These recommendations are based upon the following levels of evidence:
Level A: The data were derived from multiple randomized clinical trials.
Level B The data were derived from single randomized or non randomized studies.
Level C: When the consensus opinion of experts was the primary source of recommendation. Cardiovascular Disorders in the Adult and Geriatric Patient Essay