Treating Older Adults Beyond Their Cardiovascular Illness: A Holistic Approach to Management

Jun 25, 2021   |  Abdulla Damluji, MD, PHD, FACC; Ashok Krishnaswami, MBBS, FACC

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Quick Takes

  • In the United States and the developed world, the prevalence coexisting geriatric syndromes among older adults with cardiovascular disease has increased over the past decades.
  • Older patients with these conditions are being routinely evaluated on a daily basis by cardiologists in contemporary cardiovascular practice.
  • Understanding geriatric syndromes and their integration into daily cardiovascular care is essential.
  • The landmark REHAB-HF trial showed that an early, transitional, tailored, and progressive rehabilitation intervention resulted in a significant improvement in physical function domains, frailty status, quality of life, and depression scales, when compared to usual care.
  • A holistic approach to management in older adults with cardiovascular disease is critical and should include an evaluation and a tailored treatment plan to prevent, reverse, or slow down the progression of geriatric syndromes.

Demographic Shift of the United States Population

The aging of the United States (US) population is changing the population demographics at a rapid pace. In 2019, adults ≥65 year of age represented 16.5% of the US population. It is projected that this estimate will increase to 20.3% by 2030.1 At this pace, the number of older adults will surpass children by 2050.

What Does That Mean to the Cardiovascular Practice?

An increasing number of patients presenting with cardiovascular illness are older adults who are living with complex clinical conditions that do not fit into one disease category, collectively known as geriatric syndromes.2 These include frailty, physical and functional decline, multimorbidity, polypharmacy, delirium, cognitive impairment, and dementia.

The presence of these conditions can influence cardiovascular disease recovery. Similarly, cardiovascular illnesses can in turn worsen geriatric syndromes exacerbating instability. While the American College of Cardiology and the American Heart Association have emphasized the importance of these conditions as they relate to the management of cardiovascular illness, their integration into daily practice has lagged. This is related to a lack of efficacious interventions to address these conditions in clinical practice.

The Evidence is Emerging!

The REHAB-HF trial enrolled older adults hospitalized with heart failure and showed that the influence of an early, transitional, tailored, and progressive rehabilitation intervention resulted in a significant improvement in geriatric syndromes including physical function, frailty status, quality of life, and depression scale, when compared to usual care.3

Advancement in cardiovascular care were traditionally focused on preventing major adverse cardiovascular outcomes including death, rehospitalization, ischemic and safety events. The REHAB-HF trial has extended these outcomes to improve the overall health and wellbeing of the older adult population and emphasized the importance of a holistic approach to cardiovascular care in clinical practice. Moreover, it is particularly encouraging to view geriatric syndromes as possible reversible risk factors. This could be applicable when a targeted intervention is applied early during an acute cardiovascular illness.

The Future is Bright!

The REHAB-HF trial was not only important for older adults with heart failure, but it sets the stage for subsequent investigations evaluating patients with other forms of cardiovascular disease including coronary artery disease, valvular heart disease, arrhythmias, or surgical populations. More evidence to consolidate geriatric and cardiovascular care is needed to improve the overall health of a rapidly expanding sector of the US population and worldwide.

References

  1. Current Population Survey, Annual Social and Economic; Table 1: Population by Age and Sex: 2019 (US Census Bureau website). 2019. Available at: http://census.gov/data/tables/2019/demo/age-and-sex/2019-older-population.html. Accessed 06/11/2021.
  2. Damluji AA, Forman DE, van Diepen S, et al. Older adults in the cardiac intensive care unit: factoring geriatric syndromes in the management, prognosis, and process of care: a scientific statement from the American Heart Association. Circulation 2020;141:e6-e32.
  3. Kitzman DW, Whellan DJ, Duncan P, et al. Physical rehabilitation for older patients hospitalized for heart failure. N Engl J Med 2021;May 16:[Epub ahead of print].

Clinical Topics: Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Sleep Apnea

Keywords: Geriatrics, ACC Annual Scientific Session, ACC21, Quality of Life, American Heart Association, Cardiovascular Diseases, Polypharmacy, Coronary Artery Disease, Heart Failure, Cardiovascular System, Aging, Arrhythmias, Cardiac, Risk Factors, Heart Valve Diseases, Dementia, Delirium, Aged


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