1 / 60

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. AIM # 2. Research Innovative Investigator Initiated Multi-center

pearl
Download Presentation

Mat Maurer, MD Columbia University Medical Center

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Cardiovascular Syndromes in Older AdultsGreater New York Geriatric Cardiology Consortium October 18 and 19, 2011 Mat Maurer, MD Columbia University Medical Center

  2. Disclosures None

  3. Goals of GNYGCC AIM #1 AIM # 2 Research Innovative Investigator Initiated Multi-center Multi-disciplinary Seminar Series Develop membership Build enthusiasm Educate Build Camaraderie Brainstorm Ideas Leads to

  4. 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

  5. Objectives • Define disability, frailty and co-morbidity • Enumerate criteria for defining “geriatric syndromes” • Understand the added value added for Geriatric Cardiology in moving away from a “disease based model” to a more complex paradigm involving syndromes. • Delineate common “geriatric cardiovascular syndromes” and identify shared risk factors among “geriatric syndromes” • Highlight the prevalence of “geriatric syndromes” in older adults with cardiovascular disease and their independent association with outcomes.

  6. Homeostenosis Heterogeneous Selective An Aging Society:Important Tenants for Clinical Care • Aging: • A process of gradual and spontaneous change, resulting in maturation. • To acquire a desirable quality by standing undisturbed for some time • To bring to a state fit for use or to maturity

  7. Co-Morbidity, Frailty and Disability • Co-morbidity • Concurrent presence of two or more medically diagnosed diseases in the same individual

  8. Multiple, Chronic and Therefore -Multifactorial

  9. 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). 8% 60% 7%

  10. 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.

  11. Geriatric Cardiology: A delicate balance Omission Commission

  12. 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."

  13. What constitutes a Geriatric Syndrome? • High Frequency (e.g.>10%) • Particularly frail older adults • Chronic/intermittent conditions • Not isolated episodes • Triggered by acute insults • Associated with functional decline

  14. 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

  15. Common Geriatric Syndromes • Falls/Syncope • Delirium • Dizziness • Urinary Incontinence • Pressure Ulcers • Dementia • Weak Bones • Visual difficulties • Auditory difficulties • Weight loss • Sleep disorders

  16. 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

  17. Specific CriteriaPrevalence 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% Anergia Criteria The Journals of Gerontology; Medical Sciences: 2008; 63A, 707-714

  18. Severity of Anergia The Journals of Gerontology; Medical Sciences: 2008; 63A, 707-714

  19. Mild Severe Severity of Anergia None The Journals of Gerontology; Medical Sciences: 2008; 63A, 707-714

  20. Anergia: Source of Presentation and Association with Somatic Symptoms and Disease

  21. Anergia Is Associated with Mortality

  22. Anergia Is Associated with Health Service Utilizations The Journals of Gerontology; Medical Sciences: 2008; 63A, 707-714

  23. Factors Associated with Anergia: Multivariate Analyses *The adjusted confounders included age, gender, married status, education, income, self-rated health, physical function, social function, somatic symptoms, medications, co-existing diseases

  24. Anergia: A New Geriatric Syndrome? • 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. • 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

  25. Anergia: A New Geriatric Syndrome? • 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.

  26. Geriatric Syndromes: Shared Risk Factors Physical performance (arm and leg strength) Incontinence Falling Sensory Impairments Affective Impairments (Anxiety) Functional Dependence JAMA. 1995;273:1348-1353

  27. 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, 3N Engl J Med. 1997;337(18):1279-84.

  28. 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

  29. Changes in Models of Care Am J Med. 2004;116:179 –185

  30. A New Model of Care for Older Adults with Cardiovascular Disease J Am Coll Cardiol. 2011;57(18):1801-10.

  31. HFPEF: Disease or Syndrome?

  32. 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

  33. 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.

  34. 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.

  35. Trends in Heart Failure N Engl J Med. 2006 Jul 20;355(3):251-9

  36. Re-hospitalization:Heart Failure Leading the List N Engl J Med 2009;360:1418-28.

  37. HFPEF: Effective therapy? J Am Coll Cardiol 2011;57:1676–86

  38. HFPEF: Effective therapy? J Am Coll Cardiol 2011;57:1676–86

  39. HFPEF: Effective therapy? J Am Coll Cardiol 2011;57:1676–86

  40. 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.

  41. HFPEF: Embrace Complexity

  42. Heart Failure and Geriatrics:More Common than Different So why don’t we collaborate and develop a new model of care employing geriatric principles?

  43. How to Treat HFPEF? JAMA. 2008 Jul 23;300(4):431-3.

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

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

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

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

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

  49. Non-cardiac Dysfunction Predicts Incident Heart Failure Circulation. 2011;124:24-30.

  50. Geriatric Syndromes and Outcomes in Cardiovascular Disease Geriatric Syndromes • Functional Status/ADLs • Cognitive Dysfunction • Depression • Frailty Heart. 2011 Oct;97(19):1602-6.

More Related