Treating the whole patient essential for older people with cardiovascular disease

Geriatric conditions such as frailty and cognitive impairments may inadvertently worsen when older patients are treated in cardiac intensive care units - even as they receive excellent care for their heart attack, heart failure, valvular heart disease or pulmonary embolism, according to a new scientific statement from the American Heart Association, published today in the Association's premier journal Circulation.

In addition to their cardiovascular conditions, many older patients often have additional health conditions, take multiple medications for these conditions, may be frail or have cognitive impairment. Caring for older adults in the cardiac intensive care unit is markedly different than caring for younger patients, according to the statement, which provides an overview of how geriatric conditions may influence acute cardiovascular care.

Treating the whole patient - considering their entire health profile, rather than focusing only on their acute cardiovascular event - is essential for achieving the best possible outcomes among geriatric patients with acute cardiovascular disease."
Abdulla A. Damluji, M.D., M.P.H., chair of the writing group for the statement, assistant professor of medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland, and interventional cardiologist at the Inova Heart and Vascular Institute, Falls Church, Virginia

While in a cardiac intensive care unit, older patients often experience factors that are emotionally and physically disorienting - such as bright lights, excessive noise, new medications, urinary catheters, dietary shifts, sleep disruptions, and toileting challenges. "For vulnerable older adults who may already be experiencing cognitive decline, the environment in the cardiac intensive care unit may deplete already limited coping skills and could lead to delirium," said Damluji.

Delirium is a state of an acute disturbance in awareness and attention. It commonly occurs during critical illness, and it contributes to a higher risk of dying in the hospital. "Reducing the level of sedation used in older patients may help mitigate delirium, however, more research needs to be done to fully understand how best to treat this condition in the context of acute cardiovascular illness," said Damluji.

Extended bed rest, often necessary in an intensive care unit, is detrimental to patients of all ages. For older, critically ill patients, who are often frail when admitted to the cardiac intensive care unit, bedrest can significantly worsen their frailty. Further deterioration in muscle strength and bone density often occurs with prolonged immobility, which can also lead to poor medication tolerance, an increased risk of falling, weakened heart function and pressure ulcers (bed sores).

Early mobilization - getting the patient out of bed as soon as appropriate, may be helpful for some patients to address frailty. Encouraging appropriate physical movement may result in less weakness, an improved ability to walk and less time in the cardiac intensive care unit, among other benefits.

Another issue faced by older adults admitted to the cardiac intensive care unit is that they take an average of 12 different prescription medications, raising the risk of adverse side effects, drug-to-drug and drug-to-disease interactions. Patients may benefit by having some of their medications discontinued or deprescribed, if appropriate.

"In recent years, there has been a strong emphasis by the American Heart Association and other organizations to integrate geriatric syndromes into cardiovascular care for older patients, although the implementation is slow. Strategies to achieve a wholistic care approach for each patient remains an important goal to improve the care of older patients in the cardiac intensive care unit," said Damluji.

Most clinical trials on how to treat acute cardiovascular conditions were performed on younger populations, however, their findings may not be accurate for older patients. Yet, most people over age 85 years have cardiovascular disease and are likely to be admitted to a cardiac intensive care unit for treatment of an acute event, according to the statement.

American Heart Association

Journal reference:

Damluji, A.A., et al. (2019) 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. doi.org/10.1161/CIR.0000000000000741.