Dr. John A. Dodson discusses specific management considerations for treating geriatric patients with heart failure and arrhythmia.
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Welcome back everyone gives me great pleasure to introduce my good friend Dr john Dodson who is the director of the geriatric cardiology program at N. Y. U. In um new york city. Um john and I were co fellows to our cardiology fellowship and I went into heart failure and john was this master. He was always uh with statistics and public health and research and um spent um sometime with Dr Harlan Krumholz. Oh at Yale doing more outcomes research and then went to the Brigham. Um spent time up in boston did more research and then um came back to um and then joined the N. Y. U. And heading their geometric cardiology program with I don't know how he does both spend a lot of time clinically taking care of patients and has multiple grants and research projects ongoing as well in terms of uh um uh Really focusing on the elderly patients who happens to have heart disease as well. And how best did you what is right for the patient and finding that balance between delivering delivering therapies and keeping patients um interests and goals of care. # one. So thank you john thanks again for taking the time this morning and look forward to learning from you. Well. Thanks a J. For that introduction. And as a. J. Mentioned we go back about 10 years now so I appreciate the opportunity. I wish it was in person. But nonetheless um I'm I'm excited to be able to to talk about geriatric considerations in the management of heart failure arrhythmias. And um I have no disclosures for this talk. Here's an overview. I'm going to start with a brief summary of the field of geriatric cardiology. Just just very um you know, kind of high level overview of what we do. And then I wanted to talk about specific management considerations in terms of both heart failure and arrhythmias and try to keep this as clinically focused as possible. So in terms of the field of geriatric cardiology, here's the reason I think that this field is so important. So um what I've shown R. U. S. Census projections for the next several decades and as we can see, we had um 5.5 million people over age 85 2010. And this is expected to more than triple by 2050 where we'll have 18 million americans over the age of 85. Uh This is also the pattern in other developed countries. And so we're gonna be seeing a lot more older patients in our everyday practice regardless of of our specialty. And we know that our older patients are fundamentally different. So they have a combination of things, one of which are these geriatric syndromes and these are defined as um uh conditions that are not related to a single disease entity but are common in older patients. In addition to these syndromes, we also have more traditional comorbidities and many of our patients that make management more complicated, including chronic kidney disease, COPD and cancer, all of which may make treatment more challenging. So here's some examples of geriatric syndromes. Frailty is a term that's heard a lot. This uh formally is defined as an increased physiologic vulnerability, distress occurs. There are many ways to define frailty, some of which I'll mention later in the talk. Uh cognitive impairment is another syndrome. This uh involves impairment in any domain of normal brain functions such as memory, and then disability is the inability to perform activities of daily living that are necessary for normal life, such as bathing, dressing or feeding. The japanese have one of the oldest populations in the world. And they've been looking at this for a long time back in 2013, they published this in Jack looking at the association between gait speed and risk of cardiovascular events After Mark cardio infarction. Gait speed is a simple walking test and has been used as a straightforward assessment of the frailty syndrome. What they found in this population of people hospitalized with them, I was that people who walked slowly shown in red had the highest rate of cardiovascular events at follow up, um, compared with those who walked either in the middle or fastest turtle. And this remained significant after adjusting for other, more traditional risk factors. Here's an example from our own work on the Association of frailty within hospital bleeding among older adults with myocardial infarction. This was from a registry called Action, which is coordinated through the American College of Cardiology. This was an electronic health record um, uh, genotype for frailty. And our outcome was in hospital bleeding, which was captured as part of the registry. What we found here was interesting. So, overall frail patients shown in the lightest blue were more likely to experience in hospital bleeding uh, compared with patients with no frailty shown in dark blue. And then when we look at subgroups, the subgroup of people undergoing cardiac catheterization were those who really had more bleeding. So over twice the risk if you're frail of bleeding, if you undergo cardiac catheterization and you know, again, the field of geriatric cardiology has worked to kind of, you know, I think first define risk and then now look at interventions that might reverse some of these syndromes. And that's a very brief overview. But what we're trying to do is measure and incorporate these assessments into practice. So I wanted to move on to specific conditions that are relevant to this conference, the first of which is heart failure. And there are two topics that I thought were relevant to older heart failure patients. The first is this issue of cognitive impairment and heart failure and the outcome of hospital readmission. And then the second is the question of frailty and left ventricular assist device implantation. But I wanted to take a step back here and note that these geriatric cardiology, these geriatric syndromes that I mentioned are common in patients with heart failure, but not only in the older subset of heart failure patients. And the reason for this is that there are shared pathways between advanced disease, uh, and the biology of aging and shared uh, conditions such as inflammation, muscle wasting. Our scene in younger heart failure patients as well. But it's similar to what you see in older patients. So there are shared pathways that are the topic of active investigation. Looking at cognitive impairment. The prevalence varies widely, so between 25 and 75 of patients with heart failure have cognitive impairment, and this depends on the sample studied. It involves many domains such as memory, attention and executive control. And importantly, this is not just an age-related issue. If you look at patients with heart failure and age matched controls, people with heart failure are significantly more likely to have cognitive impairment present. There are multiple mechanisms that can account for cognitive impairment. The most commonly cited is decreased cerebral profusion um certainly with systolic heart failure, this makes sense not as much with diastolic heart failure, but nonetheless, the hypothesis is that because of decreased brain profusion over the long term there's neuronal dysfunction and cell death. There are other mechanisms also postulated including sleep disturbance, thrombosis, embolism and inflammation, leading to an increased likelihood of cognitive impairment and its associated with hospital readmission as well as other outcomes. But readmission comes up again and again in the literature and the proposed mechanism here is through poor self care. So we expect a lot of our heart failure patients, we expect them to take multiple medications on a daily basis. They have dietary guidance. They have to do things like way themselves daily. They have to make medical appointments with multiple specialists and it's plausible that cognitive impairment could interfere with any of these. For example, somebody forgetting to take their diuretic or taking double the dose of a medication that they weren't supposed to, where they may forget to attend their medical appointments altogether. Dr Aron Gordievsky, who now directs the heart failure program at Case Western, was formerly at Cleveland Clinic, has done a lot of work in uh cognitive impairment and has used an instrument called the Mini Cog, which is a simple cognitive assessment. It takes less than five minutes and it involves a three item recall task as well as a clock drawing exercise. In this paper here, which was published in cirque heart failure. He studied over 700 patients hospitalized for heart failure at the Cleveland clinic and they all had the mini cog administered. This is an example of what the mini cog looks like in terms of the clock drawing exercise, The two clocks at the top are normal. In the two clocks at the bottom are abnormal. And when they analyzed readmission at six months, it was actually a composite of readmission immortality. What they found was that patients with cognitive impairment shown in red had a much higher likelihood of hospital readmission or death compared with patients who had normal cognition has shown in black. Now, while this was a composite endpoint, the overwhelming number of events were due to hospital readmissions. And this has been shown in other studies as well. So I think the cognitive impairment is important to recognize. I do want to acknowledge it's difficult to manage. There's no cure for this condition per se. But it's interesting to note. And I have two references here that in patients with systolic heart failure, this actually may improve after transplant or left ventricular assist device implantation, which supports the hypothesis of decreased cerebral perfusion. So in some patients is reversible. I also wanted to mention that I do this in my own practice. So my clinic is almost exclusively people over 70 years of age and I'll do the mini cog. This is an example of one of my patients abnormal clock drawing exercises. It's amazing what you can find when you look. And we have a memory center here where I'll refer patients for formal evaluation which includes memory testing and some sort of neural imaging. Um So my my role in this is to serve as a screening uh point of care and then to refer them for further evaluation if clinically necessary. We'll now move on to frailty. So this is estimated to be present in 30-50 of all patients with heart failure. It's more common in patients with advanced systolic dysfunction and its associated with multiple poor outcomes including poor quality of life, hospitalization and death. One interesting study on frailty that that's relevant to this talk is frailty and left ventricular assist device implantation. Uh This paper is from a consortium of heart failure centers in New york city and they looked at whether L VOD implantation could reverse the frailty phenotype. So they enrolled 19 patients. This is a difficult study to enroll for it because they needed older patients who are undergoing LVAD implantation and they measured fail to using what are called the free criteria. These are as close to a gold standard as we have. They're probably the most often cited, but also um some of the more labor intensive in terms of frailty assessments, there are five things you need to do for the freed assessment. Uh This includes asking people about weight loss. You need a £10 weight loss, self reported exhaustion and low physical activity, which are based on questionnaires, slow gait speed, based on a walking test and weak grip strength. And if somebody has three out of five of these present, then they're classified as frail. What they found in this study was that frailty was present in all patients at baseline. This is actually not the norm for heart failure samples. It's usually not 100 in this population. It was again they had advanced this delic dysfunction And they found that tenant of 19 were still frail at six months despite the correction of systolic dysfunction. And the implication here is that L. VAD can reverse frailty in some older patients but um not all older patients. And this supports the hypothesis here. This was Kelsey flint And colleagues published about 10 years ago and what they postulated was that there was elevated responsive frailty shown in dark gray and elevate independent frailty shown in light gray. And the idea is that patient a for example has frailty. That is mostly due to systolic dysfunction. If you correct that with an L. VOD that frailty will almost disappear. Whereas another patient in light grey patients see has frailty that's mostly because of other factors. So for example age cancer neurological disease and if you correct the systolic dysfunction uh they still won't become unframed. And so this is an active area of research and I think we still haven't figured out exactly which older patients will become unfree laughter. Elevate implantation. We'll now move on to your with mia. And uh the arrhythmia topics that I wanted to highlight. Number one is atrial fibrillation, oral anti coagulation and the question of frailty and falls in older patients. And then the second is I. C. D. Deactivation at the end of life. So in terms of a film and oral anticoagulants, we know that anticoagulants are often not prescribed for patients age 75. And older studies show that 30 to 60% of those eligible for anti coagulation don't receive it. This is even lower at the extreme age. Uh so people over age 85 as well as those who have the frailty syndrome present. Uh concerns raised among clinicians are bleeding. So either spontaneous bleeding, like gi bleeding or trauma related from falls, as well as medical futility. For example, in people who have advanced dementia, it's a difficult question because we know that frailty predicts poor outcomes in patients with atrial fibrillation, as well as other cardiovascular conditions. A lot of my work has been in acute myocardial infarction. Uh, frail patients do worse. It's the same with atrial fibrillation. This was from a registry in Switzerland and they had a large group of patients with atrial fibrillation and they looked at outcomes when frailty was present versus what they termed pre frail and and non frail and what's shown at the bottom of this figure. So frail patients shown in the darkest line are more likely to experience bleeding, but also they're more likely to experience strokes. And so they're at higher risk of both outcomes, which makes management particularly difficult. We did some of this work ourselves in terms of um the question of falls now frailty and Falls are related, but Falls are a distinct syndrome in that frail patients are more likely to fall, but other people fall for osteoarthritis, Parkinson's disease, they aren't necessarily frail, so frail patients are more likely to bleed, they're more likely to fall. Uh And the question that comes up a lot is, you know, whether my particular patient is going to fall on experience traumatic intracranial hemorrhage, This came up a lot in the literature when we were planning this study, which I've shown here, we published this five years ago in Jama cardiology and what we were interested in looking at was the incidents and determinants of traumatic intracranial bleeding among older patients receiving warfarin. So this was an inception cohort people prescribed warfarin who had not been on Warfarin previously and then we followed them forward linking via data with Medicare data. So we had complete capture of events. What we found in this study was that The rate of traumatic intracranial bleeding after warfarin initiation was 0.5 at one year and 2.1 at three years. And so one in 50 patients at three years experience traumatic intracranial bleeding on warfarin. And this was not a very high percentage, but still obviously greater than zero. And I think underscores what we've seen clinically in some of our older patients where they do have these traumatic events and have intracranial bleeding on anti coagulation. I think one of the most interesting pieces of this study was that we looked at the chads vascular and whether or not it correlated with traumatic intracranial bleeding and it turns out that it didn't. So uh if you look at the traumatic intracranial bleeding uh incidents rate in light blue, uh there was very little correlation between chad's vast and traumatic intracranial bleeding. Whereas for ischemic stroke in dark blue as you would expect, the rate of ischemic stroke went up with increasing chad's vascular. Again, all these people were prescribed warfarin based on the way that we define the cohort and we did look at factors that predicted traumatic intracranial bleeding. There were several um I think the two most interesting. We're number one dementia predicted this outcome and number two lay by a in our so we had access to v. A. Lab data and those who had label A. And R. Had a higher rate of traumatic intracranial bleeding. Of course the guidelines have now moved to recommend direct oral anticoagulants as first line therapy. Uh In patients with atrial fibrillation with the exception of mitral stenosis that is moderate or greater or mechanical heart valve. And this is because they've shown similar or better efficacy as well as a better safety profile uh than warfarin. And so in my own practice I prescribed direct oral anticoagulants almost exclusively. Uh even with older patients with the exception of people who have a mechanical valve. We also have the option now of per cutaneous occlusion of the left atrial appendage with the Watchman device based on the trials that were done. Um I have referred patients for this procedure. My typical patient who goes for watchman is somebody with a condition that has a very high propensity to fall. That would be somebody with Parkinson's disease. For example who's following multiple times. We know based on the course of Parkinson's that they'll fall again. Um In my experience a lot of people tolerate directoral anticoagulants just fine. Uh So um I do refer patients but there's a lot of heterogeneity and some people are more apt to refer than others in terms of this procedure. I think another thing worth noting is that the guidelines state that in patients with a fib anticoagulant therapy should be individualized on the basis of shared decision making after discussion of the absolute risks and relative risks of stroke and bleeding as well as the patient's values and preferences. And as we saw older patients are at higher risk for both stroke and bleeding. And so these discussions are I think especially important in that population. I will now move on to the final topic which is I. C. D. Deactivation. So there are approximately 150,000 I. C. D. S implanted per year in the U. S. Uh They've been shown by multiple trials to prevent sudden cardiac death in selected patients and they are approved for both primary and secondary prevention. About half of patients receive a shock at some point during their lifetime. But some patients with terminal illnesses receive shocks within the final weeks of life. Um This has been studied by several people. Um uh The largest study that I'm aware of to date uh looked at um I cd shocks uh in the period close to death in a cohort of patients in. Um I think this was um Sweden where it's required that all sides are ex planted at the time of death. And so they were able to analyze the programming of these ICDs and patients with terminal illness. What they found in this sample was at 65 of these patients with kids had to do not resuscitate order. However there are 42 out of 65 who had an I. C. D. That was active within the last 24 hours of life patients with terminal illness. And 10 out of 42 of these patients received an I. C. D. Shock. Um And so this was uh you know obviously in a terminal patient these shocks are futile and could potentially prolonged suffering. Uh And um you know despite this these patients had received those shocks. The guidelines actually recommend that at the time of I. C. D. Implantation or replacement patients should be informed that their shock therapy can be deactivated if consistent with their goals of care and also in patients with refractory symptoms or nearing the end of life from other illnesses that this discussion should take place. I think 11 interesting article that's come out recently is trying to take the onus off the individual clinician and coming up with a systems based approach to advocate for deactivation in terminal patients to avoid these painful and unnecessary shocks, as was published in Jama Internal medicine within the past year. And what they said in this paper was that given that lifetime death rates remain at 100%, nearly every I see that gets implanted will become an end of life I. c. d. therefore the need to discuss. I see deactivation is high at some point during the life course. What they advocated for was a system where at multiple time points people were prompted to have these discussions. So for example, at the time of initial implant changing risk resuscitation status, if that's put in the electronic health record, discharge to hospice or any new illness with a life expectancy of less than one year. So essentially you could have the electronic health record helped prompt you to have these discussions. And again, it's not that necessarily patients or clinicians don't want to do this, but sometimes people aren't aware where there's a certain inertia and these conversations are not taking place. So one final word on geriatric cardiology in practice. And so it's uh sometimes challenging to figure out how to um uh develop what we've come up with and and have it be used in general practice. And so a lot of my work recently has been in in the health technology space and uh, we actually came up with an app for geriatric assessment. It's called jerry kit. Um, the rationale behind this is that some of the assessments I mentioned like the mini cog even though they seem straightforward um people often don't know exactly what they consist of. They might be looking it up on google search and trying to print it out or you know figure this out in the midst of a busy clinical work day. So we actually came up with an app. I was a little surprised nobody had done this. Um uh but nonetheless um what we did with the help of a program called M. Star which is funded by the National Institutes of Health was developed an app for one stop geriatric screening. We have instruments for cognition, depression activity, lower extremity strength fall history. We have an advanced care planning module which I think is relevant in terms of the I. C. D. Deactivation issue that I just discussed. It was initially designed with trainees in mind so students, residents and fellows but any practicing clinician can download this. Uh We're not trying to monetize this. Uh It's free on the app store because we thought it was just important to give people the tools to take care of older patients. Um for any of you who have an iphone. Uh if you take a picture of this it will take you to the app store and you can download jerry kit and use it in your practice. Uh We have an android version that is currently under development and uh we will roll out in the next several months. Um And again that the tool is free to use and if any of you use it in your practice I love to hear your feedback because it's relatively new. So that is the end of my talk. I'm happy to take any questions either now or later. Could you share how you use um the jury kit uh in your clinic like for clinical practice outside of um just research? Yeah. Yeah. So you know it's it's interesting because um when I when I initially came into this field I thought we should kind of screen all older patients for these syndromes. But I think what I do now is if there's a clinical suspicion, so if somebody tells me or you know I I asked him about memory, have you been having any memory problems and um if they are then that will prompt using jerry kit and using the cognitive assessment on jerry kit? Um What what's nice about the the app is that it's modular. So you don't have to use all of the um programs but you can use cognition which takes um you know it takes three minutes uh you know, to complete and then at the end you get the reference and you get the scoring. So you don't have to do the program almost thinks for you in terms of scoring it for you, but you obviously have to use it in a patient. So if there's a if there's a clinical concern uh then I'll use a tool from the app but you don't need to do a full assessment and everyone because there's a wide range of function in our older patients which you know, which we all know taking care of these people. I see a question in the chat box for dr dots and in older patients with a f what would the stroke rate be for these people without anti coagulation? In the past, the stroke grade was far higher than the intracranial hemorrhage rate. And that's the weight of evidence falls on anti coagulating folks, even in the high risk group um is how I approach my practice. I discussed with family risks and benefits, but given their risk benefit, um I tend to anti coagulate them, I might know if someone is truly demented and non cognizant of their surroundings, I might not anti coagulate them. So probably, yeah, I think, I think this gets at the, you know, the tension between kind of, you know, doing doing research studies, trying to define the absolute risks and benefits. Um what when, you know, kind of the guidelines tell us, you know, we should anti quickly people who are high risk and so, you know, for example, in our study veterans, um we know the rate of traumatic intracranial hemorrhage on warfarin. It's it's 2% after, after, you know, several years, we don't know what would have happened off warfarin because it's it's nearly impossible to come up with a match cohort. I mean, people have tried in terms of using propensity scoring. Um but you can never do randomized study in that area. So, you know, again, my general practice with older people is uh to use the directoral anticoagulant. Um with certain exceptions, one is somebody who is very high propensity to fall and has had a catastrophic big bleeding event. Watchman is also an option. And then in somebody with advanced dementia. I think there's an important conversation about medical futility and goals of care, which is in the guidelines. And so I think it's perfectly reasonable not to anticoagulants. Somebody in that situation because of the do no harm principle and that's that's totally appropriate. And um, you know, geriatric cardiology is very individualized in terms of our care and we try to follow the guidelines, but every patient is very different. Great, thank you. Thanks john, thanks for taking the time
