A Focus on the Heart for Older Patients

The first geriatric cardiology clinic in New York opened at N.Y.U. Langone Medical Center in August. It’s different.

For starters, an older patient’s first visit with cardiologist Dr. John A. Dodson, the program’s director, takes a full hour. Beyond taking a complete history, Dr. Dodson looks for frailty by measuring things like gait and grip strength and administers a short test of cognitive ability – things geriatricians routinely do and cardiologists mostly don’t.

“The No. 1 difference is time,” he told me in an interview. “To be able to spend an hour with a new patient is a gift.”

In January, when a pharmacist joins the program, Dr. Dodson will start asking patients to bring in all their prescription drug bottles for review. “They may be taking redundant medications or the wrong medications,” he explained. “Where we can, we will peel away what’s not essential.”

The conversation expands to include less medical topics, too: the patient’s goals, the extent of family support, end-of-life preferences.

The N.Y.U. program is one of only a handful of geriatric cardiology programs that have sprouted up around the country, including the first (so far as we know) at Vanderbilt University Medical Center, in 2012, and a similar program at the University of Pittsburgh Medical Center. More are likely to follow.

At Vanderbilt, “I talk about living wills and health care proxies and why they’re important,” said Dr. Susan Bell, a cardiologist and geriatrician the clinic director. “Is this the person who wants quality of life or the person who wants to push for longevity as much as possible?”

This is mostly common sense – treating an individual, rather than an organ – but it is particularly crucial for older adults.

Dr. Dodson’s patients at N.Y.U. are mostly in their 80s; the oldest is 96. Whatever has gone wrong with their cardiovascular systems, they are usually also coping with several other chronic conditions and disabilities, from diabetes to hearing loss. They take a raft of drugs. They may not cope well with procedures and regimens effective for younger patients.

Medically, age is not just a number. We grasp this when it comes to children. Because they aren’t merely smaller adults, pediatrics has spawned multiple sub-specialties: pediatric cardiologists, neurologists, hematologist/oncologists. We understand that children respond differently to drugs and surgical procedures.

That is true for old people too – but geriatrics has only one recognized sub-specialty, geriatric psychiatry. So most medical specialists who take care of 40-year-olds also see growing numbers of 80-year-olds as the population ages, and often treat them similarly despite their differences.

Adopting a geriatric approach to cardiology seems particularly sensible. Cardiovascular disease remains America’s number one cause of death and illness, Dr. Bell pointed out, and “age is overwhelmingly one of the risk factors.” The majority of cardiology patients are already seniors.

“Cardiologists are trained to treat everybody the same – use the evidence, go by the guidelines,” Dr. Dodson said. “But if I have someone who’s 85 and he’s fallen three times in the last month and is too impaired to remember what drugs he’s taking – that’s a different patient.”

Though Dr. Dodson is only following 25 patients so far in his new Wednesday-afternoon clinic, he predicts more centers will open across the country, along with fundamental change: “In 10 years, it’s going to be commonplace to have geriatric hepatologists and geriatric endocrinologists.”

His own research, conducted with colleagues at Yale where he trained, points out the pitfalls of medicine that is not adapted for older patients. The study involved a cognitive test (something cardiologists aren’t trained to do) administered to 282 older adults (mean age: 80) who had been hospitalized with heart failure.

Nearly half were cognitively impaired, the tests revealed: About 25 percent had mild impairment and 22 percent moderate to severe impairment. “It’s so common and so often unrecognized,” Dr. Dodson said. Indeed, when the researchers reviewed these patients’ hospital discharge summaries, fewer than a quarter contained any documentation of their cognitive status.

Those with undocumented cognitive impairment had a 53 percent higher likelihood of being readmitted to the hospital or dying within six months, compared with those without impairment. Yet when discharge records did include patients’ cognitive impairment, there was no significant difference in re-admissions or mortality.

Treating heart failure, a demanding task, involves considerable self-care including multiple drugs, so it figures that cognitive problems could interfere. “We expect people to weigh themselves every day, to follow a low-salt diet, to take all these medications and to come in every few weeks,” Dr. Dodson said.

If their doctors knew that memory and other cognitive issues would hinder that, they could prescribe simpler drug regimens, devise clearer discharge instructions, prescribe programs to build strength and reduce falls, enlist the help of family caregivers or home health services. They might even make house calls — Dr. Bell does this at Vanderbilt. But doctors can’t tailor their approaches if they don’t notice the problem.

Over the next few years, these neophyte geriatric cardiology clinics will compile data and attempt to demonstrate that they provide superior care. But they may also find another benefit, one that in our current climate will ensure that they spread beyond academic medical centers.

The way health care providers get compensated is changing; Medicare has already begun penalizing revolving-door hospitals. “If you can prove that geriatric cardiology clinics reduces 30-day re-admissions,” Dr. Dodson said, “everyone’s going to have one.”

Click here to see the original article on the New York Times website.