Cardiac Disease in the Elderly Population

The Management of Chronic Ischemic Heart Disease in the Elderly

Despite advances in medical and surgical therapy, ischemic heart disease remains the most important cause of death and disability in an ever growing population. The management of elderly patients with ischemic heart disease is made more difficult by the presence of comorbid medical conditions, which can both further aggravate ischemic heart disease and interfere with pharmacological and interventional therapy. Despite the difficulties in the management of ischemic heart disease in the elderly, there is substantial evidence that older patients can benefit greatly from aggressive, rational treatment of this condition and, therefore, such treatment should not be denied solely on the grounds of age. (c) 2000 by CVRR, Inc.

Benzodiazepine exposure and functional status in older people

OBJECTIVE

To determine the association between benzodiazepine exposure and functional status in older patients.

DESIGN

A nonexperimental, observational study design.

SETTING

Kaiser Permanente, Northwest Division, a health maintenance organization (HMO) providing prepaid, comprehensive inpatient and outpatient care for more than 410,000 persons.

PATIENTS

Patients were the 4192 Social HMO Project members 65 years of age and older, enrolled for 1 full year, who returned their annual health status survey during 1990.

MEASUREMENTS

Functional status was measured using self-reported activities of daily living and instrumental activities of daily living. Predictor variables were self-reported medical conditions and benzodiazepine exposure during the previous 12 months.

RESULTS

Age, gender, and living status were associated with functional status. Severe memory loss, stroke, Parkinson's disease, circulation problems, lung problems, hip fracture, urinary problems, arthritis, heart trouble, diabetes, stomach/bowel problems, and cancer were associated independently with functional status. Persons exposed to a benzodiazepine scored lower on the functional status measure. Benzodiazepine exposure added significantly to the prediction of functional status after controlling for patients' socio-demographic characteristics and medical conditions.

CONCLUSIONS

Age and medical conditions were the most significant predictors of functional status. Benzodiazepine exposure was associated with functional status to the same extent as several chronic medical conditions. When prescribing benzodiazepines for older people, caution should be taken to minimize the possibility of iatrogenic-functional limitations.

Aging and atherosclerosis in human and nonhuman primates

Atherosclerosis is a major age-related process and public health problem and its clinical manifestations (coronary heart disease [CHD] and cerebrovascular disease) continue to be responsible for approximately 50% of all deaths occurring annually. In addition, CHD is responsible for over 70 to 80% of deaths among men and women over 65 years old. As our population ages (35 million people over the age of 65 in the U.S. by the year 2030) and because of the increased morbidity and mortality associated with atherosclerosis, an understanding of the role of aging in the development of atherosclerosis is needed. Multiple risk factors such as smoking, gender, hypertension, and lipids contribute to the development of atherosclerosis. However, these risk factors in combination explain only about half of the individual variability in incidence of CHD, and it has been hypothesized that age-related conditions may play a role. To propectively evaluate the effects of age per se on atherosclerosis progression in humans would require observation over many years. Thus, animal models that are representative of both aging processes and atherosclerosis would be extremely valuable. As such, nonhuman primates have been used extensively in atherosclerosis research. However, studies that will specifically evaluate the role of aging per se in contributing to development of atherosclerosis in nonhuman primates have only recently been initiated. In this review, the contribution of nonhuman primates to atherosclerosis research will be discussed, as will the development of atherosclerosis in both human and nonhuman primates. In addition, a role for age-related conditions in atherosclerosis development in both human and nonhuman primates will be outlined.

Characterization of older adults who attribute functional decrements to "old age"

OBJECTIVE

Understanding the contributors to physical disability in older adults is an important component of the national health objective of expanding disability-free life by the year 2000. The purpose of this study was to determine the frequency with which older adults attribute their difficulty performing a number of common daily tasks to "old age" and to identify specific conditions and diseases associated with this attribution. Finally we sought to determine the characteristics that might differentiate persons able to attribute their disability to specific conditions from those who cite old age as the etiology of their disability.

DESIGN

A cross-sectional, observational, study.

SETTING

The Johns Hopkins Functional Status Laboratory.

PARTICIPANTS

Two hundred thirty community-dwelling volunteers 60 years of age and older who could stand unassisted for > or = 1 minute and who were without cognitive impairment.

MEASUREMENTS

A 1-day evaluation included physical performance evaluations, both performance-based and self-reported function for 27 tasks, and self-report of physician-diagnosed diseases. Those with difficulty in a task and those who denied difficulty but had changed the method of task performance (modification) because of an underlying health or physical condition were identified and asked to name the cause of their difficulty or task modification; options were specific diseases/medical conditions or "old age." The prevalence of "old age" citation as a cause of functional limitation, as well as its associated characteristics and medical conditions, was determined.

MAIN RESULTS

Twenty percent of the 230 participants cited "old age" as the cause of their disability in two or more tasks. Tasks for which difficulty was most frequently attributed to "old age" were dressing oneself (31%), walking around the home (25%), walking 1/2 mile (5-6 blocks) (25%), cutting toenails (16%), getting in or out of a bed or chair or out a car (14% each), and ascending/descending stairs (13%). Significantly higher levels of arthritis, heart disease, and hearing loss were reported in persons attributing their disability to "old age" than in those not reporting "old age" as the cause of their disability. We found no differences in age, gender, race, education, or cognitive status for the two groups. However, individuals citing "old age" as the cause of functional decrements walked more slowly than those who cited a specific disease.

CONCLUSIONS

These data suggest that a significant proportion of functional decline attributed to "aging" in older adults may be associated with specific conditions. Identifying and reducing the impact of these conditions may prove to be a useful approach to preventing or minimizing functional loss.

Cardiovascular disease in elderly patients

OBJECTIVE

To provide an overview of the cardiovascular consequences of the normal aging process in humans and to review unique aspects of the diagnosis and management of heart disease in the elderly population.

DESIGN

We reviewed relevant published articles and summarized the diagnostic approaches and treatment recommendations for congestive heart failure, coronary artery disease, cardiac valvular disease, and arrhythmias in elderly patients.

RESULTS

The aging process is associated with predictable anatomic and physiologic alterations in the cardiovascular system. consequently, the manifestations of heart disease in the geriatric population differ from those found in younger patients. Additionally, outcomes of cardiac diseases and therapeutic options change with advancing age because of such factors as alterations in drug metabolism.

CONCLUSION

Age-related changes in the cardiovascular system result from intrinsic cardiac aspects of human senescence, primary cardiac disease, and influence of comorbid conditions on the heart. The natural history of heart disease is generally adversely affected by age. Although many treatment strategies with demonstrated efficacy in younger patients are relevant in the elderly age-group, careful attention to the influence of concomitant illness, the unique physiologic and pharmacologic changes, and the assessment of the potential effect of therapy on survival and quality of life is essential in treating elderly patients.

Resuscitation of the geriatric patient

The elderly represent the fastest-growing segment of the population. As the country ages, the number of elderly patients who present in extremis will undoubtedly increase. Emergency physicians must be cognizant of the fact that age alone is a poor predictor of outcome in the critically ill elderly patient. Premorbid status, including previous level of functioning and pre-existing disease, is more important than chronologic age in predicting outcome, guiding assessment, and deciding on therapy. Knowledge and consideration of the geriatric ABCs includes a fundamental understanding that loss of protective airway reflexes, occult respiratory insufficiency, and clinically unrecognized shock are especially prevalent in the sickest geriatric patients. Early recognition and treatment can minimize morbidity and mortality rates in the ED.