AHA Scientific Statement on Managing Elderly in Cardiac ICU

December 09, 2019

The American Heart Association issued a Scientific Statement on managing older patients in the cardiac intensive care unit (ICU).

"We have issued this statement now as the population is aging and patients in the cardiovascular intensive care unit are often older people with multiple comorbidities and geriatric syndromes, which complicate their management," Abdulla A. Damluji, MD, chair of the writing group for the statement, told Medscape Medical News.

"We cannot treat these older patients in the same way as we treat younger, stronger patients. If we just focus on their heart conditions and overlook all their other issues, we may not be serving these patients in the best way," Damluji said.

"So in this statement we are highlighting to cardiologists all the other problems that the geriatric population may experience while they are in the coronary care unit and making some recommendations on management strategies for these patients."

The statement was published online in Circulation on December 9.

Damluji, who is assistant professor of medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland, pointed out that current cardiovascular guidelines cannot be fully applied to older adults living with multiple complex geriatric conditions such frailty and cognitive decline.

"These guidelines have been formulated based on trials in younger individuals, and they can't always be automatically extrapolated to the elderly. We need to think very carefully about whether an elderly person with many complex issues really needs certain cardiovascular procedures or treatments," he said.

Cardiologists are not trained geriatricians and don't know how to measure or manage the symptoms of complex geriatric conditions, he added.

"With this statement, we are trying to raise awareness of that and bring the two fields together," he added. "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."

For vulnerable older adults who may already be experiencing cognitive decline, the environment in the cardiac ICU may deplete already limited coping skills and could lead to delirium, Damluji explained.

For example, they 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.

Delirium is a state of an acute disturbance in awareness and attention, which commonly occurs during critical illness, and contributes to a higher risk of dying in the hospital, the statement notes.

Recommendations

"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," Damluji commented.

The statement points out that extended bedrest, often necessary in an ICU, is detrimental to patients of all ages, but for older, critically ill patients who are often frail when admitted to the cardiac ICU, 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.

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

Another issue highlighted in the statement is that older adults admitted to the cardiac ICU take an average of 12 different prescription medications, raising the risk of adverse side effects, as well as drug-to-drug and drug-to-disease interactions. Patients may benefit by having some of their medications discontinued or deprescribed, if appropriate, the authors suggest.

The statement also recommends the use of reorientation devices that enhance environmental, acoustic, and visual cognitive stimulation such as a large clock, calendar, radio, television, and telephone to reduce the occurrence of delirium in the ICU. Reorientation measures also include using the patient's first name, and repeatedly giving information about where they are and what has happened. The use of hearing aids, glasses, and memory cues via family photographs can also be helpful.

Because oral energy intake may be low, the authors suggest that implementing a feeding plan with early introduction of parenteral nutrition may promote better energy balance.

"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 implementation is slow," said Damluji. "Strategies to achieve a holistic care approach for each patient remains an important goal to improve care of older patients in the cardiac intensive care unit."

Circulation. Published online December 9, 2019. Full text

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