Risk Stratification in Elderly Coronary Artery Disease Patients: Can We Predict Which Seniors Benefit Most from Revascularization Options?

With the increased global burden of an aging population manifesting cardiovascular disease, the decision process for use of coronary revascularization options in older adults has gained attention. Assessment of physiologic status has greater bearing than chronologic age; items that have proven of particular merit in evaluating comorbidities as they relate to treatment prognosis for both PCI and CABG in older adults include EuroSCORE and frailty scoring. Evaluation of neurocognitive function can uncover the presence and severity of all-cause dementia, which may be missed in simple medical history interaction. These data have significance when considering aggressive coronary artery disease treatments in this population for symptomatic and/or survival benefit, particularly when high priority is placed on quality of life and independent living post-treatment. Recovery after procedural intervention is slower and with increased morbidity in older adults. Older adults tend to have more complex coronary artery disease; for some, the risk/benefit of revascularization may be prohibitive. Proper selection by the cardiac team for appropriateness of treatment options for each patient’s circumstances can result in excellent percutaneous coronary intervention and coronary artery bypass graft revascularization outcomes, even in the older adult.     

The clinical care of frail, older adults

Frailty and its management represent an emerging area of clinical care in older adults. Geriatricians have long recognized a syndrome of multiple comorbid conditions, immobility, weakness, and poor tolerance of physiologic stressors in older adults. Patients with these characteristics are described as frail and suffer increased adverse clinical outcomes. This article reviews the clinical spectrum of frailty in older adults, its biologic etiology, and potential clinical interventions. Several operational definitions of frailty and the associated clinical signs, symptoms, and outcomes are outlined. The biologic mechanisms hypothesized to underlie frailty are explored, particularly in the musculoskeletal, endocrine, and immune systems. Treatment options for frail, older adults are discussed, including physiologic system-targeted interventions and geriatric models of care.     

Infectious diseases in the elderly

As the percent of our population over age 65 increases, infectious disease in this group is becoming a serious public health concern. Much of our knowledge of infections in the elderly is based on clinical experience and lacks a firm scientific foundation. The increased risk of infections observed with aging may be due to physiologic changes that accompany "normal" aging or the age-associated chronic diseases and the medical, surgical, and diagnostic interventions that accompany them. Epidemiologic studies on populations of well and hospitalized older persons in defined age ranges are needed to examine the relation between specific infectious diseases and risk factors. Although the increased susceptibility of older persons to infectious diseases frequently has been attributed to the decline in immune function that occurs with aging, there are very few data confirming this hypothesis. Additional research is clearly needed on other contributory factors such as nutrition, ciliary transport, bacterial adherence, neutrophil and macrophage function, and complement.     

Gambling behavior and problems among older adults: a systematic review of empirical studies

Objectives. With the rapid aging of the population and the increased availability of gambling facilities over the past three decades, older adults may gamble more and may be increasingly at risk for problem gambling (PG) or pathological gambling disorder (PGD). To facilitate a better understanding of gambling behavior among older adults that will inform preventive strategies, this article systematically examined empirical studies on issues related to older adults' gambling. Method. This article reviewed 75 empirical studies including data on the distribution and determinants of PG and PGD and the outcomes of gambling. RESULTS: This review used the broad term of "disordered gambling" as a means to explain a continuum of problems caused by PG and PGD. The analyses covered seven topics concerning older adults' gambling behaviors: Participation rates for gambling, prevalence rates of disordered gambling, motivation for initially beginning to gamble, risk and protective factors for disordered gambling, and negative and positive health outcomes from gambling. Discussion. Based on research gaps identified in the review, this article proposes six recommendations for future studies focusing on well-being of older adults who gamble, research method issues, and taking into account older adults' inspirations and adjustment to the aging process in the 21st century.     

Failing to Focus on Healthy Aging: A Frailty of Our Discipline?

The academic geriatrics community has provided outstanding leadership in addressing frailty and complexity in older adults, but a minority of older adults are frail. Although resources to treat older adults are limited, and it is appropriate to focus clinical efforts on those with frailty and multimorbidity, there is also important expertise that can be brought to bear on the health of ALL older adults. A review of the literature suggests that attention to healthy or successful aging has failed to keep pace with the focus on frailty. By providing leadership to promote successful aging, the quality of life of older adults across the spectrum can be improved and transitions to frailty reduced. The template that leaders have established in understanding frailty—defining and operationalizing it, understanding outcomes, identifying pathophysiology—can be used as an approach to successful aging. Several community‐based programs have been successful in promoting successful aging. These are potentially highly scalable and could have a substantial effect on the aging population, but their essential components need to be better understood. The geriatrics community is uniquely positioned to take on this role. This is a critical time to work together to make the lives of all older adults as healthy and fulfilling as possible.     

Clin-Star corner: What's new at the interface of geriatrics,infectious diseases,and antimicrobial stewardship

Antibiotics are among the leading causes of adverse drug events in older adults. Short-course antibiotic therapy has been shown to work as well as the traditional longer durations for many types of infections. Antibiotic stewardship interventions including deprescribing strategies have shown a reduction in patient readmissions and mortality among older adults. We identified practice-changing clinical trials focusing on three major domains of overprescribing antibiotics in older adults – community-acquired pneumonia, urinary tract infections, and gram-negative bacteremia. The selected articles underscore the safety and effectiveness of shorter durations of antibiotic treatment for infections in older adults, thus highlighting an opportunity for deprescribing in the aging population. By optimizing antibiotic use, we stand to reduce adverse events and enhance overall health outcomes in older adults.     

Hypertension in older adults: Assessment,management, and challenges

Hypertension in older adults is related to adverse cardiovascular outcomes, such as heart failure, stroke, myocardial infarction, and death. The global burden of hypertension is increasing due to an aging population and increasing prevalence of obesity, and is estimated to affect one third of the world's population by 2025. Adverse outcomes in older adults are compounded by mechanical hemodynamic changes, arterial stiffness, neurohormonal and autonomic dysregulation, and declining renal function. This review highlights the current evidence and summarizes recent guidelines on hypertension, pertaining to older adults. Management strategies for hypertension in older adults must consider the degree of frailty, increasingly complex medical comorbidities, and psycho-social factors, and must therefore be individualized. Non-pharmacological lifestyle interventions should be encouraged to mitigate the risk of developing hypertension, and as an adjunctive therapy to reduce the need for medications. Pharmacological therapy with diuretics, renin-angiotensin system blockers, and calcium channel blockers have all shown benefit on cardiovascular outcomes in older patients. Given the economic and public health burden of hypertension in the United States and globally, it is critical to address lifestyle modifications in younger generations to prevent hypertension with age.     

Breathlessness in older adults: What we know and what we still need to know

Breathlessness is common among older adults, but it is often hidden as “normal aging “or considered narrowly as a symptom of cardio-respiratory diseases. Studies on breathlessness in older adults are mostly focused on specific diseases, whereas older adults are characterized by multimorbidity and multi-system age-related impairments. This article aims to provide an overview of what is known so far on breathlessness in the general population of older adults and identify areas for further research. Research shows that breathlessness in older adults is a multifactorial geriatric condition, crossing the borders of system-based impairments and diseases, and a valuable independent prognostic indicator for adverse outcomes. Further research needs to investigate (1) the multi-factorial mechanisms of breathlessness in community-dwelling older adults including the role of respiratory sarcopenia; (2) the influence of affective and cognitive changes of older age on the perception and report of breathlessness; (3) the best way to assess and use breathlessness for risk prediction of adverse outcomes in general geriatric assessments; and (4) the most appropriate multi-modal rehabilitation interventions and their outcomes. Clinicians need to shift their approach to dyspnea from a disease symptom to a multifactorial geriatric condition that should be proactively searched for, as it identifies higher risk for adverse outcomes, and can be addressed with evidence-based interventions that can improve the quality of life and may reduce the risk of adverse outcomes in older adults.     

Frailty and chronic diseases in older adults

There are two hallmarks of aging that must be considered primary concerns when trying to improve health for older adults: frailty and chronic diseases. Some pathologic mechanisms related to diseases may help to explain frailty. This article describes known associations among frailty and chronic diseases and introduces punished inefficiency as an explanatory framework for frailty. Punished inefficiency proposes that having several physiologic impairments leads to physiologic inefficiencies. These inefficiencies may become manifest as frailty, often in the presence of disease. Therefore, frail older adults perform less external work because they must spend more on an absolute scale out of a smaller pool of internal resources. Stress imposed on frail older adults strengthens this negative feedback to activity, leading to disuse. This article discusses how people with frailty and chronic diseases may experience a malignant course and thereby intends to improve the ability to identify beneficial biologic and health care delivery strategies for older adults with, or at risk of, frailty.     

Era of geriatric medical challenges: Multimorbidity among older patients

The number of older adults is increasing worldwide, including in Asian countries. Various problems associated with medical care for older adults are being highlighted in aging societies. As the number of chronic diseases increases with age, older adults are more likely to have multiple chronic diseases simultaneously (multimorbidity). Multimorbidity results in poor health‐related outcomes, leading to increased use and cost of healthcare. Above all, it leads to deterioration in older adults’ quality of life. However, it is unclear whether any medical interventions are effective for multimorbidity, which means medical practitioners currently offer medical care “in the dark.” It is therefore necessary for researchers and medical professionals involved in geriatric medicine to establish ways to manage multimorbidity among older adults. This means that the development of research in this field is essential. Geriatr Gerontol Int 2019; 19: 699–704 .     

Autologous transplantation in elderly patients with multiple myeloma: are we asking the right questions?

Multiple myeloma is a disease of the elderly. Survival outcomes remain unacceptably low in older adults with multiple myeloma. To date, no obvious difference in tumor biology has been elucidated to explain the survival disparity between older and younger patients. Multiple factors including comorbidity, performance status, decreased physiologic reserve and potentially undertreatment contribute to poor outcomes in elderly patients with multiple myeloma. High-dose chemotherapy with autologous stem cell transplantation (ASCT) is increasingly being used to treat elderly patients with multiple myeloma in an effort to improve survival outcomes. Recent case comparison studies, and preliminary transplant registry data suggest that selected older patients can be treated with high-dose chemotherapy effectively with similar toxicity and survival benefits compared to younger patients. Traditional upper age limits for autologous transplantation are being challenged along with the definition of 'elderly' itself. Ultimately, the role of high-dose chemotherapy with stem cell rescue in the upfront treatment of older adults with multiple myeloma can only be established by prospective randomized trials. In the process of designing studies to investigate the use of ASCT in older patients, multiple issues unique to the elderly population will need to be considered. First, it will be critical to develop and validate patient selection algorithms that incorporate measures of comorbidity, cognitive function, physiologic reserve and psychosocial function to identify patients most likely to tolerate and benefit from ASCT. Second, preparative and conditioning regimens will need to be further tailored to maximize the benefit to risk ratio. Finally, outcome measures in clinical trials should include disability and quality of life measures, which may be equally important in making treatment decisions for older patients. The future application and study of autologous transplantation in older patients with multiple myeloma provides a unique opportunity to challenge ageism and serve as a model for development of tailored assessments and interventions in this population.     

Addressing the aging crisis in U.S. criminal justice health care

The U.S. criminal justice population is aging at a significantly more rapid rate than the overall U.S. population, with the population of older adults in prison having more than tripled since 1990. This increase is at the root of a prison healthcare crisis that is spilling into communities and public healthcare systems because nearly 95% of prisoners are eventually released. The graying prison population is also straining state and local budgets. In prison, older prisoners cost approximately three times as much as younger prisoners to incarcerate, largely because of healthcare costs. In the community, older former prisoners present the least risk of recidivism yet are vulnerable to serious and costly social and medical challenges such as housing instability, poor employability, multiple chronic health conditions, and health-related mortality; however older current and former prisoners are largely ignored in the current geriatrics evidence base. Knowledge about the health, functional, and cognitive status of older prisoners is limited, with even less known about risk factors for long-term poor health outcomes during and after incarceration. This article provides an overview of aging in the criminal justice system. It then describes how geriatric models of care could be adapted to address the mounting older prisoner healthcare crisis and identifies areas where additional research is needed to explore prison-specific models of care for older adults.     

Are cognitive researchers ignoring their senses? The problem of sensory deficit in cognitive aging research

Sensory impairments are common in older adult populations and have notable impacts on aging outcomes. Relationships between sensory and cognitive functions have been clearly established, though the mechanisms underlying those relationships are not fully understood. Given the growing burden of dementia, older adults with sensory deficits are an important and growing population to study in cognitive aging research. Yet, cognitive research sometimes excludes those with uncorrected significant/severe sensory deficits and often poorly or inconsistently assesses those deficits. Observational and interventional studies that exclude participants with sensory deficits will be limited in their generalizability to the narrower subset of the older adult population without vision or hearing impairment and may be missing an opportunity to study a growing population of older adults at higher risk of cognitive impairment. Strategies exist for adapting cognitive testing instruments, and inroads could be made into collecting normative data to inform ongoing research. Bringing together psychometricians with researchers who specialize in vision and hearing impairments could launch highly innovative research on both measurement methods and cognitive disease etiology, as sensory organs provide readily accessible neuronal and vascular beds that may show pathology earlier and elucidate innovative screening opportunities for early signs of cognitive disease.     

Identification of normal aging and disease-related processes by health care professionals.

A 40-item quiz on aging was given to 46 health care professionals, before they participated in a workshop dealing with the care of the elderly patient. In the quiz, they were asked to identify physiologic and functional conditions either as normal aging processes or disease-related processes. In general the results indicated that disease processes were the easier entities to identify, and that the workshop experience enhanced this effect. Ability to identify functional disorders correctly did not differ significantly from the ability to identify physiologic symptoms correctly. Implications for the general health and the mental health of older adults are discussed.     

Obstructive Sleep Apnea in the Elderly: Extent of the Problem and Therapeutic Options

Obstructive Sleep Apnea (OSA) is an underdiagnosed and potentially serious disorder that is more common but less well characterized in older adults than in the middle-aged. With aging, anatomic and physiologic changes to the upper airway make it prone to collapse. Except in female nursing home residents and older adults with excessive daytime sleepiness, there is no association between OSA and mortality in the elderly. In comparison to the middle-aged, cardiovascular consequences also are substantially attenuated in the elderly; however, the limited existing evidence supports a relationship between OSA and arrhythmia, heart failure, stroke, and cognitive dysfunction. Currently, the diagnosis of clinically significant OSA in the elderly is similar to that of the general population. Special care to a patient’s physical and cognitive impairments is critical to consider when administering CPAP, oral appliances, and surgery in older adults.     

Aging in Southeast and East Asia: Issues and Policy Directions

Population aging is unique in Asia given the speed at which it is occurring and the immense social and economic changes that the region is experiencing at the same time. Compared to their Western counterparts, Asian governments have much less time to prepare for population aging. Asian countries that have traditionally relied on family-based support for older family members are worried that increased numbers of older adults may stress these family systems. At the same time, information concerning the effectiveness of formal programs for older adults is scarce. This paper reviews current research on informal support versus formal support of older adults in Southeast and East Asia, with a larger aim of assessing the current well-being of older Asians and suggesting areas of policy concern. Current research reveals that formal programs in the majority of Southeast and East Asian countries have very low coverage of today's older adults, and the figures for future generations are not that much higher. However, family support of older persons may not be deteriorating as predicted by modernization theory. Asian families continue to play a major role in supporting older members, thus policies should focus on enabling Asian families to provide this support.     

Domain Management Approach to Heart Failure in the Geriatric Patient: Present and Future

Heart failure (HF) is a quintessential geriatric cardiovascular condition, with more than 50% of hospitalizations occurring in adults age 75 years or older. In older patients, HF is closely linked to processes inherent to aging, which include cellular and structural changes to the myocardium, vasculature, and skeletal muscle. In addition, HF cannot be considered in isolation of physical functioning, or without the social, psychological, and behavioral dimensions of illness. The role of frailty, depression, cognitive impairment, nutrition, and goals of care are each uniquely relevant to the implementation and success of medical therapy. In this paper, we discuss a model of caring for older adults with HF through a 4-domain framework that can address the unique multidimensional needs and vulnerabilities of this population. We believe that clinicians who embrace this approach can improve health outcomes for older adults with HF.     

The ADOPT Model: Accelerating Diffusion of Proven Technologies for Older Adults

The growing older adult population faces unprecedented health challenges. Home and community-based technologies have proven to be an effective way of helping older adults improve health outcomes and maintain independence. However, such technologies are currently not widely used by older adults for health purposes. Nor have they been widely adopted by the providers serving older adults; to date, successful health technology diffusion has occurred mainly within capitated and integrated health systems, such as the Veterans Health Administration (VHA) and Kaiser Permanente (KP). This article presents a conceptual model of technology diffusion, ADOPT (Accelerating Diffusion of Proven Technologies), which discusses important considerations for diffusing health technologies in home and community-based settings for older adults. At the center of the ADOPT model is a framework that highlights factors that affect technology adoption and use relevant to older adults, their collaborators, and their context. The model then overlays seven important “diffusion strategies” that older adults’ collaborators (including technology companies, aging services organizations, formal/informal caregivers, family members, medical providers, insurance companies, and others) can undertake to help facilitate technology diffusion. The goal of this article is to introduce the ADOPT model to guide older adults’ collaborators in achieving greater technology diffusion, in order to create widespread health outcome improvements and promote independent living for this population.     

Fecal incontinence in older adults

Fecal incontinence is an underreported and underappreciated problem in older adults. Although fecal incontinence is more common in women than in men, this difference narrows with aging. Risk factors that lead to the development of fecal incontinence include dementia, physical disability, and fecal impaction. Treatment options include medical or conservative therapy for older adults who have mild incontinence, and surgical options can be explored in selected older adults if surgical expertise is available.     

Exploring the Relationship Between Internet Use and Leisure Satisfaction Among Older Adults

Using the Internet is an important aspect of leisure among older adults, and satisfaction with Internet usage may be conducive to the well-being of older adults. This study explored via questionnaires the relationship between older adults' leisure satisfaction and their affinity for the Internet. A total of 103 older adults were recruited from a local aging agency in a Midwestern city in the United States. The results showed that low and high affinity groups had significantly different means for psychological benefits, educational stimulation, social relationship, and relaxation. The findings suggest that older adults with higher levels of affinity for the Internet are likely to be satisfied with their leisure pursuits. While some studies have reported negative aspects of using the Internet, such as increased depression and loneliness, the present study supports the results from a variety of studies that suggest that using the Internet has positive outcomes for older adults.