The number of older patients in cardiovascular clinics, procedure rooms, and hospital wards is increasing due to demographic shifts and the synergy between aging and cardiovascular disease. The population is living longer with chronic conditions due in part to successes in acute cardiovascular care in prior decades. The care of complex older patients will certainly not be solely provided in primary care or geriatric clinics. In fact, ranks of geriatric providers are shrinking as the older population is expanding. In 2010, there were ten times as many cardiology fellows as geriatric fellows, and many geriatric fellowships did not fill existing slots. Five geriatricians are needed for every 10,000 patients over age 75 in the US to provide primary care services, but there are currently 1.3 geriatricians for 10,000 patients. Cardiovascular disease is a demand driver, so the cardiology clinic will be the place where older patients often present for care. As cardiology providers, we need to reflect on patient-centered care, give ourselves permission to treat the cardiovascular condition in context rather than follow evidenced-based guidelines from younger populations, and when multimorbidity or frailty is present, consider functional aging as much as chronologic age.

Frailty, at the extreme of functional aging, has no agreed upon definition, but is loosely defined as a biological syndrome of decreased reserve and resistance to stressors resulting in multiple declines across physiologic systems causing vulnerability. Its specific pathways may include diminished mitochondrial function, oxidative stress, inflammation, shortened telomeres, and cell senescence. Frailty is identified after an "unmasking event," such as a medical procedure, a fall, or an infection. When the individual is stressed, the narrowed reserves across redundant systems are apparent. The key is to identify frailty prior to an adverse event. At every age, as many are not frail as are frail. Some remain exceptionally fit, such as Jeanne Calment, the longest lived human in recorded history, who survived to 122 years, or Keizo Miura, who skied the Swiss Alps in his 90s. In the Canadian Study of Health and Aging, only 40% of nonagenarians met criteria for frailty. So assessments are necessary for identifying those who are not frail, for whom care is likely to result in outcomes predicted by general study results.

The phenotype of frailty includes sarcopenia or weakness, slowness, low physical activity or exhaustion, and nutritional deficits. Cognitive impairment, multiple comorbid conditions, and disability are often associated but distinct. Frailty can also be described by the cumulative deficit model, simply adding the number of comorbid conditions and impairments. The assessments of functional aging and frailty have been extensively described; some are clinical scales like the Canadian Frailty Scale, some are scores like Fried or Rockwood, and some are simple performance measures like gait speed. There is no one assessment which stands as a gold standard, and all add important information beyond age. Cardiology care should incorporate functional aging and frailty assessments for those over age 75 years in the clinic and hospital, and be ready to place the cardiovascular care in the context of the older adult. Dr. Atul Gawande described our challenges well, "Most of us in medicine don't know how to think about decline. Give us a disease, and we can do something about it....but give us an elderly woman with colon cancer, high blood pressure, arthritic knees, and various other aliments besides – an elderly woman at risk of losing the life she enjoys – and we are not sure what to do." Geriatric cardiology is the perspective which embraces the heterogeneity of aging and the cardiovascular care of the older adult in the context of their general condition and goals of care.

Keywords: Aged, Aged, 80 and over, Cardiology, Cardiovascular Diseases, Colonic Neoplasms, Comorbidity, Demography, Geriatrics, Hypertension, Inflammation, Mitochondria, Oxidative Stress, Patient Care Planning, Patient-Centered Care, Phenotype, Sarcopenia, Telomere, Telomere Shortening

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