Editor's Note: Commentary based on Grant EV, Skolnick AH, Chodosh J, et al. Improving care using a bidirectional geriatric cardiology consultative conference. J Am Geriatr Soc 2018;66:1415-9.

Objective: There is an increased need for interdisciplinary patient-centered care for older adults (age ≥75) with cardiovascular disease (CVD) given knowledge gaps due to under-representation of older adults and geriatric metrics in cardiovascular trials. The bidirectional Geriatric Cardiology Conference is one example of collaboration aimed to bridge these gaps and focus on geriatric-specific metrics and define the boundary between high-risk and futile interventions at an institutional level.¹

Background: It is well known that the US population is aging, and with it we see an increased prevalence of older adults with CVD.² With aging comes important physiological changes in patients (e.g., sarcopenia, vascular stiffness) as well as other considerations such as changing goals of care.³ However, current training models generally fail to acknowledge these unique aspects of caring for older adults with CVD.⁴ Specifically, cardiologists lack expertise in geriatric-specific care, and geriatricians do not have the same expertise in CVD management.⁴ Accordingly, older patients with CVD may be left with discordant advice on appropriate medications and procedures.⁴ Further, most CVD clinical trials (with the notable exception of transcatheter valve studies) were based on relatively young populations, and the relative benefits among older adults remains unclear.

Methods: In our recent paper in Journal of the American Geriatrics Society, we describe how cardiologists and geriatricians at NYU Langone Health (NYULH) formally convened to discuss optimal strategies for CVD in their older patients.¹ These meetings took the form of a monthly interdisciplinary patient case conference. Attendees were invited from both specialties and included attending physicians, physician assistants and nurse practitioners as well as trainees (fellows, residents and medical students). For sake of clarity and structure, a spreadsheet was created to gather case information and distribute it to attendees. The following data are presented for each patient: (1) description of medical and social history, including diagnostic laboratory and imaging data; (2) current list of medications (including over-the-counter supplements); (3) status of geriatric impairments (e.g., frailty, cognitive impairment); (4) summaries of last several clinic visits and (5) goals of care and patient preferences, as described by the patient during the most recent clinical encounter.¹

Results: To date, patients presented at NYULH's conference ranged in age from 70 to 95 years, focusing on questions of medical management, appropriateness of procedures, end-of-life decisions and a minority involving diagnostic dilemmas.¹ Surveys from attendees showed that the conferences changed the way clinicians would treat and think about this subset of patients.1 Moreover, anecdotally the clinicians enjoyed the conference and the opportunity to formally interact with other specialties in a case conference setting.

Perspective: The bidirectional geriatric cardiology conference provides an innovative way to address current knowledge gaps in cardiology and geriatrics. Attendees emphasize the conference's pedagogical value, allowing them to better serve their patients through applying the wisdom of a multidisciplinary group in the setting of limited evidence from clinical trials as well as the unique impairments faced by older adults. In addition, the conference provides a venue for trainees to gain insight into the field of geriatric cardiology and implementing principles of person-centered care to optimize decision-making for older adults.

As a current medical student (EG), the experience of coordinating this conference has made me very sensitive to the way geriatrics is introduced to us throughout our medical training. I have seen that traditional education models have left cardiologists (and other non-geriatric specialties) with little training on how to deal with the complexities of older adults. This conflicts with the changing demographics, which will impact a significant number of specialties. I hope to act as an advocate for increased geriatric training earlier in our education.

References

1. Grant EV, Skolnick AH, Chodosh J, et al. Improving care using a bidirectional geriatric cardiology consultative conference. J Am Geriatr Soc 2018;66:1415-9.
2. US Census Bureau. The next four decades: the older population in the United States: 2010 to 2050. 2010. Available at http://www.census.gov/prod/2010pubs/p25-1138.pdf. Accessed Oct 25 2018.
3. Alpert JS, Powers PJ. Who will care for the frail elderly? Am J Med 2008;120:469-71.
4. Rich MW, Chyun DA, Skolnick AH, et al. Knowledge gaps in cardiovascular care of the older adult population: a scientific statement from the American Heart Association, American College of Cardiology, and American Geriatrics Society. J Am Coll Cardiol 2016;67:2419-40.
5. Dodson JA, Matlock DD, Forman DE. Geriatric cardiology: an emerging discipline. Can J Cardiol 2016;32:1056-64.

Clinical Topics: Cardiovascular Care Team, Geriatric Cardiology

Keywords: Geriatrics, Sarcopenia, Patient Preference, Prevalence, Vascular Stiffness, Nurse Practitioners, Physician Assistants, Decision Making, Patient-Centered Care, Ambulatory Care, Cardiovascular Diseases, Patient Care Planning, Terminal Care

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