Treatment decisions in older adults with multiple chronic conditions (MCC) require a deliberate balance of risks, benefits and patient priorities. Tools to assist cardiovascular clinicians in meeting this common and thorny challenge have been lacking. Fortunately, the American Geriatrics Society (AGS) has provided clinicians with helpful guiding principles for the care of older adults with multimorbidity.¹ AGS has now put forth a framework of actions for implementing these principles in the clinical care of older adults with multiple chronic conditions.² These core actions are of great relevance for clinicians in cardiology care. A focused overview of these core actions follows:

MCC ACTION #1: Identify and communicate patients' health priorities and health trajectory

Identification of health priorities is particularly relevant for older patients in whom there may be uncertain data supporting available therapies and heterogeneity in preferences and goals. Validated approaches for identifying health priorities should be utilized by clinicians caring for older adults with multiple chronic conditions, including cardiologists (examples include patientprioritiescare.org & GeriatricsCareOnline.org).³ When making decisions regarding cardiovascular medications and invasive procedures, aligning care with patient's priorities is paramount to patient satisfaction and achieving a positive outcome.

Incorporating patients' health trajectory into decision making is equally important to the care of older adult patients. Health trajectory incorporates not only survival expectations but also anticipated trajectory of functional and health status as well as quality of life. If a more aggressive cardiovascular therapeutic option offers a small survival benefit at the cost of functional status or quality of life, older cardiac patients may prioritize the more conservative option.^4,5

MCC ACTION #2: Stop, start, or continue care based on potential benefit vs. harm in relation to individual health priorities, and health trajectory

The "one size fits all" approach does not apply when making decisions whether to stop, start or continue care. Clinicians must acknowledge the gaps in the literature that exist in the therapeutic care of older adults and variability in health priorities also exist among this population. If medications cause harm or the healthcare burden outweighs the benefit, these should be stopped. Is your octogenarian's primary prevention statin causing bothersome myalgias? Is an expensive medication causing serious financial hardship for your older adult patient with modest life expectancy? We must step back and consider the benefits and harms of the therapies we prescribe beyond the straightforward modicum of major adverse cardiovascular events, while taking the entire person into account.

MCC ACTION #3: Align decisions and care among patients, caregivers, and other clinicians with patients' health priorities and health trajectory

The patient-centered model values the alignment of individual decisions and care; accomplishing this goal begins with agreement across all participating parties on the factors that inform the patient's decision. What are the anticipated benefits, potential adverse effects (bleeding, falls, etc.), and other concerns, stressors, competing conditions, or contexts that impact the decision or the patient's ability to adhere to the therapy in the future? Patient goals-directed care can unite clinicians across specialties rather than operating within silos on disease-specific outcomes:⁶ cardiologists and primary care doctors alike can focus together on an individual patient's goal to reduce their angina so that they can walk with their spouse at night. Because of the wealth of efficacious medications and therapies available to contemporary cardiologists, our tendency may lean towards more aggressive care, which may clash with the priorities of a patient with multiple chronic conditions who prefers a "less is more" approach. Despite varying perspectives, and even when it means accepting a patient's decision that reflects healthcare preferences and goals that may differ from their own, compromise can usually be identified. When adequately informed, the patient's decision is nearly always the right decision.

References

1. American Geriatrics Society Expert Panel on the Care of Older Adults With Multimorbidity. Guiding principles for the care of older adults with multimorbidity: an approach for clinicians. J Am Geriatr Soc 2012;60:E1-25.
2. Boyd C, Smith CD, Masoudi FA, et al. Decision making for older adults with multiple chronic conditions: executive summary for the American Geriatrics Society guiding principles on the care of older adults with multimorbidity. J Am Geriatr Soc 2019;67:665-73.
3. Naik AD, Dindo LN, Van Liew JR, et al. Development of a clinically feasible process for identifying individual health priorities. J Am Geriatr Soc 2018;66:1872-9.
4. Gill TM, Allore HG, Holford TR, Guo Z. Hospitalization, restricted activity, and the development of disability among older persons. JAMA 2004;292:2115-24.
5. Boyd CM, Landefeld CS, Counsell SR, et al. Recovery of activities of daily living in older adults after hospitalization for acute medical illness. J Am Geriatr Soc 2008;56:2171-9.
6. Tinetti ME, Naik AD, Dodson JA. Moving from disease-centered to patient goals-directed care for patients with multiple chronic conditions: patient value-based care. JAMA Cardiol 2016;1:9-10.

Keywords: Geriatrics, Aged, 80 and over, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Health Priorities, Caregivers, Life Expectancy, Myalgia, Quality of Life, Decision Making, Physicians, Primary Care, Primary Prevention, Primary Health Care, Morbidity

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