Advances in cardiology have led to greater longevity in patients with cardiovascular (CV) disease(s). This success has led to higher proportions of older adults with age-related coexisting conditions such as multimorbidity, frailty, and cognitive dysfunction – resulting in substantially more complicated cardiac-specific decision making.

Geriatricians are well-known for team-based approaches when caring for complicated older adults. The 5M's epitomize care improvement strategies by employing an easily recognizable mnemonic¹:

• Mind: Maintaining mental activity.
• Mobility: Maintaining the ability to walk, and independence.
• Medications: Addressing medication overload and de-prescribing medications when pertinent.
• Multimorbidity: Understanding and addressing multiple chronic conditions.
• Matters most: Ensuring that patients' health goals are reflected in treatment plans.

One suggested strategy to address these difficult decisions by geriatricians and geriatric cardiologists is a movement away from disease-based care to goals-directed care.² Here value becomes a function of patient-centered outcomes and inversely to the treatment burden that patients are willing to endure. It is therefore important to recognize that geriatric cardiology is more than just cardiovascular care of adults who happen to be older.³ It is the integration of a patient-centered and age-friendly approach to patients' cardiovascular needs.

One of the major challenges to providing cardiovascular care to older adults is that many "real-world" older adults have been systematically excluded from the major cardiovascular clinical trials that have shaped recommendations and guidelines.⁴ This highlights the need for more research on real-world population of older adults. To address this shortfall, the National Institutes of Health now requires investigators of clinical trials to include all participants of all ages.⁵

Now, we have a new metric called 'the 5Ts' to facilitate inclusion of older adults in evidence generation.

Below, we succinctly describe a recent article published by Bowling et al in Journal of the American Geriatrics Society that aims to develop a framework to increase and improve the current evidence-base for care of older adults. This framework can be particularly applicable to CV clinicians interested in pursuing research in this area.

• To better understand the complexities of aging research, Bowling et al⁶ elicited challenges to research, that includes older adults, from non-geriatrician researchers and staff. They then asked aging research expert's responses to these challenges and finally developed a communication framework in an iterative fashion.
• Challenges and examples faced by non-geriatrician subspecialists when conducting research that included older adults were the following:
  • Lack of knowledge (Examples: lack of training in aging research, geriatric syndromes or common age-related impairments, lack of awareness of knowledge gaps and high-priority research questions in aging, overwhelmed by extent of existing measures in geriatrics (such as when assessing for frailty or cognitive dysfunction)
  • Rigid study structure (Examples: Emphasis on meeting recruitment targets, concerns surrounding high withdrawal rates and need to report unrelated adverse events)
  • Focus on individual disease processes (Examples: underappreciation of value of geriatrics/gerontology research expertise, skepticism of mechanistic differences in younger versus older adult)
• The resulting comprehensive communication framework known as the 5Ts (Target population, Team, Tools, Time, Tips to Accommodate) is shown below:

Domain	Description	Example to Address Challenge
Target population	Real-world older adults	Avoid exclusions limiting generalizability.
Team	Entire team (research, patient, family, caregivers)	Engage geriatrician researchers and aging experts.
Tools	Measurement tools when conducting aging research	Choose appropriate measures of cognitive and physical function, patient-reported outcomes. Balance data-collection with patient burden.
Time	Participant, caregiver, family time and study time	Anticipate longer study visits and scheduling follow-up visits along with specific accommodations that may be needed (such as anticipating dietary needs).
Tips to accommodate	Improve recruitment and retention	Budget for transportation needs, large font size for printed materials; plan for increased attrition rate (may affect sample size/power calculations).

Limitations of study:

1. Single academic medical center
2. Interviews not recorded
3. Formal thematic analysis not conducted
4. No formal evaluation thus far of framework

Take Home Message: To best care for the aging population, many of whom develop cardiovascular conditions, we need to routinely generate data on the efficacy and safety of various therapeutic interventions. Integrating the 5Ts offers a platform for incorporating geriatric-specific aspects and principles into clinical trials, and can thus increase the quality and improve the applicability of research in older adults with cardiovascular disease.

References

1. Tinetti M, Huang A, Molnar F. The Geriatrics 5M's: a new way of communicating what we do. J Am Geriatr Soc 2017;65:2115.
2. 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.
3. Miller AP, Maurer M, Alexander KP. Geriatric cardiology: two decades of progress and strategy for the future. J Am Coll Cardiol 2018;71:2970-73.
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. Lauer M. Inclusion Across the Lifespan Policy (NIH Extramural Nexus website). Available at: https://nexus.od.nih.gov/all/2018/01/24/nih-announces-inclusion-across-the lifespan-policy/. Accessed 8/4/18.
6. Bowling CB, Whitson HE, Johnson TM, 2nd. The 5Ts: preliminary development of a framework to support inclusion of older adults in research. J Am Geriatr Soc 2019;67:342-46.

Keywords: Geriatrics, Caregivers, Longevity, Research Personnel, Syndrome, Follow-Up Studies, National Institutes of Health (U.S.), Decision Making, Cardiovascular Diseases, Academic Medical Centers, Cognition

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