THE ELDERLY POPULATION

Cardiovascular Disease in the Elderly Coronary Artery Disease Hypertension, HHD Stroke Peripheral Artery Disease Dysrhythmias Valvular Heart Disease Heart Failure

DISEASE PREVALENCE

Differentiation between Age-Associated Changes and CVD in Older People

AGE-ASSOCIATED CHANGES CARDIOVASCULAR DISEASE Differentiation Between Age-Associated Changes and Cardiovascular Disease in Older People AGE-ASSOCIATED CHANGES ORGAN CARDIOVASCULAR DISEASE Increased intimal thickness Arterial stiffening Increased pulse pressure Increased pulse wave velocity Early central wave reflections Decreased endothelium-mediated vasodilation Vasculature Systolic hypertension Coronary artery obstruction Peripheral artery disease Carotid artery obstruction Increased left atrial sice Atrial premature complexes Atria Atrial fibrillation Decreased maximal heart rate Decreased heart rate variability Sinus node Sinus node dysfunction, sick sinus syndrome Increased conduction time Atrioventricular node Type II block, third-degree block Sclerosis, calcification Valves Stenosis, regurgitation Increased left ventricular wall tension Prolonged myocardial contraction Prolonged early diastolic filling rate Decreased maximal cardiac output Right bundle branch block Ventricular premature Ventricle Left ventricular hypertrophyheart failure (with or without preserved systolic function) Ventricular tachycardia, fibrillation

Guidelines for Medication Prescribing in Older Patients In general, loading doses should be reduced. Weight (or body surface area) can be used to estimate loading dose requirements. Weight differences between the sexes are greatest for white people Use estimates of glomerular filtration to guide dosing of renally cleared medications and contrast agent administration. Reduce initial doses of metabolically or hepatically cleared drugs but tutrate to effect. Time between dosage adjustments and evaluation of dosing changes should be longer in older patients than in younger patients. Routine use of strategies to avoid drug interactions is essential. incorporation of reference materials, a team approach, and quality improvement efforts are effective strategies. Knowledge of effects of noncardiac medicaions is critical. Assessment of adherence and attention to factors contributing to nonadherence should be part of the prescribing process. Physicians must be familiar with the patient’s source of prescription medication coverage and provide education and assistance with obtaining critical medications. Multidisciplinary approaches to monitoring of medication therapy may improve outcomes.

Estimates of creatinine clearance with the Cockcroft and Gault Formula (left panels) and estimates of glomerular filtration rate with the MDRD simplifies algorithm (right panel) for men and women aged 45 – 85 years

The relationship between the number of drugs consumed and drug interactions

Approach to the Older patient with : Hypertension Coronary Artery Disease Stroke Peripheral Artery Disease Heart Failure Atrial Fibrillation Valvular Disease

Approach to Hypertension in Older Patients Systolic as well as diastolic hypertension should be treated; current recommendations are based on brachial artery measurement : Diastolic target is < 90 mm Hg Systolic target is < 140 mm Hg for most (< 150 mm Hg for patients older than 80 years). The focus should be on achieving blood pressure control, not initial therapy Multiple medications are usually required in older patients, and combination shoud be based on concomitant diseases. Drug dosing regimens should be adjusted for age and disease-related changes in drug metabolism and potential drug-drug interactions. Patients should be monitored for adverse effects and drug interactions, especially : Postural hypotension and postprandial hypotension Hypovolemia with diuretics Hyperkalemia with ACE inhibitors, ARBs, aldosterone, renin antagonists

In-hospital mortality rates reported for revascularization procedures by age group 19

SR SM Risk of stroke (light blue) is compared for medical and surgical therapy for patients with hemispheric transient ischemic attack in the North American Symptomatic Carotid Endarterectomy Trial are shown on the left. On the right are more recent data comparing risk of stroke (light blue) and risk of death (dark blue) with surgical carotic endarterectomy with protected stenting (SAPPHIRE long-term follow-up) in high-risk patients. Earlier medical therapy did not include aggressive lowering of lipids or blood pressure, and the data shown differ for lower risk as well as for older patients 21

Incidence rates of heart failure by age in a nationally reperesentative sample of nearly 3 million Medicare beneficiaries. The incidence of heart failure increases with increasing age within the Medicare population 24

Estimation of 4-year mortality in the Elderly Age Gender BMI Smoking Disease : DM,Ca,Lung, HF Assistance needed Difficulty

The End