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Medical decision making for older adults： an international perspective comparing the United States and India

Journal of Geriatric Cardiology 2015年第4期12卷 329-334页

作者： Ankur Kalra daniel e forman Sarah J Goodlin Division of lnterventional Cardiology Beth lsrael Deaconess Medical Center and Harvard Medical School Boston Massachusetts USA Division of Cardiology Department of Medicine Kalra Hospital SRCNC Pvt. Ltd. New Delhi India Section of Geriatric Cardiology University of Pittsburgh Medical Center Pittsburgh PA USA Geriatrics Research Education and Clinicai Center VA Pittsburgh Healthcare System Pittsburgh PA USA Department of Medicine-Geriatrics Oregon Health & Sciences University and Veterans Affairs Portland Health Care System Portland Oregon USA

There has been a significant decline in cardiovascular morbidity and mortality amidst pervasive advances in care, including percutane- ous revascularization, mechanical circulatory support, and transcatheter valvular therapies. While advancing therapies may add significant longevity, they also bring about new end-of-life decision-making challenges for patients and their families who also must weigh the advan- tages of reduced mortality to the possibility of longer lives consisting of high morbidity, frailty, pain, and poor quality of living. Advance care entails options of withholding or withdrawing therapies, and has become a familiar part of cardiovascular care for older patients in Western countries. However, as advanced cardiovascular practices extend to developing countries, the interrelated concept of advance care is rarely straight forward as it is affected by local cultural traditions and mores, and can lead to very different inferences and use. This paper discusses the concepts of advance care planning, surrogate decision-making, orders for resuscitation and futility in patients with cardiac dis- ease with comparisons of West to east, focusing particularly on the United States versus India.

关键词： Advance care planning Advance directive end-of-life India Surrogate decision-making

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Secondary cardiovascular prevention in older adults： an evidence based review

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Journal of Geriatric Cardiology 2015年第5期12卷 459-464页

作者： Abdulla A Damluji Archana Ramlreddy Lynda Otalvaro daniel e forman Cardiovascular Division and elaine and Sydney Sussman Cardiac Catheterization Laboratory University of Miami Miller School of Medicine MiamL FL USA Geriatric Cardiology Section University of Pittsburgh Medical Center Pittsburgh PA USA

1 BackgroundIn the United States, life expectancy is rising, particularly among the older population （〉 65 years）, with projected estimates approaching 20% by year 2050. Despite improved survival estimates, cardiovascular diseases remain the leading cause of morbidity and mortality resulting in substantial increase in health care cost. For younger adults, the evidence for secondary cardiovascular prevention is well established and corroborated by robust data. However, the application of risk reduction strategies in older populations remains an area of active debate. Many assume that vulnerability to chronic cardiovascular diseases is an inexorable part of aging such that the risks attributable to prevention outweigh potential benefits.

关键词： Cardiovascular disease Cardiovascular prevention Dyslipidemia Diabetes mellitus The elderly

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Stable ischemic heart disease in the older adults

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Journal of Geriatric Cardiology 2016年第2期13卷 109-114页

作者： Xuming DAI Jan Busby-Whitehead daniel e forman Karen P Alexander Division of Cardiology University of North Carolina at Chapel Hill Chapel Hill North Carolina USA Division of Geriatric Medicine Center for Aging and Health University of North Carolina at Chapel Hill North Carolina USA Section of Geriatric Cardiology University of Pittsburgh Medical Center Geriatrics Research Education and Clinical Center VA Pittsburgh Healthcare System Pittsburgh PA USA Division of Cardiology Duke University Medical Center Durham North Carolina USA

1 Introduction Ischemic heart disease is caused by atherosclerotic and/or thrombotic obstruction of coronary arteries. Clinical spec- trum of ischemic heart disease expands from asymptomatic atherosclerosis of coronary arteries to acute coronary syn- dromes （ACS） including unstable angina, acute myocardial infarction （non-ST elevation myocardial infarction and ST elevation myocardial infarction）. Stable ischemic heart dis- ease （SIHD） refers to patients with known or suspected SIHD who have no recent or acute changes in their symp- tomatic status, suggesting no active thrombotic process is underway.

关键词： Aging Coronary artery disease Older adults Risk assessment Stable ischemic heart disease

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Clinical pharmacology relevant to older adults with cardiovascular disease

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Journal of Geriatric Cardiology 2015年第3期12卷 192-195页

作者： Jorge A Brenes-Salazar Laith Alshawabkeh Kenneth e Schmader Joseph T Hanlon daniel e forman Department of Medicine Division of Cardiovascular Diseases Mayo Clinic Rochester MN USA Department of Medicine Division of Cardiovascular Medicine University of lowa Iowa City IA USA Department of Medicine Division of Geriatrics Duke University School of Medicine Durham NC USA Departments of Medicine (Division of Geriatric Medicine) Pharmacy and Epidemiology University of Pittsburgh Geriatric Research Education and Clini- cal Center and Center for Health Equity Research and Promotion VA Pittsburgh Health System Pittsburgh PA USA Department of Medicine (Divisions of Geriatric Medicine and Cardiology) University of Pittsburgh Medical Center Geriatric Research Education and Clinical Center VA Pittsburgh Health System Pittsburgh PA USA

1 Introduction Although older adults are generally among the highest users of cardiovascular medications, they are typically underrepresented or excluded from most efficacy and safety trials. Drug developers are usually reluctant to include many senior adults in randomized controlled clinical trials in part due to their high prevalence of multiple comorbidities, frailty, and polypharmacy; and to age-related pharmacokinetic and pharmacodynamic complexities. Consequently, there is often insufficient high quality evidence-based data to inform pharmacologic management of common cardiovascular conditions on older adults. In the absence of data, clinicians often rely on conceptual principles regarding metabolism and drug-drug interactions to minimize adverse drug events, but this is often not well-substantiated or standardized. A related challenge is poor cardiovascular medication adherence among older adults, and its detrimental impact on their health outcomes. In this brief review we highlight some aspects of these topics.

关键词： Metabolism Pharmacokinetics Pharmacodynamics Polypharmacy

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老年心血管疾病医护照料

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英国医学杂志中文版 2022年第2期25卷 87-100页

作者： Deirdre e O′Neill daniel e forman 唐施祺(译) 周红霞(校) University of Alberta Hospital EdmontonABCanada University of Pittsburgh University of Pittsburgh Medical Center and VA Pittsburgh GeriatricResearchEducation and Clinical Center(GRECC)PittsburghPAUSA 广西医科大学外国语学院广西医科大学公共卫生学院

年龄是心血管疾病的独立危险因素。随着老年人口的加速增长,老年医学与心脏病照护越来越息息相关。尽管年轻的心血管疾病患者一般不伴有其他疾病,但老年患者常伴随与年龄相关的多种疾病。因此,对心血管疾病的管理方案也会因其他共病、... 详细信息

年龄是心血管疾病的独立危险因素。随着老年人口的加速增长,老年医学与心脏病照护越来越息息相关。尽管年轻的心血管疾病患者一般不伴有其他疾病,但老年患者常伴随与年龄相关的多种疾病。因此,对心血管疾病的管理方案也会因其他共病、衰弱、多重用药、认知功能障碍、机体功能减退和年龄相关的复杂问题而变化。这意味着在管理老年心血管疾病患者时,需要更多的洞察力和技能来应对普遍存在的相关问题。本综述涵盖了治疗老年心血管疾病时可能存在的其他老年问题,特别是在心血管疾病管理方面应考虑的问题。传统的实践指南通常比较适合健康的老年人,用于应对多变的医疗状况、实现特殊照护目标的个体化治疗方案才会使更多人受益。这需要根据患者的总体状况权衡风险和效益,同时具备在决策时与患者沟通,并在适宜情况下与其他照护者进行交流的能力。这种个性化方案的效果尤为显著,为老年患者提供了改善机体功能和提升生活质量的机会,而这往往是治疗老年患者的首要目标。

关键词：老年心血管疾病老年问题医疗状况实践指南老年患者照护者多重用药老年医学

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Conditions for autonomous choice： a qualitative study of older adults＇ experience of decision-making in TAVR

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Journal of Geriatric Cardiology 2017年第1期14卷 42-48页

作者： elisabeth Skaar Anette Hylen Ranhoff Jan erik Nordrehaug daniel e forman Margrethe Aase Schaufel Department of Heart Disease Haukeland University Hospital Bergen Norway Department of Clinical Science University of Bergen Bergen Norway Kavli Research Centre for Geriatrics and Dementia Haraldsplass Deaconess Hospital Bergen Norway University of Pittsburgh Medical Center VA Pittsburgh Healthcare System Pittsburgh USA Research Unit for General Practice Uni Research Health Bergen Norway Department of Thoracic Medicine Haukeland University Hospital Bergen Norway

Background Patient autonomy is a leading principle in bioethics and a basis for shared decision making. This study explores conditions for an autonomous choice experienced by older adults who recently underwent trans-catheter aortic valve replacement （TAVR）. Methods Qualitative study entailing semi-structured interviews of a purposive sample often older （range 73-89, median 83.5 years） adults after TAVR （median 23 days）. The study setting was a cardiac department at a university hospital performing TAVR since 2010. Analysis was by systematic text condensation. Results even when choice seemed hard or absent, TAVR-patients deliberately took the chance offered them by processing risk assessment, ambivalence and fate. They regarded declining the treatment to be worse than accepting the risk related to the procedure. The experience of being thoroughly advised by their physician formed the basis of an autonomous trust. The trust they felt for the physicians＇ recommendations mitigated ambivalence about the procedure and risks. TAVR patients expressed feelings consistent with self-empowerment and claimed that it had to be their decision. even so, choosing the intervention as an obligation to their family or passively accepting it was also reported. Conclusions Older TAVR patients＇ experience of an autonomous decision may encompass frank tradeoff; deliberate physician dependency as well as a resilient self-view. Physicians should be especially aware of how older adults＇ subtle cognitive declines and inclinations to preserve their identities which can influence their medical decision making when obtaining in- formed consent. Cardiologists and other providers may also use these insights to develop new strategies that better respond to such inherent complexities.

关键词： Aortic stenosis Older adults Patient-centered care Shared decision-making Trans-catheter aortic valve replacement

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Care of older adults

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Journal of Geriatric Cardiology 2016年第1期13卷 1-7页

作者： Susan P Bell Nileshkumar Patel Nish Patel Rajesh Sonani Apurva Badheka daniel e forman Division of Cardiovascular Medicine Department of Medicine Vanderbilt University School of Medicine Nashville TN USA Department of Cardiology University of Miami Miller School of Medicine Miami FL USA Department of Internal Medicine Emory University School of Medicine Atlanta GA USA Department of Cardiology the Everett Clinic Everett WA USA Section of Geriatric Cardiology University of Pittsburgh School of Medicine Pittsburgh PA USA

In the United States, approximately 40 million adults over the age 65 are affected by one or more forms of cardiovascular disease and it remains the leading cause of morbidity and mortality in this population. Among older adults, therapeutic goals for cardiovascular diseases （CVD） are often confounded by comorbid diseases and/or conditions that dominate their overall sense of health and well-being. Thus, even while CVD is usually considered a principal concern,

关键词： Aging Delirium Dementia Disability elderly Frailty Multi-morbidity

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Influence of age in estimating maximal oxygen uptake

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Journal of Geriatric Cardiology 2016年第2期13卷 126-131页

作者： Christina G de Souza Silva Barry A Franklin daniel e forman Claudio Gil S Araujo Heart Institute edson Saad and Medical School Federal University of Rio de Janeiro Rio de Janeiro R J Brazil exercise Medicine Clinic CLINIMEX Rio de Janeiro R J Brazil Preventive Cardiology and Cardiac Rehabilitation William Beaumont Hospital Royal Oak MI United States Section of Geriatric Cardiology University of Pittsburgh Medical Center Geriatrics Research Education and Clinical Center System University of Pittsburgh Pittsburgh PA USA

Objective To assess the influence of age on the error of estimate （ee） of maximal oxygen uptake （VO2max） using sex and population specific-equations in cycle ergometer exercise testing, since estimated VO2 max is associated with a substantial ee, often exceeding 20%, possibly due to intrinsic variability of mechanical efficiency. Methods 1850 adults （68% men）, aged 18 to 91 years, underwent maximal cycle ergometer cardiopulmonary exercise testing. Cardiorespiratory fitness （CRF） was assessed relative to sex and age [younger （18 to 35 years）, middle-aged （36 to 60 years） and older （〉 60 years）]. VO2max [mL.（***）-1] was directly measured by assessment of gas exchange and estimated using sex and population specific-equations. Measured and estimated values of VO2max and related ee were compared among the three age- and sex-specific groups. Results Directly measured VO2max of men and women were 29.5 ± 10.5 mL.（***）-1 and 24.2 ± 9.0 mL.（kg·min） -1 （P 〈 0.01）. ee [mL·（kg·min）-1] and percent errors （%e） for men and women had similar values, 0.5 ± 3.2 and 0.4 ± 2.9 mL·（kg·min）-1, and -0.8 ± 13.1% and -1.7 ± 15.4% （P 〉 0.05）, respectively. ee and %e for each age-group were, respectively, for men： younger = 1.9 ± 4.1 mL·（kg·min）-1 and 3.8 ± 10.5%, middle-aged = 0.6 ± 3.1 mL.（kg·min）-1 and 0.4 ± 10.3%, older = -0.2 ± 2.7 mL·（kg·min） -1 and -4.2 ± 16.6% （P 〈 0.01）; and for women： younger = 1.2 ± 3.1 mL.（***）-1 and 2.7 ±10.0%, middle-aged = 0.7 ± 2.8 mL·（kg·min）-1 and 0.5 ± 11.1%, older = -0.8 ± 2.3 mL-（kg·min）-1 and -9.5 ± 22.4% （P 〈 0.01）. Conclusion VO2max were underestimated in younger age-groups and were overestimated in older age groups. Age significantly influences the magnitude of the ee of VO2max in both men and women and should be considered when CRF is estimated using population specific equations, rather than directly measured.

关键词： Aging Cardiopulmonary exercise testing error of measurement

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essentials of cardiovascular care for older adults： extending a US-based educational resource for collaboration with our China colleagues

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Journal of Geriatric Cardiology 2015年第3期12卷 191-191页

作者： daniel e forman Nanette K Wenger University of Pittsburgh Medical Center Pittsburgh PA USA emory University School of Medicine Atlanta GA USA.

1 The rationale for a geriatric cardiology skillset Throughout most of the world, people are living substantially longer. As a result, there is a rapidly expanding population of older adults who did not previously survive into old age. These adults are exposed to advanced aging processes that did not previously occur. Physiological changes of age predispose to cardiovascular diseases. Ironically, coronary heart disease, heart failure, valvular heart disease, peripheral artery disease, arrhythmias and other cardiovascular problems all soar with survival into senior years.

关键词：老年人教育资源心血管合作中国护理美国心脏病

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Associations of accelerometry-measured and self-reported physical activity and sedentary behavior with skeletal muscle energetics:The Study of Muscle,Mobility and Aging(SOMMA)

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Journal of Sport and Health Science 2024年第5期13卷 621-630页

作者： Yujia(Susanna)Qiao Terri L.Blackwell Peggy M.Cawthon Paul M.Coen Steven R.Cummings Giovanna Distefano Samaneh Farsijani daniel e.forman Bret H.Goodpaster Stephen B.Kritchevsky Theresa Mau Frederico G.S.Toledo Anne B.Newman Nancy W.Glynn Department of epidemiology School of Public HealthUniversity of PittsburghPittsburghPA 15261USA San Francisco Coordinating Center California Pacific Medical Center Research InstituteSan FranciscoCA 94143USA Department of epidemiology and Biostatistics University of CaliforniaSan FranciscoCA 94143USA Translational Research Institute AdventHealthOrlandoFL 32804USA Department of Medicine(Geriatrics and Cardiology) University of Pittsburghand GeriatricsResearchEducationand Clinical Center(GRECC)VA Pittsburgh Healthcare SystemPittsburghPA 15261USA Department of Internal Medicine Section on Gerontology and Geriatric MedicineWake Forest School of MedicineWinston-SalemNC 27109USA Division of endocrinology and Metabolism Department of MedicineUniversity of PittsburghPittsburghPA 15261USA

Background:Skeletal muscle energetics decline with age,and physical activity(PA)has been shown to offset these declines in older ***,many studies reporting these effects were based on self-reported PA or structured exercise ***,we examined the associations of accelerometry-measured and self-reported PA and sedentary behavior(SB)with skeletal muscle energetics and explored the extent to which PA and sedentary behavior would attenuate the associations of age with muscle ***:As part of the Study of Muscle,Mobility and Aging,enrolled older adults(n=879),810(age=76.4±5.0 years old,mean±SD;58%women)had maximal muscle oxidative capacity measured ex vivo via high-resolution re spirometry of permeabilized myofibers(maximal oxidative phosphorylation(maxOXPHOS))and in vivo by ^(31)phosphorus magnetic resonance spectroscopy(maximal adenosine triphosphate(ATP_(max))).Accelerometry-measured sedentary behavior,light activity,and moderate-to-vigorous PA(MVPA)were assessed using a wrist-worn ActiGraph GT9X over 7 ***-reported sedentary behavior,MVPA,and all PA were assessed with the Community Healthy Activities Model Program for Seniors(CHAMPS)*** regression models with progressive covariate adjustments evaluated the associations of sedentary behavior and PA with muscle energetics,as well as the attenuation of the age/muscle energetics association by MVP A and sedentary *** a sensitivity analysis,we also examined activPAL-measured daily step count and time spent in sedentary behavior and their associations with muscle ***:every 30 min/day more of ActiGraph-measured MVPA was associated with 0.65 pmol/(s×mg)higher maxOXPHOS and 0.012 mM/s higher ATP_(max)after adjusting for age,site/technician,and sex(ped with maxOXPHOS or ATP_(max).Meanwhile,every 30 min/day spent in ActiGraph-measured sedentary behavior was associated with 0.39 pmol/s×mg lower maxOXPHOS and0.

关键词： Aging exercise Mitochondria

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