Polypharmacy in the elderly and need of a Geriatric Consultant:
It is essential to keep in mind the other illnesses of the elderly population while treating their cardiac problem. Common associations are, degenerative joint problems like osteo-arthritis, prostate enlargement in males or prolapsed uterus in ladies. Overactive urinary bladder needing frequent toilet visits, Impaired hearing and failing visual acuity. Cancers active or old, needing long term drugs, radiation. Depression, anxiety and lack of sleep. Neurological problems like Parkinsonism, old strokes and Alzheimer’s disease. Chronic lung disease like bronchitis. For these reasons, a Geriatric consultant being a part of the team is desirable and a necessity. This would help in avoiding drug-drug interactions and avoiding drugs with opposing actions and reactions and yet getting the best treatment.
Concept of Palliative Care in end stage heart disease like Chronic Heart Failure:
Progressive decline and loss of independence, poor quality of life despite optimal treatment, frequent hospitalization, cardiac transplant or mechanical circulatory devices not possible and clinical assessment indicating close to end of life, calls for a palliative care.
Adding life to years versus adding years to life is an important decision especially in elderly patients with chronic worsening heart failure who are already on all the pillars of pharmacotherapy.
Focus should be on optimizing the quality of life, focussing on symptom relief, psychological and often spiritual support. Patients’ preferences around death time need assessment by having a meeting with close family members and avoiding energetic and painful treatment algorithms.
Take Home Message:
The increasing elderly population represents a major challenge to the physicians, health care providers and the society at large. Long exposure to risk factors along with age related co-morbidities frequently result in complex cardiovascular problems in them .The available therapies have been proven to be beneficial but there are several issues in using them and need to provoke a thought process and a debate.
The narrow therapeutic window of several drugs, cognitive impairment, frailty and the important question of quality-of-life vs mortality are the issues . The treatment using drugs and mechanical interventions should always focus on the patient’s preference and the quality of life. The optimal therapy should be determined by a multidisciplinary team which involves the patient and the family in the decision-making process.
