|Year : 2022 | Volume
| Issue : 2 | Page : 68-72
Spectrum of cardiovascular diseases with increasing age and its association with geriatric syndromes
Pramod Kumar1, Bhrigu Jain1, Nidhi Soni1, SN Dwivedi2, Aparajit Ballav Dey1, Prashun Chatterjee1, Avinash Chakrawarty1
1 Department of Geriatric Medicine, AIIMS, New Delhi, India
2 Department of Biostatistics, AIIMS, New Delhi, India
|Date of Submission||11-Mar-2022|
|Date of Decision||06-May-2022|
|Date of Acceptance||06-May-2022|
|Date of Web Publication||15-Jul-2022|
3095-A, 3rd Floor, Academic Block, Department of Geriatric Medicine, AIIMS, New Delhi
Source of Support: None, Conflict of Interest: None
Objective: The burden of cardiovascular diseases (CVDs) is highest among the older adults, who are often carriers of various geriatric syndromes. Studies evaluating CVDs among the old adults in the low- and middle-income countries are limited. This study was conducted to assess the frequency of CVDs and their risk factors among the older population and their association with geriatric syndromes. Subjects and Methods: In this cross-sectional study, 200 health-care seeking adults aged ≥75 years were subjected to routine comprehensive geriatric assessment (assessment for functionality, cognition, depression, frailty, and various geriatric syndromes) and a detailed cardiovascular evaluation using electrocardiography, chest X-ray, echocardiogram, HbA1c level, fasting lipid profile, thyroid function test, serum homocysteine level, and serum NT-pro-BNP. Results: The overall frequency of CVDs in this study was 76%. Polypharmacy, multi-morbidity, cognitive impairment, depression, frailty, and impairment of basic and instrumental activities of daily living were present in 50.5%, 91.5%, 6.5%, 10%, 30.5%, 24.5%, and 55% individuals, respectively. CVDs were significantly associated with increased risk of geriatric syndromes (multi-morbidity [odds ratio (OR) 3.61, confidence interval (CI) 1.13 – 11.54, P = 0.030], polypharmacy [OR 5.46, CI 2.23 – 13.34, P = 0.001] and frailty [OR 3.29, CI 1.01 – 10.64, P = 0.047]). Conclusion: The prevalence of CVDs and their risk factors among the older population was high and significantly associated with increased risk of geriatric syndromes. These observations further strengthen the need for routine geriatric assessment and integrated management of geriatric syndromes in older patients with CVDs.
Keywords: Cardiovascular diseases, cardiovascular risk factors, frailty, geriatric syndrome, multimorbidity
|How to cite this article:|
Kumar P, Jain B, Soni N, Dwivedi S N, Dey AB, Chatterjee P, Chakrawarty A. Spectrum of cardiovascular diseases with increasing age and its association with geriatric syndromes. J Indian Acad Geriatr 2022;18:68-72
|How to cite this URL:|
Kumar P, Jain B, Soni N, Dwivedi S N, Dey AB, Chatterjee P, Chakrawarty A. Spectrum of cardiovascular diseases with increasing age and its association with geriatric syndromes. J Indian Acad Geriatr [serial online] 2022 [cited 2022 Dec 8];18:68-72. Available from: http://www.jiag.com/text.asp?2022/18/2/68/351066
| Introduction|| |
Aging results in a number of changes in the cardiovascular system and is a major risk factor for cardiovascular diseases (CVDs). Nearly 25% of all the deaths in India can be atributed to CVDs, and with the increasing life expectancy, the prevalence of CVDs has also risen considerably.
Geriatric syndromes are health conditions that are multifactorial and encountered in older adults commonly but do not fit into a discrete disease category. The prevalence of geriatric syndromes is higher in patients with CVDs and is associated with poor prognosis and higher mortality. Frailty, an important geriatric syndrome, is more common in people with CVDs and entails higher mortality rate and recurrent hospitalizations. Common pathophysiological processes, such as vascular aging and inflammation, have been proposed as the link between CVDs and geriatric syndromes.,
With increasing burden of CVDs among older Indian population, it is intriguing to study the interaction of geriatric syndromes and CVD in these patients. In a previously published article of our study, we have discussed in detail the echocardiographic findings, cardiovascular risk factors, and CVD prevalence among 200 adults aged above 75 years. In this article, we discuss the association between geriatric syndromes and CVDs in this population.
| Subjects and Methods|| |
In this pilot cross-sectional observational study, a total of 200 older adults aged ≥75 years were recruited from geriatric medicine outpatient services of a tertiary care hospital in north India after obtaining informed consent. Patients not able to undergo detailed evaluation and unwilling to participate in the study were excluded from the study. Patients were recruited using nonprobability sampling method, where the first two cases fulfilling the inclusion and exclusion criteria were recruited daily.
After recruitment, participants were subjected to a detailed assessment which included demographic details, anthropometric measurements, established clinical evaluation, comprehensive geriatric assessment (CGA), and detailed non-invasive cardiovascular evaluation.
CGA included assessment for the presence of common geriatric syndromes using predefined questionnaire. It included fall (history of one or more episodes of fall in the past 1 year), incontinence (history of involuntary passage of urine or stool, one or more times in the past 3 months), insomnia (presence of decreased duration or quality of sleep, increased day time sleepiness, persistent and severe enough to interfere with normal physical, mental, social and emotional functioning), pain (history of any chronic, persistent or recurrent pain-causing significant interference with normal physical, mental, social and emotional functioning), and anorexia (self-reported decrease in appetite). Comorbidities and drug history were recorded from patients' medical records, along with self-reported vision or hearing impairment. Polypharmacy was defined as use of five or more medications daily and multi-morbidity as the presence of two or more comorbidities.
They also underwent assessment for functionality using the Barthel's Index for basic activities of daily living (BADL) and Lawton's Index for instrumental activities of daily living (IADL)., Inability to perform any one activity was taken as ADL impairment. Cognitive assessment was done using Hindi Mental State Examination and a score of ≤23 was considered as cognitive impairment. Geriatric Depression Score (15-point scale) was used for the assessment of depression (score >5 suggestive of depression). Frailty was assessed using Rockwood frailty index (score ≥0.25 suggestive of frailty).
Cardiovascular evaluation using non-invasive tools comprised of electrocardiography, Chest X-ray, echocardiogram, complete blood count, liver function test, kidney function test, HbA1c level, fasting lipid profile, thyroid function test, serum homocysteine level, and serum NT-pro-BNP.
The following cardiovascular risk factors were assessed for obesity, sedentary lifestyle, smoking, hypertension, type-2 diabetes mellitus, dyslipidemia, and hyperhomocystenemia (hhcy) (defined by standard definition based on history and blood investigations). The presence of CVD was defined with reference to the AHA data on CVD, in which ICD 10 – CM diagnosis Codes – Disease of the circulatory system 100 – 199 was used for defining CVDs., CVD was defined as the presence of one or more of the following comorbidities: hypertension, coronary artery disease (CAD), cerebrovascular disease (CVA-stroke or Transient Ischaemic Attack (TIA)), peripheral arterial disease (PAD), heart failure (HF) – clinical criteria (Framingham's criteria) or left ventricular ejection fraction <40%, arrhythmias and conduction block, pulmonary hypertension, left ventricular diastolic dysfunction grade ≥2 and moderate-to-severe valvular heart disease.
Data were analyzed using statistics software, STATA 14.0 (StataCorp LLC, Texas, USA). Chi-square/Fisher's exact test was used to find the association between categorical variables. P < 0.05 was considered as statistically significant. Variables with P < 0.25 were further included for multivariate regression analysis to find whether various factors are independently associated with the outcome.
| Results|| |
The mean age of the population was found to be 79.3 ± 4.8 years. Among co-morbidities, arthritis and visual impairment were the most common (59% each), with 91.5% of the population having multi-morbidity. Polypharmacy, pain, fall, urinary incontinence, anorexia, and insomnia were present in 50.5%, 39.5%, 24%, 17%, 14.5% and 24.5% individuals, respectively. Cognitive impairment, depression, frailty, impaired BADL, and IADL were present in 6.5%, 10%, 30.5%, 24.5%, and 55% individuals, respectively [Table 1].
Cardiovascular diseases and risk factors
Among the cardiovascular risk factors, hyperhomocystenemia (83.5%) was the most common risk factor, followed by hypertension (59.5%), dyslipidemia (41.5%), sedentary lifestyle (35%), and obesity (30.5%). Diabetes Mellitus was present in 24.5% and history of smoking in 28.5% of individuals. The frequency of CVDs was 76% (74.7% in males, 80% in females). CAD, CVA, PAD, and HF were present in 17.5%, 5.5%, 1.5%, and 10% individuals, respectively [Table 2].
Association with geriatric syndromes
Patients with CVDs had a significantly higher prevalence of multi-morbidity (96.1% vs. 77.1%, P = 0.001), polypharmacy (61.2% vs. 16.7%, P = 0.001), frailty (37.5% vs. 8.35%, P = 0.001), and BADL impairment (28.3% vs. 12.5%, P = 0.027) as compared to those without CVDs. After multivariate logistic and regression analysis, multi-morbidity (odds ratio [OR] 3.61, confidence interval [CI] 1.13 – 11.54, P = 0.030), polypharmacy (OR 5.46, CI 2.23 – 13.34, P = 0.001), and frailty (OR 3.29, CI 1.01 – 10.64, P = 0.047) were found to be independently associated with CVDs [Table 3].
| Discussion|| |
In this cross-sectional observational study, a total of 200 older adults were comprehensively assessed for cardiovascular risk factors and diseases, along with various geriatric syndromes such as frailty, cognitive decline, and functional impairment. The key findings of this study included the high prevalence of CVDs among the older population and a strong association of CVD with geriatric syndromes such as frailty, multi-morbidity, and polypharmacy.
As discussed in our previous paper, the high prevalence of CVDs in our population (75% in men and 80% in women) was similar to the AHA data, according to which the worldwide prevalence of CVDs in the age group of 60–79 years is 69.1% for men and 67.9% for women, while in the 80+-year-old age group, 84.7% of men and 85.9% of women have CVDs. The frequency of various cardiovascular risk factors such as hhcy (83.5%), diabetes mellitus (24.5%), dyslipidemia (41.5%), and obesity (35%) was found to be higher in this study compared to previous studies, which can be attributed to the higher mean age of the population and different study setting.,
On CGA, more than 90% of the population was found to have multi-morbidity (i.e., 2 or more comorbidities) and above 50% have polypharmacy. Previous studies have also documented the prevalence of multi-morbidity and polypharmacy as high as 95% and 55% respectively among the older adults., Hypertension was the most common comorbidity in this population, followed by visual impairment, degenerative joint disease, hearing impairment, anemia, and diabetes mellitus; a similar pattern of comorbidity as seen in older studies. The frequency of other geriatric syndromes such as fall, urinary incontinence, chronic pain, anorexia, and sleep disturbance was also high in this study, while that of depression and cognitive impairment was similar to the observations in previous studies from India.,
Frailty is present in 30.5% population, with a higher prevalence among the females as compared to males (44% vs. 26%). Blodgett et al. in their study found the prevalence of frailty to be 34%, using the Rockwood frailty index, with a similar gender distribution. With the frailty phenotype model, the prevalence of frailty was lower (3.4%); however, prevalence was still higher among females. 24.5% population in this study have impaired BADL, while 55% have impaired IADL. Although the BADL is preserved in 75% of the study population, only 45% are independent in the IADL. This translates to a huge onus on the caregivers and the society.
A significant association was found between CVDs and Geriatric syndromes such as multi-morbidity, polypharmacy, and frailty. In the older adults, CVDs have been found to be associated with multiple other comorbidities, especially metabolic diseases, and degenerative disease, resulting in multi-morbidity as well as polypharmacy., Current guidelines recommend combinations of multiple medications for patients with CVDs. This, along with multiple comorbidities, result in an increased prevalence of polypharmacy as well as severe drug–drug interactions in patients with CVDs.,
Frailty has been identified in 25%–50% of the patients with CVDs, depending on the frailty scale used and the population studied. This correlation can be explained by the similar pathophysiology underlying both the conditions. Although the pathways leading to CVDs and frailty are complex, both have been strongly tied to chronic low-grade inflammation. Frailty has also been found to be associated with multiple cardiovascular risk factors (including obesity, hypertension, heart rate, lung function, and renal function) in older people, independent of established CVDs., These vascular risk factors affect multiple physiological systems and are risk factors for disorders such as dementia and chronic kidney disease. Previous studies have also found association of CVDs with cognitive decline and functional impairment. The absence of a significant result in this study can be explained by factors like lower prevalence of cognitive impairment in our study population, use of different assessment tools in different studies and the hospital-based setting in our study.
Nevertheless, from the above discussion, it is evident that CVD in the older adult is not a single-disease entity, but is associated with multiple geriatric syndromes, with which it may share a common pathophysiology. The presence of multimorbidity, polypharmacy and frailty in patients with CVDs make their management more complex. As a result, there has been an increased need for individualized care and integrated care for these patients. A multidisciplinary team approach for the management of older CVD patients should be emphasized, with geriatricians playing a vital role.
Strengths and limitations
The strength of this study is the detailed cardiovascular and CGA, which has been done in the older adults, a population frequently neglected in clinical trials.
Limitations of this study include its cross-sectional study design; hence, a causative relationship of CVDs leading to geriatric syndromes cannot be confirmed. Second, being a hospital-based study, the results could not be accurately extrapolated to the general population.
| Conclusion|| |
With increasing longevity, the burden of CVD increases and is often accompanied by geriatric syndromes such as multi-morbidity, polypharmacy, functional impairment, cognitive decline, and frailty. As a result, older adults with CVDs should be assessed by CGA for presence of geriatric syndromes. Further prospective and large-scale studies are needed to assess the causal relationship between CVDs and geriatric syndromes and the effect of management of geriatric syndrome on cardiovascular outcome in these patients. A multidisciplinary approach, involving a geriatrician, is paramount in the management of these patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]