Expanding our lexicon of clinical and research assessment of cardiovascular function in older adults: Can we improve cardiovascular outcomes?

Many decades ago, at the Harvard Medical School freshman student “Orientation to the Clinic,” the late Dr. Hermann Blumgart repeated the oft cited Harvard mantra from Dr. Francis W. Peabody, “For the secret of the care of the patient is in caring for the patient.” This substantially antedated the contemporary concept of patient-centered care, with its paradigm shift from an emphasis on disease to an emphasis on the patient, initially highlighting health, functioning, and wellbeing, and then specific disease states¹.

The primary goals of cardiovascular care in older adults are to maintain independence, prevent functional decline, and improve health-related quality of life. The typically assessed clinical trial outcomes of death, myocardial infarction, and myocardial revascularization in evidence-based cardiovascular disease guidelines are often less relevant to the elderly patient than are symptoms, morbidity, function, and independence2. Standardized assessments of these latter variables as outcome measures must become a vital part of evidence-based medicine.

Prioritizing Functional Capacity

The AHA/ASA Scientific Statement “Prioritizing Functional Capacity as a Principal Endpoint for Therapies Oriented to Older Adults with Cardiovascular Disease”³ represents an important contribution to both the clinical and research cardiovascular arenas. The prototype contemporary cardiovascular patient is a geriatric patient, a population characterized by multimorbidity, polypharmacy, and a varying spectrum of geriatric syndromes. For patient-centered care, prioritizing function, independence, and life quality, rather than disease-specific outcomes of cardiovascular events and mortality – the assessment and enhancement of functional status becomes pivotal. Patient goals emphasize the avoidance of disability, dependency and frailty, often unintended consequences of illness and particularly of hospitalization².

How can and how should this new lexicon of functional assessment (testing) be incorporated into office practice, what measures should be evaluated during a hospitalization, and what constitutes appropriate functional assessment (and metrics) in skilled nursing facilities? Essentially how can we best incorporate this new spectrum of testing into routine clinical care - ? 6MWT, ? TUG, ? SPPB, ? MoCA, ? DASI, etc.?

Clinical Care

Clinicians reviewing this document should examine the testing modalities appropriate for their clinical care setting4, highlighting those which can be readily administered on a serial basis and used to ascertain functional improvement when interventions, in particular physical activity and cardiac rehabilitation, are instituted.

Functional status is the ability to perform the normal daily activities required to meet basic needs, to fulfill usual roles, and to maintain health and well-being. Metrics to ascertain functional status are available, but are underutilized and indications for their performance require standardization. Physical functional impairment and cognitive impairments are prevalent in older adults. Patients want physicians to query their health perceptions, limitations in physical function, and monitor changes over time. A fundamental barrier to improving outcomes of cardiovascular care of older adults, including their quality of life, is the lack of functional assessment in the medical record. The documentation of functional status is either not mentioned or poorly described and the relevance of functional status as an outcome of care is not routinely ascertained. If functional status is not included, suboptimal discharge planning results in the inability to enhance and monitor outcomes, effectiveness and quality of care.

There is a science of health status measurement. Routine, systematic measures of patient function and well-being must include disease-specific medical outcomes, multidimensional functional status, patient satisfaction, and cost.

Testing

Cardiorespiratory fitness declines with advancing age, as well as with cardiovascular, pulmonary and other systemic disorders. Cognitive decline and depression are also concomitants of cardiovascular illness and can substantially compromise functional capabilities. Physical frailty includes functional decline – weakness, slowness, and reduced activity – and is associated with adverse outcomes⁵. Although functional capacity was traditionally assessed by formal exercise testing, office assessment can readily be done by the 6MWT (six minute walk test)6, a facile procedure readily accomplished by office staff. Another valuable office procedure is hand grip strength, readily tested using standardized protocols and with an inexpensive hand dynamometer^{7, 8}. Repeated chair rise can also assess functional status.

The SPPB (Short Physical Performance Battery) combines gait speed with assessments of functional strength and standing balance – and has strong predictive associates, as well as providing clues to specific functional limitations.

In addition to specific test modalities, numerous questionnaires can assess activities of daily living (ADLs) and activity status [the Duke Activity Status Index (DASI)], based on patient reports of routine activity.

Cognitive assessment, with the MoCA (Montreal Cognitive Assessment), suitable for office use, can be measured serially.

Interventions

Physical function, in addition to being a quality measure of outcome in clinical trials, should be a therapeutic target for older adults. Hospitalization for a cardiac event is characteristically associated with physical disability, which has been documented to be ameliorated by a combination of aerobic exercise and strength training. Modest increases in aerobic activity and strength have striking associations with maintenance of independence for older adults⁹.

Referral to cardiac rehabilitation is a Class I recommendation in most cardiovascular clinical practice guidelines, but is particularly applicable to older adults who encounter a decline in functional capacity related both to the disease and to the hospitalization. Sadly, elderly adults are substantially under-referred for rehabilitation services.

The role of newer technologies – those enabling home cardiac rehabilitation 10, those related to device or technology-based cardiac rehabilitation 11 – are being examined intensively in the elderly population, but the emphasis should be on referral to rehabilitation for restoration of function.

Skilled Nursing Facilities

Particularly important for older adults are the physical function goals of skilled nursing facilities, characteristically the referral site of aged patients following a hospital stay. Unfortunately, many skilled nursing facilities base patient eligibility on the time for which a patient can engage in rehabilitation activity each day; this is an unwise metric. Rather the metrics should involve assessment of functional status at entry (with simple testing as in the office), physical activity goals as listed on the referral to the skilled nursing facility, and the discharge metrics documenting changes in functional capacity. Measurements should be not only of physical activity but of strength and balance.

The testing modalities used in office practice, which are responsive to longitudinal changes, can also be used as skilled nursing facility metrics, comparing admission and discharge values – SPPB, MoCA, measurement of gait speed, etc.

Research Issues

Quality of life constitutes a standardized means of assessing clinical outcomes and is a relevant endpoint in clinical trials, concomitant with survivorship, clinical events, and complications.

Functional testing can be more complex than described above, dependent on the research design, but the functional tests selected as outcome measures in clinical trials should be suitable for translation to clinical care3.

Policy Issues

Patient-oriented measures must become the focal point for cardiovascular care, changing the way physicians make decisions with their elderly patients and constituting a new approach to allocation of resources. Functional capacity is one of these measures2.

The transformation of health care has begun with the announcement of MACRA (Medicare Access and CHIP Reauthorization Act of 2015), policies of payment for value. Value is defined as quality/cost, addressing outcomes that matter (to patients), aligning their health care with their priorities. The pillars include quality, efficiency, meaningful use, and clinical process improvement. As the applications continue to evolve there is an opportunity to develop meaningful measures – and functional capacity must be highlighted. Questions will relate to how to measure what matters most to patients – their goals and care preferences and how to integrate these measures into an existing work flow.