December 17, 2020

Collaboration Between Cardiovascular and Geriatric Specialists Essential to Patients

Addressing cognition issues associated with cardiovascular disease

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Cardiovascular-disease specific conditions and/or related issues like medication side effects and nutritional deficiencies can lead to cognition issues. At Cleveland Clinic’s Center for Geriatric Medicine, providers empower older patients to stay healthy and thriving through the years. Because of this mission, Ardeshir Hashmi, MD, Cleveland Clinic Endowed Chair for Geriatric Innovation and Director, Center for Geriatric Medicine, believes in the importance of collaboration between cardiovascular and geriatric specialists and the value it brings to patients.

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In a recent article published in Clinical Cardiology, Dr. Hashmi and coauthors write that vascular cognitive impairment, which predisposes patients to increased risk of dementia, involves issues familiar to cardiovascular clinicians — like smoking, physical inactivity, and obesity.

“The most common cognitive abnormalities among patients with heart failure are learning and memory, complex attention and executive functioning,” writes Dr. Hashmi. “Fewer than 9% of patients with cognitive impairment had it documented in their medical record, highlighting the need to change practice.”

Establishing baseline of patients’ cognition necessary

Dr. Hashmi notes that cognitive impairment is now recognized as an important marker of hospital readmission risk in older adults hospitalized for heart failure.

There isn’t much data available about when and where screenings do or should take place for cognitive impairment in older adults with cardiovascular disease.

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“Based on our observations and practice, we believe such screenings may be valuable the first time a cardiovascular clinician meets a new patient in the outpatient setting, during a hospitalization and prior to discharge,” writes Dr. Hashmi.

He believes clinicians should evaluate patients in four domains: medical, physical, mind and emotion, and social environment. He says establishing an understanding of the patients’ cognition gives clinicians a sense of whether the patient can understand complex explanations and establishes a baseline as disease course and treatments impact cognition over time.

Three tools to assess cognition

While there’s no consensus about which tools should be used to assess cognition, Dr. Hashmi believes three tools are important: informal questioning of both the patient and family, formal assessment using the Mini-Cog and an assessment of the patient’s ability to handle finances and responsibility for his/her own medications.

Dr. Hashmi encourages cardiovascular clinicians to adopt a common approach to management of geriatric syndromes in older adults with cardiovascular disease that include awareness, screening, incorporation into decision-making and leveraging team-based care.

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AI-based cognitive assessment helps eliminate screening barriers

Regarding screening, he notes that despite common barriers to screening — lack of time during appointments and resistance from patients — tools exist to help clinicians who have little to no formal training in this area. One such tool is an AI-based cognitive assessment on a self-administered computerized platform. This machine learning algorithm consists of a complex memory test that can be completed in about ten minutes.

He hopes conversations with cardiovascular clinicians and the introduction of AI-based assessments will help identify memory changes sooner and more accurately than the traditional paper-and-pen testing methods,

Multidisciplinary care, dynamic team

In regards to a team-based approach, Dr. Hashmi credits multidisciplinary teams at Cleveland Clinic for their collaborative teamwork.

“We work with a very dynamic team. This includes nurses, pharmacists, geneticists and social workers. Care is tailored for each patient,” Dr. Hashmi says. He mentions that visits within the Successful Aging Program at the Center for Geriatric Medicine, unlike many appointments with a primary care physician, allow the luxury of time. “An entire team of individuals with different areas of expertise and knowledge spend an hour talking with a patient and his or her family.”

He adds, “We meet these people way too late in the game,” Dr. Hashmi says, noting that memory impairment can go unnoticed over a span of 20 years. “By the time we’re meeting with patients, options are limited. Medications can help stabilize further decline, but unfortunately can’t reverse what’s already been lost. If we can work together to help identify impairment earlier and start medications sooner, we can slow the disease. That buys patients time with their families and allows them to set up necessary resources for the future.”

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