Sue Wells shares her opinion with Liam Butler

Sue Wells shares her opinion with Liam Butler on CVD Risk Assessment in Older People

How can the aged care and retirement sector apply the CVD and diabetes care e-health initiatives?

Sue Wells, Associate Professor Health Innovation and Quality Improvement, at The University of Auckland:

CVD risk assessment and management in older people

People aged 75-84 years make up 4.4% of New Zealand’s population- a group expected to double in size in the next 20 years. While many suffer from chronic conditions, an increasing number are fit, thriving and still in the workforce. New Zealanders are also living longer. Life expectancy has increased by over 10 years in the last 50 years and is projected to rise further. The leading causes of health loss for people aged 75-84 years are cardiovascular diseases (CVD) and cancers. CVD is a term covering a range of conditions including angina, heart attacks and strokes and if a person has had a procedure for blocked arteries such as bypass grafts and stents. This age group sustains about a quarter of all CVD deaths and hospitalisations which are mainly heart attacks and strokes.

Management of CVD

New Zealand GPs have well-established clinical guidelines for the CVD assessment and management. Screening of heart health and diabetes is recommended for men over 45 years, women over 55 years and 10 years earlier for Māori, Pacific or South Asian peoples. Screening includes looking at your medical history (e.g. previous heart problems, smoking, diabetes, family history of early heart disease), taking your blood pressure and having some laboratory tests (e.g. kidney function, blood glucose and cholesterol levels). All this data is combined together (using a mathematical equation based on risk prediction studies) to create a risk of having a heart attack or stroke in the next five years - your 5-year CVD risk. The intensity of management is then tailored according to this CVD risk score. At low CVD risk, lifestyle advice such as a healthy heart diet, regular physical activity and smoking cessation are recommended. At higher risk levels, your GP might also recommend you taking one, two or multiple medications (such as statins for cholesterol lowering, blood pressure pills and aspirin). There is a large body of evidence that, taken together, these medications could potentially halve a patient’s risk of a future CVD event over the next 5 years.

But we have a problem….

These recommendations on CVD risk assessment and management are for people younger than 75 years. Once a person turns 75, GPs are advised to use ‘clinical judgement’ taking into account ‘the results of a risk assessment, the likely benefits and risks of treatment and the person’s values.’ This advice exposes large gaps in knowledge. Firstly, the recommended CVD risk prediction equation, derived from research on people less than 75 years old, has not been validated for the people 75-84 years. Secondly, the evidence for treatment benefit in older age groups is limited. While the benefits are likely to be similar to younger people, the risk of adverse drug events increases with age and increasing numbers of medications. Thirdly, having several long term conditions is common among older people and the co-occurrence of other diseases with CVD impacts on how best to manage people and their prognosis. Given the lack of evidence to inform management, those at high CVD risk are often not treated and treatment omission has been associated with increased hospitalisations and death. Experts debate whether treatment omission amounts to ageism, or if overtreatment and polypharmacy should be reversed by de-prescribing. Furthermore, there are no studies that have investigated older people’s preferences in regard to drug treatment.

Closing the knowledge gaps

A research project led by researchers at the School of Population Health, University of Auckland aims to address these issues. Funded by the Health Research Council of New Zealand, the research will investigate the natural history of disease, risk profiles, risk prediction and treatment practice for older people. A qualitative study is already underway asking GPs how they consider other health problems, quality of life and life expectancy when advising older people about CVD risk management. A second study will also be conducted asking people aged 75-84 years about their views and preferences for CVD risk assessment and management- what outcomes they want to avoid most (e.g. death and/or hospitalisation, stroke and/or heart attack) and how they would like to be treated.

This research will create new knowledge relevant to the health and wellbeing of older New Zealanders and health delivery. It has the potential to generate substantial improvements in outcomes for this age group- and will do so in a manner that is sensitive to the complexity of care, quality of life and older people’s preferences.

A bit about Susan Wells…

I’m an Associate Professor of Health Innovation and Quality Improvement at the School of Population Health, University of Auckland. I was a GP for 10 years before becoming a public health medicine specialist.

My research focus has been on improving CVD and diabetes care via e-health initiatives such as PREDICT (a web-based decision support system), and Your Heart Forecast (a CVD risk communication tool). He primary care cohort study I lead (for CVD and diabetes research) has over 450,000 participants.

Liam Butler is a Social Worker who also contributes to insitemagazine.co.nz by asking leaders in the health and disability sector their opinion on issues affecting New Zealand’s aged care and retirement sector.

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