Geriatric medicine is undergoing a quiet revolution as physicians move away from a more palliative mindset and toward the goal of improving quality of life and promoting longevity. Part of this revolution has to do with changing demographics; people are more likely today to survive into old age than at any other time in history. This means that geriatric medicine will only grow in importance in the years ahead.
In Age and Aging, Ellis and Sevdalis advocated for a multidisciplinary approach to geriatric medicine. They wrote, “The principles of effective [multidisciplinary] working cut across skills (eg, good leadership), processes (eg, good governance in documenting action plans) and critical values (eg, centrality of the patient’s needs and respect for colleagues).” All 3 elements must be present for multidisciplinary cooperation to remain effective.
A multidisciplinary approach to geriatric medicine makes sense because the nature of frailty in older individuals means they often present with multiple comorbidities; it also makes them more vulnerable to being diagnosed with new diseases. In addition, the elderly population is more likely to have significant past medical and surgical histories.
Pulmonary arterial hypertension (PAH) is characterized by an increase in pulmonary vascular resistance, leading to heart failure and mortality. PAH has traditionally been associated with young people, and studies in the 1980s demonstrated that the group most likely to be affected by PAH is young women. However, recent studies have revealed this is no longer the case; PAH is now mostly affecting individuals who are significantly older.
Why is this the case? PAH can be idiopathic in nature, so the trigger for this disease remains a mystery. However, this can be explained in part by the advancements in diagnostic modalities, allowing previously undetected PAH to be discovered in the elderly.
Read more about PAH epidemiology
Let’s take a look at the mean age of PAH diagnosis across the world today. It is 36 years in the US, 45 years in Spain, 50 years in France, and 50.1 years in the UK and Ireland.
In the Journal of the Chinese Medical Association, Chen and colleagues wrote, “Despite the changing demographics of PAH, a limited number of studies have examined the characteristics of elderly individuals diagnosed with PAH.” They hence conducted a literature review to provide a picture of how PAH should be managed in a geriatric setting.
Diagnostic Difficulties in PAH
A diagnosis of PAH needs to be suspected in order for investigations to be carried out. However, other comorbidities, such as coronary artery disease and chronic obstructive pulmonary disease (COPD), can make PAH easy to miss.
In Clinical Cardiology, Rothbard and colleagues wrote, “Delays in diagnosis may be detrimental as elderly patients tend to present at a worse functional class, which may be due to their underlying comorbidities or even extrinsic factors such as socioeconomic status.”
In order to understand the hemodynamics of a patient, a comprehensive set of investigations is needed. This usually includes electrocardiogram, pulmonary function tests, chest x-ray, arterial blood gas, and echocardiography.
PAH can be categorized as group 1 pulmonary hypertension, meaning that it is a “precapillary” form of pulmonary hypertension. The current definition of PAH is a mean pulmonary arterial pressure of more than 20 mmHg and a pulmonary capillary wedge pressure of less than 15 mmHg.
Treatment Considerations in the Elderly
The most commonly prescribed medications in the management of PAH remain phosphodiesterase type-5 inhibitors, such as sildenafil and tadalafil, as well as prostacyclin analogs, such as epoprostenol, treprostinil, and iloprost. Lung transplantation is a curative option for PAH, but its viability as a treatment strategy in the elderly is questionable, considering the high risk of mortality.
Overall, PAH pharmacology has greatly improved over the last few years, resulting in better clinical outcomes. However, many treatment regimens prescribed for younger patients involve multiple medications. Due to a higher risk of the adverse effects of polypharmacy, physicians are limited in terms of the types, dosage, and number of drugs they can prescribe for geriatric patients.
Read more about PAH treatment
“In the elderly population, delayed diagnosis usually means advanced disease at presentation,” Rothbard and colleagues cautioned. “With evidence pointing towards initial combination therapy, the use of multiple drugs working on multiple PAH pathways creates the possibility of drug–drug interactions in the elderly population.”
In addition, studies have found that elderly patients exhibit a poorer response to PAH therapies compared to younger patients. For example, a few months into therapy, younger patients are more likely to exhibit better performance on the 6-minute walk test, compared to older patients. In addition, younger patients are more likely to have functional class I/II after a year of therapy compared to older patients.
Although the care of PAH in elderly patients remains challenging, it should not deter physicians from attempting to diagnose and treat this disease. More research is needed on PAH in the geriatric population to identify the best therapeutic strategies for them.
Chen CY, Hung CC, Chiang CH, et al. Pulmonary arterial hypertension in the elderly population. J Chin Med Assoc. 2022;85(1):18-23. doi:10.1097/JCMA.0000000000000658
Ellis G, Sevdalis N. Understanding and improving multidisciplinary team working in geriatric medicine. Age Ageing. 2019;48(4):498-505. doi:10.1093/ageing/afz021
Rothbard N, Agrawal A, Fischer C, Talwar A, Sahni S. Pulmonary arterial hypertension in the elderly: clinical perspectives. Cardiol J. 2020;27(2):184-193. doi:10.5603/CJ.a2018.0096