The Struggle to Deal with the Presently Incurable Issues of Aging

The struggles and sufferings of the old are largely conducted behind the curtain, not talked about all that much in the public sphere. How does one manage the last phase of life for a failing, complex machine that cannot be repaired, only coaxed into a slightly slower decline? As it turns out, a fair amount of not thinking about it is involved: on the part of younger people, and particularly on the part of research and development institutions that do not wish to be burdened with the very complex, interacting nature of late life age-related diseases. New treatments and adjustments to the standard of care are rarely formally tested in the older, more frail part of the patient population.

30-40% of people hospitalized with ACS are age 75 or older. ACS includes heart attack and unstable angina (heart-related chest pain). Cardiovascular changes that occur with normal aging make ACS more likely and may make diagnosing and treating it more complex: large arteries become stiffer; the heart muscle often works harder but pumps less effectively; blood vessels are less flexible and less able to respond to changes in the heart's oxygen needs; and there is an increased tendency to form blood clots. Sensory decline due to aging may also alter hearing, vision and pain sensations. Kidney function also declines with age, with more than one-third of people ages 65 and older having chronic kidney disease. These changes should be considered when diagnosing and treating ACS in older adults.

Clinical practice guidelines are based on clinical trial research. However, older adults are often excluded from clinical trials because their health care needs are more complex when compared to younger patients. ACS is more likely to occur without chest pain in older adults, presenting with symptoms such as shortness of breath, fainting or sudden confusion. Measuring levels of the enzyme troponin in the blood is a standard test to diagnose a heart attack in younger people. However, troponin levels may already be higher in older people. Age-related changes in metabolism, weight and muscle mass may necessitate different choices in anti-clotting medications to lower bleeding risk. As kidney function declines, the risk of kidney injury increases, particularly when contrast agents are used in imaging tests and procedures guided by imaging. Although many clinicians avoid cardiac rehabilitation for patients who are frail, they often benefit the most.

As people age, they are often diagnosed with health conditions that may be worsened by ACS or may complicate existing ACS. As these chronic conditions are treated, the number of medications prescribed may result in unwanted interactions or medications that treat one condition may worsen another. Older adults differ widely in their independence, physical or cognitive limitations, life expectancy, and goals for the future. The goals of care for older people with ACS should extend beyond clinical outcomes (such as bleeding, stroke, another heart attack or the need for repeat procedures to reopen arteries).