How can a structured Cardiac Geriatric Service be set up for patients ≥65 years with cardiac disease (e.g., coronary artery disease, heart failure, atrial fibrillation, valvular disease) and associated frailty or comorbidities?

Setting Up a Structured Cardiac Geriatric Service

Establish a multidisciplinary collaborative model centered on comprehensive geriatric assessment integrated with cardiovascular expertise, using monthly case conferences and systematic evaluation protocols to address the complex interplay of cardiac disease, frailty, multimorbidity, and patient-centered goals in adults ≥65 years. 1, 2

Core Structural Components

1. Multidisciplinary Team Assembly

Build your team with the following essential members:

• Geriatricians and cardiologists as co-leaders to provide dual expertise in aging physiology and cardiovascular disease 1, 3
• Cardiothoracic surgeons for procedural decision-making in high-risk older adults 1
• Clinical pharmacists for medication reconciliation and polypharmacy management 4
• Physical/occupational therapists for functional assessment 4
• Palliative care specialists for goals-of-care discussions 4
• Nurse coordinators for care transitions and remote monitoring 4

2. Regular Case Conference Structure

Implement a monthly Geriatric Cardiology Conference as the operational backbone:

• Present active cases requiring complex decision-making (not retrospective reviews) 1
• Analyze each case in detail with consensus-building among all disciplines 1
• Include trainees at multiple levels for educational continuity 1
• Document treatment strategies and follow-up plans systematically 1

Clinical Assessment Framework

Initial Comprehensive Evaluation

Every patient entering the service requires systematic assessment across four domains 4:

Medical and Lifestyle Domain:

• Document all cardiac diagnoses (CAD, HF, AF, valvular disease) with severity staging 4, 3
• Identify the 10 most common comorbidities: hypertension, hyperlipidemia, diabetes, chronic kidney disease, arthritis, anemia, COPD, hypothyroidism, dementia, depression 4
• Screen for polypharmacy (≥5 medications) with prescription fill data to assess adherence 4
• Check for drug-drug interactions using EHR alerts 4
• Adjust dosing based on eGFR for renal function 4

Physical Functioning Domain:

• Frailty assessment using validated tools (Fried criteria or Clinical Frailty Scale) 3, 2, 5
• Functional status measurement (ADLs, IADLs) 2, 6
• Fall risk evaluation 5
• Mobility testing (gait speed, 6-minute walk test) 7

Mind and Emotions Domain:

• Cognitive screening (Mini-Cog, Montreal Cognitive Assessment) 5, 6
• Depression screening (PHQ-9) 4
• Delirium risk stratification for procedural candidates 7

Social and Environmental Domain:

• Caregiver availability and burden assessment 4, 5
• Social support networks and living situation 4
• Access to transportation and community resources 4

Patient-Centered Decision-Making Protocol

Goals-of-Care Elicitation

Conduct structured conversations at every initial visit 4, 6:

• Use the "Ask-Tell-Ask" communication framework 4
• Provide advance care planning tools (Five Wishes booklet, Prepare for Your Care website) 4
• Document specific health outcome priorities: longevity vs. quality of life vs. functional independence 6
• Clarify preferences regarding invasive procedures and hospitalization 6

Shared Decision-Making Algorithm

Follow this systematic approach 4, 6:

1. Identify therapies treating multiple conditions simultaneously:

   • SGLT2 inhibitors for HF + diabetes + CKD 4
   • ACE inhibitors/ARBs for hypertension + HF + CKD 4
   • Beta-blockers for AF + HF + CAD 4

2. Prioritize interventions by absolute benefit in older adults:

   • Rank options based on mortality reduction, disability prevention, and quality of life improvement 2, 6
   • Consider time-to-benefit relative to life expectancy 4, 5

3. Assess treatment burden:

   • Medication complexity and side effect profile 5
   • Frequency of monitoring requirements 4
   • Procedural risks in frail patients 7

4. Deprescribe systematically:

   • Remove medications without ongoing indication 4
   • Eliminate duplicate therapies within drug classes 4
   • Stop potentially harmful medications in reduced life expectancy 4

Operational Systems

Care Coordination Infrastructure

Establish these practical mechanisms 4:

• Centralized scheduling for all specialty appointments to reduce patient burden
• EHR interoperability with health information exchange access for outside records 4
• Telemedicine/telehealth capabilities for follow-up visits 4
• Remote patient monitoring for HF (daily weights, symptoms) 4
• Pharmacy consultation services embedded in clinic flow 4

Follow-Up Protocols

Structure ongoing care with specific triggers 4:

• Reassess comprehensive geriatric assessment every 6 months or with status change 3
• Medication reconciliation at every visit with prescription fill verification 4
• Laboratory monitoring based on medication regimen (eGFR, potassium, BNP) 4
• Functional status tracking to detect decline early 2

Quality Improvement Metrics

Track these outcomes to evaluate program effectiveness 7:

• Complication rates (particularly delirium incidence in procedural patients) 7
• Quality of life scores using validated instruments 7
• 30-day readmission rates 7
• Medication appropriateness (reduction in polypharmacy, PIMs) 4
• Advance directive completion rates 4

Common Pitfalls to Avoid

Do not apply disease-specific guidelines rigidly without considering frailty status and life expectancy—robust older adults can follow standard protocols, but frail patients require personalized approaches 2, 5

Do not neglect caregiver involvement—family members must be integrated into visits and decision-making, as they often manage medications and recognize clinical deterioration 4, 5

Do not defer goals-of-care discussions—these conversations should occur proactively at baseline, not during acute illness 4, 6

Do not overlook geriatric syndromes (falls, cognitive impairment, functional decline) when focusing on cardiac optimization—these often determine outcomes more than cardiac metrics alone 3, 5