specialty practice series
Best Practices in Nursing
Care to Older Adults
From The Hartford Institute for Geriatric Nursing, New York University, College of Nursing,
and Preventive Cardiovascular Nurse’s Association
Series Editor: Marie Boltz, PhD, GNP-BC
Series Co-Editor: Sherry A. Greenberg, MSN, GNP-BC
New York University College of Nursing
Cardiac Risk Assessment of the Older Cardiovascular Patient:
The Framingham Global Risk Assessment
sment Toools
By: Lola A. Coke, PhD, ACNS-BC, Rush University College of Nursing
and Preventive Carrddiovascular Nurse’’s Asso
Association
WHY: The American Heart Association estimated 785,000 Americans would have a new coronary attack in 2009 (AHA Statistics, 2009). In
the healthy older adult or the older adult with cardiovascular disease (CVD), determination of cardiovascular risk is important. Modifiable
cardiovascular risk factors include: physical inactivity, overweight and obesity
presence of metabolic syndrome (presence of three of the following five symptoms: abdominal obesity [waist circumference (men >40
inches, women >35 inches)]; elevated triglycerides *150 mg/dL; decreased HDL Cholesterol (men: <40 mg/dL, women <50 mg/dL); blood
pressure *130/*85 mmHg; and fasting blood glucose *110-125 mg/dL) and diabetes mellitus, as well as depressive symptoms and depression.
Evidence-based national guidelines provide information needed to conduct comprehensive management of these cardiovascular risk factors.
BEST TOOLS: The Framingham Global Risk Assessment tools have been used extensively with men and women and with a number of
ethnic groups. They are considered the “gold standard” for risk assessment. The lipid profile and anthropometric measures are needed to
complete the risk assessment.
Lipid Profile: Dyslipidemia leads to the build-up of atherosclerotic plaque in the arteries. Management of the lipid profile resulting in
normal lab values reduces the risk of CVD. The table below provides the elements of the lipid profile and their values. ATP III treatment
guidelines from the National Cholesterol Education Panel (NCEP) may be obtained at: [Link]
LIPID TYPE LAB
AB V
VA
ALUES
Tootal Cholesterol Desirable: <200; Borderline high: 200-239; High >240
Low-density (LDL) Cholesterol Optimal: <100; Near/above optimal: 100-129
Borderline high: 130-159; High: 160-189; Very high: >190
High-density (HDL) Cholesterol (high values are optimal) Low: <40; Borderline: 40-59; High >60
Triglycerides Desirable: <150; Borderline: 150-199; High >200
Anthropometric Measures: Determine the Body Mass Index (BMI) (weight in kg/ height in meters2) and waist circumference (measured with
a measuring tape at the upper hip bone and top of the iliac crest; in inches) and develop a plan for either weight maintenance or weight loss.
In some cases with frail older adults, weight gain and nutritional stabilization may be needed. Nutrition guidelines may be obtained from the
American Dietetic Association
on at: [Link]
p .[Link].
BMI V
VA
ALUES WA
WAIST CIRCUMFERE
MFERENCE V
VA
ALUES
Underweight: <18.5; Normal: 18.5-24.9; Men: Desirable: <40 inches; High: >40 inches
Overweight: 25-29.9; Class I Obesity: 30-34.9 Women:
o Desirable: <35 inches; High: >35 inches
Class II Obesity: 35-39.9;
Extreme Class III Obesity: *40
Framingham Global Risk Factor Assessment: CVD risk factor assessment is operationalized in many ways including comprehensive history
and physical examination including vital sign assessment, serum lab work, diagnostic testing, and use of risk assessment tools. The
Framingham Global Risk Assessment tools are comprehensive and effective measures to assess CVD risk in a variety of populations. The best
tool is based on: cardiovascular outcome, population of interest, risk timeline, and presence of risk factors. Specific Framingham tools are
provided and the Global Risk Assessments for men are on page 2 as an exemplar. All the tools may be accessed at: National Heart Lung and
Blood Institute, Interactive Tools
o and Resources: [Link]
p .n
[Link]/health/prof/other/ind
g p [Link]#tools.
Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-profit educational purposes only, provided that
The Hartford Institute for Geriatric Nursing, New York University, College of Nursing is cited as the source. This material may be downloaded and/or distributed in electronic format,
including PDA format. Avvailable
va on the internet at [Link] and/or [Link]. E-mail notification of usage to: [Link]@[Link].
Framingham Global Risk Categorical Values
Values
a measured in Global
Gl Points Range/Risk
/Risk Total
Tootal
Assessment Tools
o
Tools Risk Assessments = Composite Score* of 30 points for all scales
1. “Hard” coronary heart disease (Myocardial 1. Age <9 = <1% risk;
infarction or coronary death)* 2. Total
o cholesterol *25 = >30% risk
2. Coronary heart disease: 2-year and 10-year risk* 3. High-density lipoprotein cholesterol (HDL)
3. General CVD* 4. Treated/untreated blood pressure
4. Stroke/Death after atrial fibrillation 5. Smoking status
5. Intermittent claudication 6. Presence of diabetes mellitus
6. Recurring coronary heart disease
7. Congestive heart failure
8. Atrial fibrillation
* Categorical values for global risk assessment tools. The other tools have additional categorical values. CVD = cardiovascular disease
TARGET POPULA ATTION: Cardiac risk factor assessment is important for any older adult; all adults over 40 years should be screened for CVD
risk. The extent of assessment is dependent on family history, presence of CVD, other co-morbidities, and the number of identifiable risk
factors.
ALIDITY AND RELIABILIITY: The two most widely used and tested Framingham Global Risk Assessment tools have high sensitivity and
VA
specificity [Coronary heart disease 10-year (95% and 83%) and 2-year risk (67% and 98%)] respectively. All the Framingham Global Risk
Assessment tools have high sensitivity and specificity within these same ranges.
STRENGTHS AND LIMITATION AT S: The Framingham Global Risk Assessment Toools are gender specific and include different tools for
individuals with a variety of cardiovascular outcomes. There are instances when the tool overestimates risk in low-risk populations and
underestimates in high-risk groups. Recent studies have examined the accuracy of Framingham risk scores in women, different ethnic and
social groups (Brindle, et. al, 2006). A limitation is that they are not age specific.
FOLLOW-UP: If cardiovascular risk factors are identified, management and treatment guidelines for intervention and/or educational
resources are available. Primary care providers, in collaboration with interdisciplinary team members, should formulate goals and
comprehensive plans of care with patients, families and caregivers.
MORE ON THE TOPIC:
Best practice information on n care of older adults: [Link].
g
American Heart Association Statistics Committee & Stroke Statistics Subcommittee. (2009). Heart disease and stroke statistics – 2009
update. Retrieved October er 4, 2009 from [Link]
[Link]
p j [Link]/cgi/reprint/CIRCULA
g g p AT
TIO
TIONAHA.108.191261.
Brindle, P.,. Beswick, A., Fahey
Fahe , T. & Ebrahim, S. (2006). Accuracy
Accur and impact of risk assessment in the primary prevention of cardiovascular
disease: A systematic review. Heart, 92, 1752-1759.
TTable
aable 4. — Framingham Risk Scores for MEN TTable
able
a 4. 4 — Framingham Risk Scores for MEN (cont)
&TUJNBUFPGZ3JTL 'SBNJOHIBN1PJOU4DPSFT
Systolic BP (mm Hg) If Untreated If Treated
Age Points Assess Patient’s Risk of Heart Disease 120 0 0
120-129 0 1
To find out your patient’s risk of heart disease,
complete this assessment. 130-139 1 2
140-159 1 2
0 1. Circle the number of points in each section that
relaates to the patient’s current status. r160 2
2. Add up the points in the section provided (next p). Add Up the Points Total Points 10-y Risk %
6
.BUDIUIFUPUBMXJUIUIFOVNCFSTJOUIFMJTUUP Age: 0 1
the right of that section. This will tell you your TC: 0 1
10 paatient’s chance of having heart disease in the
11 next 10 years. 4NPLFS 1 1
12 )%-$ 2 1
4#1 1
TOTAL: 1
Tootal Points
Cholesterol 5 2
Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
Z3JTL @@@@@@@@@@ 6 2
160 0 0 0 0 0
7
160-199 2 1 0
200-239 7 5 1 0
240-279 9 6 2 1 9 5
r280 11 5 1 10 6
11
Points
12 10
Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
Nonsmoker 0 0 0 0 0 12
Smoker 5 1 1 16
15 20
HDL (mg/dL) Points Copyright © 2009 Preventive
16 25
r60 Carrddiovascular Nurses Association.
0 r17 r
All rights reserved.
1 "EBQUFEGSPN64%FQUPG)FBMUIBOE)VNBO4FSWJDFT1VCMJD)FBMUI4FSWJDF/BUJPOBM*OTUJUVUFTPG
2 )FBMUI/BUJPOBM)FBSU
-VOH
BOE#MPPE*OTUJUVUF/*)1VCMJDBUJPO/P
.BZ
MEDSURG Nursing is pleased to publish this regular feature, “Try This: Best Practices in Nursing Care to Older Adults,” developed by the Hartford Institute
for Geriatric Nursing.
This article was reprinted with permission from “Try This: Best Practices in Nursing Care to Older Adults” series from the John A. Hartford Foundation Institute
for Geriatric Nursing. Mathy Mezey, EdD, RN, FAAN, is Director of the Institute and Terry Fulmer, PhD, RN, FAAN is Co-Director. Series Editor is Sheila Molony, MS,
RN,C.
Address correspondence to the John A. Hartford Foundation Institute for Geriatric Nursing, New York University, The Steinhardt School of Education, Division
of Nursing, 246 Greene St, 5th Floor, New York, NY 10003, or call (212) 998-9018, or email [Link]@[Link] or access the Website at [Link].
Permission is hereby granted to reproduce this material provided The Hartford Institute for Geriatric Nursing, Division of Nursing, New York University is cited as
the source. Available on the Internet at [Link]. E-mail notification of usage would be appreciated to: [Link]@[Link].