Geriatric Community Research Articles

Morbidity profile, health seeking behaviour and home environment survey for adaptive measures in geriatric population-Urban community study

Background: Population ageing is a significant product of demographic transition. Declining fertility and improved health and longevity have generated rising proportions of the older population. Double burden of communicable and noncommunicable diseases affects the geriatric segment of the population with variable health seeking behaviour. Objectives: To assess morbidity profile, health seeking behaviour and home environmental survey for adaptive measures in geriatric population from an urban community. Material and Methods: Crosssectional study stratified systematic random sampling was applied. Research tool was interviewer based closed ended questionnaire. Adaptive measures as part of environment survey were assessed. Proportions and Pearson’s chi-square test were calculated. Results: 64.1% participants were from 60-69 years age category, 9.1% current smokers. 94.1% had 1-3 morbidities, 4.1% had 4-6 morbidities .37.3% gave a history of fall and 31.4% history of fracture. 13.6% cataract operation, 16.8% procedure for fracture.10% had dental procedure. 54.2% went to UHC and GOVT/BMC hospitals for treatment and 78.6% received both allopathic and ayurvedic treatment. History of fall was not associated with adaptive measures in the house (p=0.952). Conclusions: Majority of the participants suffered from old age related morbidities, hypertension emerged as a major morbidity. Most of the participants relied on government hospitals for treatment. Adaptive measures were lacking in most of the houses.

Police on the front line of community geriatric health care: challenges and opportunities.

As the population ages, police increasingly serve as first responders to incidents involving older adults in which aging-related health plays a critical role. The goals of this study were to assess police officers' knowledge of aging-related health, to identify challenges police experience in their encounters with older adults, and to describe their recommendations for how to address those challenges. This was a mixed-methods study of 141 San Francisco police officers recruited from mandatory police trainings between 2011 and 2013. Descriptive statistics were used to analyze 141 self-administered questionnaires, and principles of grounded theory were used to analyze open-ended questionnaire responses and 11 additional qualitative interviews. Eighty-nine percent of officers reported interacting with older adults at least monthly. Although 84% of police reported prior training in working with older adults, only 32% rated themselves as knowledgeable about aging-related health. Participants described themselves as first responders to medical and social emergencies involving older adults and identified several challenges, including identifying and responding to aging-related conditions and ensuring appropriate medical and social service handoffs. To address these challenges, officers recommended developing trainings focused on recognizing and responding to aging-related conditions and improving police knowledge of community resources for older adults. They also called for enhanced communication and collaboration between police and clinicians. These findings suggest that, because they assume a front-line role in responding to older adults with complex medical and social needs, many police may benefit from additional knowledge about aging-related health and community resources. Collaboration between police and healthcare providers presents an important opportunity to develop geriatrics training and interprofessional systems of care to support police work with a rapidly aging population.

Multi-compartment compliance aids (MCAs): Application to the geriatric community

The high prevalence of co-morbidities in older people gives rise to an increasing number of prescribed medicine increasing the complexity of medicine management. Multi-compartment compliance aids and dispensing systems have the potential to organize the daily life of an older person. Various features of currently available compliance aids (such as multi-compartment design or an automated reminder function) have proved successful in assisting older patients to take their medication. This in turn enables them to manage their own often-complex drug regimens. Further investigations and collaborations between healthcare professionals, patients and carers are required for validated and effective use of compliance aids.

Screening for alcohol and substance use for older people in geriatric hospital and community health settings.

We aimed to determine the rates of alcohol and substance use in geriatric hospital and community health settings, and to evaluate the performance of screening instruments. A two-phase cross-sectional study was undertaken in geriatric and aged care psychiatry wards and associated community services of a teaching hospital. Participants were screened with the Brief Alcohol Use Disorders Identification Test (AUDIT-C) and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) for other substances; Geriatric Depression Scale-15 for mood; the Connor-Davidson Resilience Scale; and the Subjective Quality of Life scale. Medical conditions were established. Screen positives for risky substance use continued with the full AUDIT, full ASSIST, CAGE, Addenbrooke's Cognitive Examination-Revised, and the Functional Activities Questionnaire. Medical records were reviewed after three months to ascertain recognition and management of substance use. Of 210 participants aged 60+ (mean age 81.9, 63.3% female) without dementia or delirium and Mini Mental State Examination score ≥24, 41 (19.5%) were screen positive - 36 (17.1%) for alcohol, seven for non-medical benzodiazepine use (3.3%) (four alcohol and benzodiazepine) and two for non-medical opioid use (0.95%). Screen positives differed from screen negatives on few demographic or health measures. On the ASSIST, 26 (12.4%) were rated as medium/high risk. The AUDIT-C with cut-point of ≥5 was the optimal measure for detecting risky alcohol use. Many patients in geriatric health services have risky alcohol or substance use, but few clinical features distinguish them from other patients. Routine screening of alcohol and substance use is recommended.

Effects of a Multidomain Lifestyle Modification on Cognitive Function in Older Adults: An Eighteen-Month Community-Based Cluster Randomized Controlled Trial

Background: A healthy lifestyle may protect against cognitive decline. We examined outcomes in elderly individuals after 18 months of a five-group intervention program consisting of various modalities to prevent cognitive decline. Methods: We conducted a cluster randomized controlled trial assessing 460 community-dwelling individuals aged 60 years and older in a geriatric community mental health center in Suwon, Republic of Korea, between 2008 and 2010. We developed an intervention program based on the principles of contingency management, which could be delivered by ordinary primary health workers. Group A (n = 81) received standard care services. Group B (n = 80) received bimonthly (once every 2 months) telephonic care management. Group C (n = 111) received monthly telephonic care management and educational materials similar to those in group B. Group D (n = 93) received bimonthly health worker-initiated visits and counseling. Group E (n = 94) received bimonthly health worker-initiated visits, counseling, and rewards for adherence to the program. Results: The primary outcome was the change in Mini-Mental State Examination (MMSE) scores from baseline to the final follow-up visit at 18 months. Group E showed superior cognitive function to group A (adjusted coefficient β = 0.99, p = 0.044), with participation in cognitive activities being the most important determining factor among several health behaviors (adjusted coefficient β = 1.04, p < 0.01). Conclusions: Engaging in cognitive activities, in combination with positive health behaviors, may be most beneficial in preserving cognitive abilities in community-dwelling older adults.

Foundation training in community geriatrics

Daniel Eckford, the first doctor to have a foundation programme post in community geriatrics, describes work in the specialty and his experiences

From doctor to “hybrid” health professional

Over the coming decades, doctors’ training and practice will have to undergo substantial change to meet the needs of an ageing and increasingly unwell patient population. Some of those changes will mean shifting the traditional boundaries between different sectors of the health service, and this week Daniel Eckford describes his experience of undertaking foundation training in community geriatrics (http://careers.bmj.com/careers/advice/view-article.html?id=20018142). The project …

Impact of observation on disposition of elderly patients presenting to emergency departments with non-specific complaints.

BackgroundEmergency Departments (EDs) have to cope with an increasing number of elderly patients, often presenting with non-specific complaints (NSC), such as generalized weakness. Acute morbidity requiring early intervention is present in the majority of patients with NSC. Therefore, an early and optimal disposition plan is crucial. The objective of this study was to prospectively study the disposition process of patients presenting to the ED with NSC.MethodsFor two years, all patients presenting with NSC presenting to an urban ED were screened and consecutively included. The initial disposition plan was compared to the effective transfer after observation. Optimal disposition was defined as a high accuracy regarding disposition of patients with acute morbidity to an internal medicine ward.ResultsThe final study population consisted of 669 patients with NSC. Admission to internal medicine increased from 297 (44%) planned admissions to 388 (58%) effective admissions after observation. Conversely, transfers to geriatric community hospitals and discharges decreased from the initially planned 372 (56%) patients to 281 (42%) effectively transferred and discharged patients. The accuracy regarding disposition of patients with acute morbidity increased from 53% to 68% after observation.ConclusionDisposition planning in patients with NSC improves after observation, if defined by the accuracy regarding hospitalization of patients with acute morbidity. Further research should focus on risk stratification tools for timely disposition planning in order to reduce high admission rates for patients without acute morbidity and high readmission rates for discharged patients with non-specific complaints.

Reports of Depression in Older Women with Osteoporosis

Osteoporosis is a significant problem in the aging population, is associated with considerable morbidity and depression, and contributes to increased health care costs. Because age and post-menopausal status are primary risk factors, older women in the geriatric community are at increased risk. Recent studies have suggested that depression and osteoporosis have a bidirectional link, and use of SSRIs has been associated with frailty and reduced bone mass (Vyas, 2013; Diem, et al., 2007) which lead to fractures, disability, deformity and death.

Providing Mental Health Services within Community Geriatric Interdisciplinary Teams: Challenges and Successes

On Lok Lifeways (On Lok), the original Program of All-inclusive Care for the Elderly (PACE) organization provides comprehensive health care for community dwelling frail seniors in San Francisco and South Bay areas, California. On Lok serves over a thousand participants who speak 30 languages. Prior to 2005, On Lok did not have an on-site mental health component and participants were referred to off-site contracted psychiatrists and psychologists for all mental health services. In 2005 On Lok introduced an on-site Mental and Behavioral Health (MBH) team. Currently the team includes a neuropsychologist, five psychotherapists and two part-time psychiatrists. In addition, a full time chaplain is assisting participants with their spiritual needs. The goal of the MBH program is to increase interdisciplinary team effectiveness in care of frail elders with mental and behavioral health issues and to improve access to mental health services for a vulnerable and diverse senior population. MBH team members are providing various direct and indirect services to On Lok participants and staff. Key responsibilities include assessment of mental and behavioral health needs for applicants or new enrollees; routine reassessment every 6 months for participants with a psychiatric diagnosis; counseling to participants and their family members; administration and interpretation of neuropsychological tests for participants with cognitive impairments; crisis intervention and management; and psychotropic medication management as requested by primary care providers. In addition, mental health clinicians conduct regular trainings for all staff regarding various mental health and spiritual issues. Implementing on-site MBH services resulted in quadrupling of the number of appointments to mental health clinicians. There was a reduction in psychiatric inpatient utilization from 12 admissions/1000 patients/year in 2004, to 3 admissions/1000 patients/year in 2005. This reduction was sustained over the past 8 years. The availability of MBH clinicians who can provide timely consultations significantly increased interdisciplinary team understanding of mental health issues and increased team confidence in dealing with difficult mental health cases in an outpatient setting. Inclusion of mental and behavioral health clinicians on geriatric interdisciplinary care teams increased the complexity of care coordination; however the integration of mental health component into comprehensive geriatric care improved the quality of care by increasing timely access to mental health services, reduced the rate of psychiatric inpatient admissions, and reduced anxiety and stress of interdisciplinary teams caring for frail elders with mental health diagnoses.

An Innovative Community Geriatrics Elective to Teach Year 4 Medical Students About Nursing Home Care

In Singapore, Geriatrics is core curriculum in medical undergraduate training. Year two medical students are introduced to aging in a four hour program based in a nursing home. In their final year they spend one month in geriatric medicine as part of their 3 month internal medicine posting. In the fourth year there is an elective period of six weeks where they choose postings that they would like to spend time to learn more about the subject. There are 65 NHs in Singapore with 9495 beds as compared to 6 acute hospitals with 7500 beds. The NHs have more patients for students to learn from. The residents are also more stable to engage the students and participate in their learning. The NH also has unique aspects of Long Term care like managing severely disabled individuals including dementia, tube feeding, decision making and choices, ethics, pain, reversible conditions like delirium, depression and functional decline. In 2010, a course to teach medical care of older people in nursing homes was developed. The aims of the course were to teach geriatric medicine in the nursing home environment, to understand aspects of end-of-life care such as tube feedings, pain and symptom control, ethics, families' and residents' goals. Twenty students have enrolled, and the course has been fully subscribed each year. This is a description of the course and its effects on students. Aims: to describe the content and implementation of the course. The course was funded by the University of Singapore Medical School and organized by the Division of Community Geriatrics of Changi General Hospital, a regional acute hospital in collaboration with two nursing homes in the healthcare cluster. The elective in Community Geriatrics was put up on the students' website stating objectives, content, outcomes, duration (two weeks) and the periods offered (12 weeks block). Supervisors were consultants with interest in community geriatrics and actively involved in community eldercare programs PLUS strong interest in teaching. There were four consultants. The 'syllabus' comprised of: a)reading materials; b) site visit: clerk two cases and discussion, one lecture, see ten types of cases and discuss care issues: 3 physical disability (Parkinson, stroke, spinal), dementia with disruptive behaviour, chronic pain, resident on feeding tube, recurrent faller, pneumonia, diabetes; c) keep a log book; d) a short clinical project (optional) - either an audit or an observational study (e.g., caregiving, environments); f) participate in a meal with residents and answer a few questions after that; and g) a short 10 question test. At the end of the 2 week elective there was a closing session with students and their respective tutors/teachers which included debriefing, reflection and mutual feedback given by and received from students.

A New Model for End-of-Life Care in Nursing Homes

ObjectivesThis study aimed to promote quality end-of-life (EOL) care for nursing home residents, through the establishment of advance care plan (ACP) and introduction of a new care pathway. This pathway bypassed the emergency room (ER) and acute medical wards by facilitating direct clinical admission to an extended-care facility. DesignAn audit on a new clinical initiative that entailed the Community Geriatrics Outreach Service, ER, acute medical wards, and an extended-care facility during winter months in Hong Kong. MethodsThe participants were older nursing home residents enrolled in an EOL program. We monitored the ratio of clinical to emergency admissions, ACP compliance rate, average length of stay (ALOS) in both acute hospital and an extended-care facility, and mortality rates. ResultsA total of 76 patients were hospitalized from January to March 2013. Of them, 30 (39%) were directly admitted to the extended-care facility, either through the liaison of Community Geriatrics Outreach Service (group A, 19/76, 25%) or transferred from the ER (group B, 11/76, 14%). The remaining 46 patients (group C, 61%) were admitted via the ER to acute medical wards following the usual pathway, followed by transfer to an extended-care facility if indicated. The ACP compliance rate was nearly 100%. In the extended-care unit, groups A and C had similar ALOS of 11.8 and 11.1 days, respectively, whereas group B had a shorter stay of 7.6 days. The ALOS of group C in acute medical wards was 3.5 days. The in-hospital mortality rates were comparable in groups A and C of 26% and 28%, respectively, whereas group B had a lower mortality rate of 18%. ConclusionsNearly 40% of EOL patients could be managed entirely in an extended-care setting without compromising the quality of care and survival. A greater number of patients may benefit from the EOL program by improving the collaboration between community outreach services and ER; and extending hours for direct clinical admission to an extended-care facility.

The Use of Frailty as a Surgical Risk Assessment Tool in Elderly Patients

With the continued aging of the population, a rising proportion of surgical procedures will be performed in elderly patients. Current surgical decision-making tools rely on subjective judgments and were developed without special geriatric considerations. As a result, they have certain inadequacies that limit their utility in this population. Frailty, described for decades by the medical geriatric community, has just recently begun to be investigated as a surgical risk assessment tool. Identifying the frailty phenotype has been shown by multiple investigators to reliably predict which patients are at increased risk of adverse peri-operative outcomes. Perhaps, most importantly, it is a tool that can potentially discriminate among the elderly, identifying those that warrant heightened concern, "pre-habilitation", or special postoperative attention from those at no increased risk compared to the general population. Alternatively, some patients may be identified as “too frail” to undergo surgery, and alternative nonsurgical treatment options may be considered.

Public engagement workshop: How to improve medicines for older people?

Public engagement in medication management has become more and more important in promoting population health. A public engagement workshop attended by 78 members of the geriatric community, family carers as well as professionals from academic research, industry and regulatory agencies entitled 'How to improve medicines for older people?' took place on the 2nd July 2013 at the University College London (UCL) School of Pharmacy. The main aim of the event was to provide a dynamic environment for information exchange and to identify ways of improving current and future geriatric drug therapy. The day opened with presentations from UCL School of Pharmacy researchers on the use of medicines at home, formulations, administration devices and multi-component compliance aids (MCAs) whilst a representative from UCL Interaction Centre gave an insightful presentation on human errors and resilience strategies regarding medication use. These opening presentations encouraged participants to share their own experiences as well as initiating a lively debate. Following the plenary presentations, the workshop was divided into 8 groups for parallel discussion session. These opinion sharing sessions witnessed fruitful discussions between patients, carers and researchers. The day closed with a panel session of representatives from the European Medicines Agency (EMA), the Medicines and Healthcare products Regulatory Agency (MHRA), the Geriatric Medicines Society and Guy's and St. Thomas' NHS Foundation Trust (GSTT). Participants were encouraged to voice their questions, concerns and recommendations about medications. The main concern expressed by both patients and carers from the workshop were (but are not limited to) formulation changes, MCA accessibility difficulties, interactions of different medicines, carers' concerns with the administration of medicines and not having enough knowledge of services provided by community pharmacists i.e. medicines use reviews (MURs) or new medicine service (NMS). Overall, this workshop created a useful forum for members of the geriatric community, their carers as well as research and industrial professionals to have an input in the improvement and management of geriatric drug therapy and this event also provided an excellent opportunity for the researchers to share the latest research innovations with attendees.

The interplay between inflammation, physical activity and metabolic syndrome in a remote male geriatric community in Southern Taiwan: the Tianliao Old People (TOP) study 03

BackgroundBoth physical activity and inflammation are important in the pathophysiology of metabolic syndrome (MetS). Our study aim is to explore their associations in an elderly male (≥ 65 years old) cohort.MethodsWe enrolled 309 elderly male residents (mean age: 74.4 ± 6.0 years) in a remote southern Taiwan community. The physical activity was recorded by a standard questionnaire. A high-sensitivity C-reactive protein (hsCRP) level > 3.0 mg/L indicated a high inflammatory status.ResultsThe total prevalence rate of MetS was 27.8% in this male geriatric cohort. Median hsCRP levels were significantly higher in the MetS group (1.60 ± 0.7 vs. 1.0 ± 0.3 mg/L, p < 0.01), and the risk of elevated hsCRP increased with escalating MetS components (p for trend < 0.001). The non-MetS group had higher amount of median weekly physical activity (183.1 ± 19.0 vs. 173.5 ± 10.6 MET-hr/week, p = 0.029), which was also higher among those with lower hsCRP levels (186.1 ± 14.1 vs. 167.8 ± 38.5 MET-hr/week, p = 0.013). Multivariate analysis showed that higher body mass index (ORs: 1.527, 95% CI: 1.319-1.768, p < 0.01) insulin (OR: 1.128, 95% CI: 1.045-1.218, p < 0.01) and physical activity (ORs: 0.997, 95% IC: 0.994-0.999, p < 0.05) were independent predictors of MetS, but not hsCRP level (p > 0.05).ConclusionsReduced physical activity was one major pathophysiological MetS factor in our Asian geriatric participants.

Mortality and health services utilisation among older people with advanced cognitive impairment living in residential care homes

To study the demography, clinical characteristics, service utilisation, mortality, and predictors of mortality in older residential care home residents with advanced cognitive impairment. Cohort longitudinal study. Residential care homes for the elderly in Hong Kong West. Residents of such homes aged 65 years or more with advanced cognitive impairment. In all, 312 such residential care home residents (71 men and 241 women) were studied. Their mean age was 88 (standard deviation, 8) years and their mean Barthel Index 20 score was 1.5 (standard deviation, 2.0). In all, 164 (53%) were receiving enteral feeding. Nearly all of them had urinary and bowel incontinence. Apart from Community Geriatric Assessment Team clinics, 119 (38%) of the residents attended other clinics outside their residential care homes. In all, 107 (34%) died within 1 year; those who died within 1 year used significantly more emergency and hospital services (P<0.001), and utilised more services from community care nurses for wound care (P=0.001), enteral feeding tube care (P=0.018), and urinary catheter care (P<0.001). Independent risk factors for 1-year mortality were active pressure sores (P=0.0037), enteral feeding (P=0.008), having a urinary catheter (P=0.0036), and suffering from chronic obstructive pulmonary disease (P=0.011). A history of pneumococcal vaccination was protective with respect to 1-year mortality (P=0.004). Residents of residential care homes for the elderly with advanced cognitive impairment were frail, exhibited multiple co-morbidities and high mortality. They were frequent users of out-patient, emergency, and in-patient services. The development of end-of-life care services in residential care homes for the elderly is an important need for this group of elderly.

Commissioning services for people with dementia: how to get it right

SummaryThe current emphasis on improving the quality of dementia services is welcome, but it treats dementia as if it were separable from complex comorbidities, disability and frailty. As a consequence, dementia can overshadow other problems, from heart failure to multisystem failure at the end of life, which may be poorly managed. Three ways in which old age psychiatrists can reconnect dementia with the diseases and disorders of later life are described in this editorial. The first is to improve skills in general practice so that general practitioners (GPs) can take on the bulk of the clinical work of both diagnosis and management of dementia and its comorbidities, while specialists retain complex decision-making and management tasks. The second is for old age psychiatrists to function as consultants to social enterprises run by GPs for the purpose of managing almost all patients with dementia in general practice. The third is for community geriatricians and old age psychiatrists to work together in integrated organisations that take full clinical responsibility for older people with dementia.

Frailty as a Novel Predictor of Delayed Graft Function in Kidney Transplant Recipients

The ability to predict outcomes following kidney transplantation (KT) is limited by the complex physiologic decline of kidney failure, a latent factor that is difficult to capture using conventional comorbidity assessment. The frailty phenotype is an inflammatory state of increased vulnerability to stressors resulting from decreased physiologic reserve and dysregulation of multiple physiologic systems, recently described and validated in geriatrics patients. We hypothesized that frailty would be associated with delayed graft function (DGF), based on similar associations between inflammatory cytokines, frailty, and early graft dysfunction. Methods: We prospectively measured frailty (grip strength, walking speed, unintentional weight loss, exhaustion, and low physical activity, based on the Fried scale) in 183 KT recipients between 12/08-4/10. We also collected recipient factors (age, BMI, race, gender, time on dialysis, pre-emptive KT, history of cerebrovascular event and diabetes) as well as donor factors (donor type, creatinine, donation after cardiac death (DCD), extended criteria donors (ECD), and cold ischemia time (CIT)). Parsimonious models were designed by examining AIC and likelihood ratio tests for nested models. Independent associations (adjusted for donor and recipient factors) between frailty and DGF were analyzed using modified multivariate Poisson regression. Results: Rate of DGF was 30% in frail and 15% in non-frail recipients. After adjusting for multiple donor and recipient factors, frailty was independently associated with twice the risk of DGF (RR 1.94, 95% CI 1.13-3.36, p-value=0.02). Conclusion: Frailty, an inflammatory construct developed in the geriatrics community, may provide further insights into the pathophysiology of allograft dysfunction and improve our ability to preoperatively risk-stratify KT recipients.

Frailty as a Novel Predictor of Delayed Graft Function in Kidney Transplant Recipients

The ability to predict outcomes following kidney transplantation (KT) is limited by the complex physiologic decline of kidney failure, a latent factor that is difficult to capture using conventional comorbidity assessment. The frailty phenotype is an inflammatory state of increased vulnerability to stressors resulting from decreased physiologic reserve and dysregulation of multiple physiologic systems, recently described and validated in geriatrics patients. We hypothesized that frailty would be associated with delayed graft function (DGF), based on similar associations between inflammatory cytokines, frailty, and early graft dysfunction. Methods: We prospectively measured frailty (grip strength, walking speed, unintentional weight loss, exhaustion, and low physical activity, based on the Fried scale) in 183 KT recipients between 12/08-4/10. We also collected recipient factors (age, BMI, race, gender, time on dialysis, pre-emptive KT, history of cerebrovascular event and diabetes) as well as donor factors (donor type, creatinine, donation after cardiac death (DCD), extended criteria donors (ECD), and cold ischemia time (CIT)). Parsimonious models were designed by examining AIC and likelihood ratio tests for nested models. Independent associations (adjusted for donor and recipient factors) between frailty and DGF were analyzed using modified multivariate Poisson regression. Results: Rate of DGF was 30% in frail and 15% in non-frail recipients. After adjusting for multiple donor and recipient factors, frailty was independently associated with twice the risk of DGF (RR 1.94, 95% CI 1.13-3.36, p-value=0.02). Conclusion: Frailty, an inflammatory construct developed in the geriatrics community, may provide further insights into the pathophysiology of allograft dysfunction and improve our ability to preoperatively risk-stratify KT recipients.

Minimally Invasive Surgery for Aortic Stenosis in the Geriatric Patient: Where are We Now?

Minimally invasive aortic valve surgery has evolved with time and become the routine approach for aortic surgery in select surgical centers. The success of these procedures in the nonelderly has led some to embark on using minimal access techniques in the geriatric population as well. With the geriatric community often inflicted with the greatest disease burden, suffering not only from a valvular process but also cumulative comorbidities, geriatric patients may be the patients most likely to derive benefit from a minimally invasive approach. Alternative therapies for symptomatic aortic stenosis include conventional full-sternotomy aortic valve replacement in addition to transcatheter aortic valve implantation. Each option has its advantages and disadvantages. The role of minimal access aortic valve surgery and its impact on the progressively aging population in the face of conventional surgery and transcatheter technology is discussed.