Heart Failure in the Oldest Patients: The Impact of Comorbid Conditions

Use of Medicines that May Exacerbate Heart Failure in Older Adults: Therapeutic Complexity of Multimorbidity

BACKGROUND

Multimorbidity is common in older patients with heart failure (HF), complicating therapeutic management and increasing the risk of harm.

OBJECTIVE

This study sought to examine the prevalence of medicines for the treatment of comorbid conditions potentially associated with harm in older people, before and after HF hospitalization.

METHODS

A retrospective cohort study of older people hospitalized with a primary diagnosis of HF over a 12-month period was conducted using administrative health claims data from the Department of Veterans' Affairs (DVA) Australia. We examined the prevalence of medicines that may exacerbate or worsen HF as defined by the American Heart Association (AHA) and Australian HF clinical guidelines, in the 30 days prior and 120 days before and after discharge for HF.

RESULTS

A total of 4069 older adults were hospitalized for HF during the study period; almost 60% (n = 2435) received at least one medicine associated with an increased risk of harm before hospitalization, with the majority (66.7%, n = 1623) dispensed in the 30 days prior. A small but significant reduction after hospitalization was observed, but 56% (n = 1638) received at least one of these medicines after hospitalization (p = 0.001). Over one-quarter received two or more medicines before hospitalization, and this only reduced to 22% post-hospitalization (p < 0.0001).

CONCLUSIONS

Little change in the prescribing of potentially harmful medicines for HF was observed; 56% of older adults received at least one following hospitalization for HF, highlighting the therapeutic complexity of multimorbidity in HF. Use of the AHA list to facilitate identification of potentially harmful medicines, followed by prioritization of treatment goals and appropriate risk mitigation are needed to facilitate reduction in hospitalization for patients with HF with multimorbidity.

Prognostic Utility of the Braden Scale and the Morse Fall Scale in Hospitalized Patients With Heart Failure

Geriatric syndromes are common in hospitalized elders with heart failure (HF), but association with clinical outcomes is not well characterized. The purpose of this study ( N = 289) was to assess presence of geriatric syndromes using Joint Commission-mandated measures, the Braden Scale (BS) and Morse Fall Scale (MFS), and to explore prognostic utility in hospitalized HF patients. Data extracted from the electronic medical record included sociodemographics, medications, clinical data, comorbid conditions, and the BS and MFS. The primary outcome of mortality was assessed using Social Security Death Master File. Statistical analysis included Cox proportional hazards models to assess association between BS and MFS scores and all-cause mortality with adjustment for known clinical prognostic factors. Higher risk BS and MFS scores were common in hospitalized HF patients, but were not independent predictors of survival. Further study of the clinical utility of these scores and other measures of geriatric syndromes in HF is warranted.

Addressing the conundrum of multimorbidity in heart failure: Do we need a more strategic approach to improve health outcomes?

There is clear evidence across the globe that the clinical complexity of patients presenting to hospital with the syndrome of heart failure is increasing - not only in terms of the presence of concurrent disease states, but with additional socio-demographic risk factors that complicate treatment. Management strategies that treat heart failure as the main determinant of health outcomes ignores the multiple and complex issues that will inevitably erode the efficacy and efficiency of current heart failure management programmes. This complex problem (or conundrum) requires a different way of thinking around the complex interactions that underpin poor outcomes in heart failure. In this context, we present the COordinated NUrse-led inteNsified Disease management for continuity of caRe for mUltiMorbidity in Heart Failure (CONUNDRUM-HF) matrix that may well inform future research and models of care to achieve better health outcomes in this rapidly increasing patient population.

Frailty predictors and outcomes among older patients with cardiovascular disease: Data from Fragicor

The aim of this study was to evaluate predictive factors for frailty among older outpatient adults with cardiovascular disease (CVD) and to assess the predictive value of frailty in regard to mortality, disability and hospitalization at 1-year follow-up. A prospective cohort study was carried out with subjects over 65 years of age from an outpatient Cardiology clinic, with at least one CVD. At baseline, we classified frailty as proposed by Fried, i.e.; unintentional weight loss (10lbs in the past year), self-reported exhaustion, weakness (measured by grip strength), slow walking speed, and low physical activity. A frail person was defined by the presence of three or more criteria, prefrail by one or two and robust by the absence of them. Disability, previous hospitalizations, falls, morphometric and socio-demographic variables were collected; as well as the presence of CVD and hemodynamic parameters (HP): systolic (SPB) and diastolic blood pressure (DBP), heart rate (HR) and ejection fraction (EF). At 1-year follow-up, the outcomes assessed were: disability, number of hospitalizations and death. 172 subjects were included in this study with a mean age of 77 years old. The prevalence of frail was 39.8%, prefrail 51.5% and robust was 8.7%. Among the CVD and HP evaluated, myocardial infarction (MI), presence of three or more CVDs, lower SPB and DBP were significant and independent factors associated with the frailty phenotype. At 1-year follow up, frailty was an independent predictor for disability (Odds Ratio (OR): 3.94 (1.59-9.75); p=0.003) and it increased death probability by three times if compared to the robust group. In conclusion, older outpatients with CVD have a higher probability to be frail than older adults who do not have a CVD. Low SPB and DBP must always be taken into consideration due to their high association with frailty. It is also important to diagnose frailty in this population due to the high association with mortality and disability.

End-of-life care in patients with heart failure

Stage D heart failure (HF) is associated with poor prognosis, yet little consensus exists on the care of patients with HF approaching the end of life. Treatment options for end-stage HF range from continuation of guideline-directed medical therapy to device interventions and cardiac transplantation. However, patients approaching the end of life may elect to forego therapies or procedures perceived as burdensome, or to deactivate devices that were implanted earlier in the disease course. Although discussing end-of-life issues such as advance directives, palliative care, or hospice can be difficult, such conversations are critical to understanding patient and family expectations and to developing mutually agreed-on goals of care. Because patients with HF are at risk for rapid clinical deterioration or sudden cardiac death, end-of-life issues should be discussed early in the course of management. As patients progress to advanced HF, the need for such discussions increases, especially among patients who have declined, failed, or been deemed to be ineligible for advanced HF therapies. Communication to define goals of care for the individual patient and then to design therapy concordant with these goals is fundamental to patient-centered care. The objectives of this white paper are to highlight key end-of-life considerations in patients with HF, to provide direction for clinicians on strategies for addressing end-of-life issues and providing optimal patient care, and to draw attention to the need for more research focusing on end-of-life care for the HF population.

Clinical characteristics and one-year survival in heart failure patients more than 85 years of age compared with younger

BACKGROUND

Heart failure (HF) is frequent in elderly patients, but few studies have focused on patients older than 84 years. The aim of this study was to evaluate major comorbidities and 1-year survival in HF patients aged ≥85 years compared with younger age groups.

METHODS

Patients included in a prospective national registry of HF (RICA) were evaluated. Sociodemographic data, Charlson comorbidity index, cognitive status, basal functional status, body mass index, NYHA functional class, and left ventricle ejection fraction (LVEF) were recorded. Patients aged ≥85 years were compared with the rest using the Cox regression model to detect independent predictive factors of 1-year survival.

RESULTS

Of the 1172 patients included, 224 (19%) were aged over 84 years-old, mostly women, with hypertensive heart disease (46%, p<0.001) and preserved LVEF (68.7%; p<0.001). Diabetes (p<0.001), dyslipidemia (p=0.03) and obesity (p<0.001) were less prevalent in this group of patients. One-year mortality in the oldest old patients was 26.3%, which was higher than the rest (p<0.001). By multivariable analysis, a higher NYHA functional class (p=0.038), anemia (p=0.037), absence of obesity (p=0.002), and a worse functional status (p=0.049) were related to a worse 1-year survival in the oldest HF patients.

CONCLUSIONS

The oldest old HF patients have differential characteristics with lower prevalence of diabetes, dyslipidemia and obesity and a lower 1-year survival. Independent factors related to a worse 1-year survival in the oldest age group were a higher NYHA class, a worse functional status, presence of anemia and absence of obesity.

Pharmacotherapy of heart failure in the elderly: adverse events

Aging is associated with numerous alterations in body composition and organ function that result in substantial changes in the absorption, distribution, metabolism, and elimination of virtually all drugs. In addition, older patients with heart failure (HF) almost invariably have multiple coexisting medical conditions for which they are receiving medications. This article reviews common adverse drug effects and drug interactions associated with HF therapy in older patients and discusses strategies for reducing the risk of adverse drug events. In order to minimize these risks, it is essential that clinicians avoid prescribing unnecessary medications, adjust medication dosages to optimally balance benefits and side effects, and remain ever vigilant to the potential for medications to cause or contribute to clinically important adverse events and impaired quality of life. In treating older HF patients, the oft-cited dictum "start low, go slow" clearly applies. Despite the inherent challenges, with careful management and close follow-up, most older HF patients can be successfully treated through the judicious use of guideline-recommended HF therapies.

Impact of diabetes on cognitive impairment and disability in elderly hospitalized patients with heart failure

AIM

Heart failure (HF) and diabetes mellitus (DM) are each associated with cognitive impairment and disability. The aim of the present study was to evaluate the impact of DM on cognitive impairment and functional status in elderly hospitalized patients affected by HF.

METHODS

A total of 79 elderly hospitalized patients with HF were enrolled in the present study. They underwent physical and instrumental examination, and geriatric multidimensional assessment including Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS), activities of daily living (ADL) and instrumental activities of daily living (IADL). Differences between groups were established by t-test, Spearman's correlation coefficient was searched to examine the relation between variables. All results were considered significant if P was <0.05.

RESULTS

HF and DM coexisted in 43 patients (54.4% of cases); when they occurred together patients showed, compared with non diabetic patients, a greater clinical severity of HF (44.2% were in New York Heart Association class IV vs 16.7%, P = 0.017), a lower MMSE score (20.4 ± 3.6 vs 23 ± 3.8, P = 0.004), and a lower number of preserved functions in ADL (3 ± 1.6 vs 4 ± 1.8, P = 0.008) and in IADL (3.2 ± 1.7 vs 4.6 ± 2.3, P = 0.003). The correlation between DM and cognitive impairment, and disability was confirmed by multivariate and univariate analysis.

CONCLUSIONS

We confirm that DM is frequent in elderly hospitalized patients with HF, and we report that it has a negative impact on cognitive functions and functional status, worsening cognitive impairment, and disability observed in these patients. Comprehensive geriatric assessment is necessary for older adults with HF, especially when DM coexists.

A randomized controlled trial of self-management programme improves health-related outcomes of older people with heart failure

AIMS

This paper is a report on the effectiveness of a self-management programme based on the self-efficacy construct, in older people with heart failure.

BACKGROUND

Heart failure is a major health problem worldwide, with high mortality and morbidity, making it a leading cause of hospitalization. Heart failure is associated with a complex set of symptoms that arise from problems in fluid and sodium retention. Hence, managing salt and fluid intake is important and can be enhanced by improving patients' self-efficacy in changing their behaviour.

DESIGN

Randomized controlled trial.

METHODS

Heart failure patients attending cardiac clinics in northern Taiwan from October 2006-May 2007 were randomly assigned to two groups: control (n = 46) and intervention (n = 47). The intervention group received a 12-week self-management programme that emphasized self-monitoring of salt/fluid intake and heart failure-related symptoms. Data were collected at baseline as well as 4 and 12 weeks later. Data analysis to test the hypotheses used repeated-measures anova models.

RESULTS

Participants who received the intervention programme had significantly better self-efficacy for salt and fluid control, self-management behaviour and their heart failure-related symptoms were significantly lower than participants in the control group. However, the two groups did not differ significantly in health service use.

CONCLUSION

The self-management programme improved self-efficacy for salt and fluid control, self-management behaviours, and decreased heart failure-related symptoms in older Taiwanese outpatients with heart failure. Nursing interventions to improve health-related outcomes for patients with heart failure should emphasize self-efficacy in the self-management of their disease.

Outcomes of cardiac resynchronization therapy in the elderly

BACKGROUND

Octogenarians (>80 years) have been underrepresented in clinical trials of cardiac resynchronization therapy (CRT).

OBJECTIVE

To determine the benefit of CRT with or without a defibrillator in older elderly patients.

METHODS

We retrospectively studied consecutive patients who received CRT at our institution from 2002 through 2008. New York Heart Association (NYHA) class and echocardiographic parameters were assessed before and after CRT. Thirty-day complications after device implant were collected. Survival data were obtained from the national death and location database. Data were compared between those 80 years and younger and those older than 80 years.

RESULTS

Of 728 patients identified, 90 (12.4%) were older than 80 years. After CRT, older and younger patients had similar improvements in NHYA class (P = 0.41), ejection fraction (P = 0.48), and mitral valve regurgitation (MR) severity (P = 0.42). In the older patients, defibrillator implantation was associated with comparable improvement in NYHA class, ejection fraction, and MR grade severity (P > 0.05), as in those without a defibrillator. Overall survival was worse in octogenarians than in the younger patients by Kaplan-Meier estimates (P = 0.001). Multivariate analysis showed similar survival between the younger and older subjects (hazard ratio, 1.23; 95% confidence interval, 0.83-1.84; P = 0.31). The observed complication rate in all study subjects was 12.2%, with no difference between the two age groups.

CONCLUSION

Octogenarian patients who received CRT with or without a defibrillator for advanced heart failure had similar clinical benefits as younger patients. CRT should not be withheld from octogenarians meeting current selection guidelines.

The comorbidity conundrum: a focus on the role of noncardiovascular chronic conditions in the heart failure patient

The rapid aging of the US population combined with improvements in modern medicine has created a new public health concern of comorbidity, a chronic condition that co-exists with a primary illness. Over 141 million Americans suffer from one or more comorbid conditions. In the heart failure (HF) patient, this comorbidity burden is particularly high, with over 40% of patients having five or more chronic conditions. These comorbidities can vary from being a risk factor to a cause of HF progression or even a precipitating factor for decompensation. Comorbidities, particularly the noncardiovascular conditions, have been associated with greater health resource utilization, poor health outcomes, and increased mortality. To minimize the negative impact that these comorbidities have on patient outcomes, appropriate attention should be paid to identifying, prioritizing, and managing each condition; minimizing medication complexity and polypharmacy; and improving overall coordination of care between providers and patients.

Self-management in heart failure: where have we been and where should we go?

Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their families, the community, and the health care system because there are no real “cures”. Adding to the burden are longer life expectancies and increased numbers of people living with multiple chronic conditions. Today, whether engaging in a health-promoting activity, such as exercise, or living with a chronic disease such as HF, the individual is responsible for actively managing day-to-day activities, a concept referred to as self-management. Self-management emerged as the cornerstone for chronic care models and multidisciplinary disease-management strategies in chronic illness care. Moreover, self-management has been prioritized as a central pathway for improving the quality and effectiveness of most chronic HF care. Adherence to self-management is vital to optimize the treatment outcomes in HF patients, but implementing chronic disease self-management (CDSM) strategies and identifying the difficulties in self-management has proved to be a challenge. Understanding both where we have been and the future direction of self-management in HF care is not only timely, but a crucial aspect of improving long-term outcomes for people with HF and other chronic diseases.

A qualitative meta-analysis of heart failure self-care practices among individuals with multiple comorbid conditions

BACKGROUND

Most heart failure (HF) patients have other comorbid conditions. HF self-care requires medication and diet adherence, daily weight monitoring, and a thoughtful response to symptoms when they occur. Self-care is complicated when other chronic conditions have additional self-care requirements. The purpose of this study is to explore how comorbidity influences HF self-care.

METHODS

Using qualitative descriptive meta-analysis techniques, transcripts from 3 mixed methods studies (n = 99) were reexamined to yield themes about perceptions about HF and self-care and to explore the influence on HF self-care. The Charlson Comorbidity Index identified comorbid conditions.

RESULTS

The sample was 74% Caucasian, 66% male (mean age of 59.6 years ± 15 years). Fifty-three percent of the sample was New York Heart Association Class III. All had at least 1 other chronic condition. Narrative accounts revealed that adherence to diet, symptom monitoring, and differentiating symptoms from multiple conditions were the most challenging self-care skills. Emerging themes included 1) attitudes drive self-care prioritization and 2) fragmented self-care instruction leads to poor self-care integration and self-care skill deficits.

CONCLUSIONS

Individuals with multiple chronic conditions are vulnerable to poor self-care. Research testing coaching interventions that integrate self-care requirements and focus on developing skill in self-care across multiple chronic conditions is needed.

Cluster analysis of elderly cardiac patients' prehospital symptomatology

BACKGROUND

Chest pain routinely brings patients into the healthcare system, and elderly patients may present with more complex symptoms presaging ischemic heart changes than do younger patients.

OBJECTIVE

To examine, using cluster analysis, how elderly patients experiencing an ischemic coronary heart disease cluster based on presenting symptoms in the week before hospitalization and how they vary in terms of their general physical and mental health, mood states, and quality of life.

METHODS

Elderly (age >or=65 years), unpartnered patients (N = 247) admitted with ischemic coronary heart disease to one of five university medical centers were inducted into a clinical trial; only baseline data are reported. Interviews assessed cardiac symptoms, medical history, general physical and mental health, mood states, and quality of life. Patients were clustered (grouped) using squared Euclidean distances and weighted average linkage. Characteristics of patients were examined using analysis of variance and chi-squared analyses.

RESULTS

Three clusters (groups) were identified: (a) Classic Acute Coronary Syndrome (severe ischemic pain; 22%), (b) Weary (severe fatigue, sleep disturbance, and shortness of breath; 29%), and (c) Diffuse Symptoms (mild symptomatology; 49%). Post hoc tests revealed that the Weary group was more likely to have a history of heart failure; they also exhibited significantly more psychological distress and lower quality of life than the other subgroups.

CONCLUSION

Cluster analysis proved useful in grouping patients based on their symptom experience, but further research is needed to clarify the relationships among identified symptoms, psychological distress, and health outcomes; develop interventions for Weary patients; and extend the findings of this study.

[Advances in geriatric cardiology]

The continued aging of the population is an acknowledged fact. The proportion of individuals in the European Union aged over 65 years will reach 29.9% by 2050, almost double the present figure of 16.4%. Approximately one third of people in this age-group has clinically significant cardiovascular disease. Physicians dealing with cardiology in older patients have to be aware of the specific clinical and prognostic features of cardiovascular disease in the elderly, and with its treatment. Consequently, it is clear that continuing medical education in geriatric cardiology is essential, and that is one of the tasks of the Working Group on Geriatric Cardiology. This special issue provides a magnificent opportunity for presenting an update on important topics in geriatric cardiology, such as the aging of the cardiovascular system, heart failure, and atrial fibrillation.

Long-Term Follow-Up of Very Old Heart Failure Patients Enrolled in a Trial of Exercise Training

Little is known about how physical and psychological status changes with time in older heart failure patients. The authors followed up a cohort of 82 patients (mean age, 80.5 years) enrolled in a randomized controlled trial of exercise training in heart failure. Six-minute walk test, accelerometry, functional status, quality of life, anxiety, and depression were measured at baseline, 3 months, 6 months, and a mean of 19 months post-enrollment. There were no significant differences between the exercise and control groups at long-term follow-up. Six-minute walk distance declined by only 0.2 m/month in those attending final follow-up (vs 4.6 m/month in nonattenders; P=.03). Similar results were seen for other outcomes. Only a small proportion of the variance in change of any of the outcomes was explained by differences in baseline variables.

The Impact of Using Nursing Presence in a Community Heart Failure Program

Nursing presence is the foundation of a long-term nurse-patient relationship that improves clinical decision making and ultimately patient outcomes. A home-based, advanced practice nurse-directed program uses presence at the heart of service delivery in an outpatient heart failure program that addresses complex healthcare needs of this patient population. The Community Case Management program has the following goals: (1) to improve access to appropriate cost-effective healthcare, (2) to prevent hospitalizations, and (3) to improve quality of life. An advanced practice cardiac nurse conducts home visits providing skilled nursing assessments, targeted education, emotional support, and advanced care planning to a vulnerable group of heart failure patients. Common nursing interventions are patient and caregiver education, therapeutic presence, supervision of adherence, and advocacy. The Community Case Management program provides a full continuum of care including disease management, case management, and palliative care serving patients and loved ones over the duration of their illness until death. Community Case Management results in fewer emergency room visits, unplanned hospitalizations, cost avoidance, as well as high patient satisfaction and improved quality of life. It is the contention of this author that the success of the program, while resting on expert multidisciplinary care, is also influenced by the spirit of a long-term therapeutic relationship that develops between the nurse, patient, and the patient's loved ones.

Advances in the treatment of acute decompensated heart failure in the elderly

Acute decompensated heart failure is the leading cause of hospitalization in older adults, and more than half of all patients admitted with this condition are over 75 years of age. In addition, hospital mortality is threefold higher in patients over 75 years of age compared with younger patients. This article reviews the pathophysiology, clinical features and management of acute heart failure in older adults, highlighting recent advances in the field. It is anticipated that over the next 5–10 years, new approaches to the treatment of acute decompensated heart failure will become available. Nonetheless, additional research is required to develop more effective strategies for the prevention and management of both acute and chronic heart failure in our rapidly growing elderly population.

Heart failure in older adults

Heart failure affects approximately 5 million Americans, half of whom are at least 75 years of age, and is the leading cause of hospital admission among older adults. Additionally, the prevalence of heart failure is increasing, largely owing to the aging of the population. Heart failure in older adults differs in many respects from heart failure that occurs during middle age, including an increased proportion of women, increasing prevalence of heart failure with preserved left ventricular systolic function, and a marked increase in the number of coexisting medical conditions. In light of these factors, this article reviews the epidemiology, pathophysiology, clinical features, and treatment of heart failure in older adults.

Cardiac surgery in the elderly: indications and management options to optimize outcomes

The elderly have increasingly benefited from the advances in cardiac surgical techniques and perioperative care. Compared to the same procedures in younger patients their operations can be more technically demanding and their level of reserve leaves less margin should complications occur. The importance of using realistic indications for operations with a focus on improving the quality of their lives and of optimal preoperative preparation of patients is emphasized.