Heart failure at the end of life: symptoms, function, and medical care in the Cardiovascular Health Study

Symptom distress in advanced chronic organ failure: disagreement among patients and family caregivers

BACKGROUND

Proxy reporting is frequently used to assess symptom distress of patients with advanced chronic organ failure. The aim of the present cross-sectional study was to examine agreement in severity of symptom distress, presence of symptom-related interventions, and satisfaction with medical treatment among patients with advanced chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF) and chronic renal failure (CRF) and their family caregivers.

METHODS

Outpatients with advanced COPD (n=73), CHF (n=45) and CRF (n=41) and their family caregivers rated severity of physical and psychological symptoms experienced by the patient using Visual Analogue Scales (VAS). The presence of symptom-related interventions was recorded by patients and family caregivers. Finally, patients and family caregivers rated satisfaction with medical treatment of the patient using VAS. Agreement was determined using intraclass correlation coefficients (ICC) for continuous variables and Cohen's kappa for categorical variables.

RESULTS

Family caregivers reported a higher number of symptoms than patients (mean [standard deviation; SD]: 8.2 [3.5] versus 7.3 [3.6], respectively [p<0.0005]). For most symptoms, agreement about severity between patients and family caregivers was moderate (ICC: 0.41-0.60). Agreement about satisfaction with medical treatment was fair (ICC [95% confidence interval; CI]: 0.21 [0.05-0.35]). Agreement was poor to moderate for presence of symptom-related interventions (kappa: -0.03-0.54).

CONCLUSIONS

Studies using proxy reporting reflect the views of proxies and do not accurately represent the patients' experience. For clinical care, it's important to pay attention to the perception from the patient as well as the perception from the family caregiver of symptom distress, presence of symptom-related interventions, and satisfaction with treatment.

Effect of chronic disease-related symptoms and impairments on universal health outcomes in older adults

OBJECTIVES

To determine the extent to which disease-related symptoms and impairments, which constitute measures of disease severity or targets of therapy, account for the associations between chronic diseases and universal health outcomes.

DESIGN

Cross-sectional.

SETTING

The Cardiovascular Health Study (CHS) and the Health, Aging and Body Composition Study (Health ABC).

PARTICIPANTS

Five thousand six hundred fifty-four CHS members and 2,706 Health ABC members.

MEASUREMENTS

Diseases included heart failure (HF), chronic obstructive pulmonary disease (COPD), osteoarthritis, and cognitive impairment. The universal health outcomes included self-rated health, basic and instrumental activities of daily living (ADLs and IADLs), and death. Disease-related symptoms and impairments included HF symptoms and ejection fraction (EF) for HF, Dyspnea Scale and forced expiratory volume in 1 second for COPD, joint pain for osteoarthritis, and executive function for cognitive impairment.

RESULTS

The diseases were associated with the universal health outcomes (P<.001) except osteoarthritis with death (both cohorts) and cognitive impairment with self-rated health (Health ABC). Symptoms and impairments accounted for 30% or more of each disease's effect on the universal health outcomes. In CHS, for example, HF was associated with one fewer (0.918) ADL and IADL performed without difficulty than no HF; HF symptoms accounted for 27% of this effect and EF for only 5%. The hazard ratio for death with HF was 6.5 (95% confidence interval=4.7-8.9) with EF accounting for 40% and HF symptoms for only 14%.

CONCLUSION

Disease-related symptoms and impairments accounted for much of the significant associations between the four chronic diseases and the universal health outcomes. Results support considering universal health outcomes as common metrics across diseases in clinical decision-making, perhaps by targeting the disease-related symptoms and impairments that contribute most strongly to the effect of the disease on the universal health outcomes.

Hip fractures and heart failure: findings from the Cardiovascular Health Study

AIMS

The aim of the study was to find the epidemiology of hip fractures in heart failure. The increasing survival rate for patients with heart failure places them at risk for other diseases of ageing, including osteoporosis.

METHODS AND RESULTS

We included 5613 persons from the Cardiovascular Health Study (CHS) with an average of 11.5 year follow-up. We determined incidence rates and hazard ratios (HRs) in persons with heart failure compared with persons without heart failure and mortality hazards following these fractures. Annualized incidence rates for hip fractures were 14 per 1000 person-years in heart failure and 6.8 per 1000 person-years without heart failure. Unadjusted and multivariable adjusted HRs for hip fracture associated with heart failure in men were 1.87 (95% CI 1.2-2.93) and 1.59 (95% CI 0.93-2.72), respectively. Respective HRs for women were 1.75 (95% CI 1.27-2.4) and 1.41 (95% CI 0.98-2.03). Mortality hazard was approximately 2-fold greater in patients with heart failure and hip fracture compared with those having heart failure alone.

CONCLUSION

Persons with heart failure are at high risk for hip fractures. However, much of the association between hip fractures and heart failure is explained by shared risk factors. Hip fractures are a substantial contributor to mortality in men and women with heart failure.

Daily symptom burden in end-stage chronic organ failure: a systematic review

Chronic diseases are nowadays the major cause of morbidity and mortality worldwide. Patients with end-stage chronic organ failure may suffer daily from distressful physical and psychological symptoms. The objective of the present study is to systematically review studies that examined daily symptom prevalence in patients with end-stage chronic organ failure, with attention to those that included patients with either congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) or chronic renal failure (CRF). Thirty-nine articles (8 CHF, 7 COPD, 2 CHF and COPD, 22 CRF) have been included. The included studies used various study designs. There was a wide range of daily symptom prevalence that may be due to the heterogeneity in methodology used. Nevertheless, findings suggest significant symptom burden in these patients. This review highlights the need for further prospective and longitudinal research on symptom prevalence in patients with end-stage CHF, COPD and CRF to facilitate the development of patient-centred palliative care programs.

Pain and quality of life in hospitalized patients with heart failure

The pain experience of patients with heart failure (HF) and its impact on their quality of life (QOL) has not been described in sufficient detail. This study sampled patients hospitalized with HF to describe the prevalence and severity of bodily pain; evaluate differences in bodily pain related to selected demographic and disease-specific characteristics; and evaluate the effect of selected demographic, disease-specific characteristics, bodily pain, and mental health on QOL. Two items from the Medical Outcomes Study--Short Form (SF-36) were used to measure pain, and one subscale of the SF-36 was used to evaluate mental health. The Minnesota Living With Heart Failure Questionnaire was used to measure QOL. Patients with HF (n=93) had a mean age of 75 years, were predominantly male (65%), and lived alone (47.3%). Lung diseases and diabetes were the most common comorbidities; 58% were categorized as New York Heart Association (NYHA) Class III, whereas 58% of the sample was diagnosed with HF in the past four years. Of note, 85% of the patients reported pain and 42.5% said that it was in the severe or very severe range. No demographic variables were associated with pain, whereas a higher number of chronic conditions were associated with pain. SF-36 mental health and pain scores, as well as NYHA class, explained 34.1% of the variance in QOL in patients with HF. These data suggest that pain is highly prevalent and has a significant impact on the QOL of patients with HF. However, additional research is warranted to determine the specific causes and characteristics of pain in these patients.

Symptom distress and quality of life in patients with advanced congestive heart failure

Little is known about the burden of illness associated with advanced congestive heart failure (CHF). Understanding the needs of this population requires further information about symptoms and other factors related to quality of life. We studied a convenience sample of 103 community-dwelling patients with New York Heart Association Class III/IV CHF. The primary outcome, quality of life, was measured with the Multidimensional Index of Life Quality. Potential correlates of quality of life included overall symptom burden (Memorial Symptom Assessment Scale, MSAS), including global symptom distress (MSAS Global Distress Index, GDI); psychological state (Mental Health Inventory-5); functional status (Sickness Impact Profile); spirituality (Functional Assessment of Chronic Illness Therapy-Spirituality Scale); and co-morbid conditions (Charlson Comorbidity Index). Patients had a mean age of 67.1 years (SD=12.1); were mostly white (72.8%), male (71.8%), and married (51.5%); and had a mean ejection fraction of 22.3% (SD=6.8). The most prevalent symptoms were lack of energy (66%), dry mouth (62%), shortness of breath (56%), and drowsiness (52%). Pain was reported by about one-third of patients. For each of these symptoms, high symptom-related distress was reported by 14.1%-54.1%. Quality of life was moderately compromised (Multidimensional Index of Life Quality composite, median=56, possible range 12-84). Impairment in quality of life was strongly associated with global symptom distress (MSAS GDI; r=0.74, P<0.001); burden of comorbid conditions (r = -0.32, P=0.002), female sex (r=-0.22, P=0.03), functional impairment, particularly psychological impairment (r=-0.55, P<0.001), and poorer psychological well-being (r=0.68, P<0.001). In multivariate analyses, impairment in quality of life was significantly related to high symptom distress, poorer psychological well-being, and poor functional mobility (R2=0.67; P=0.002 for all). Distressful symptoms related to impaired quality of life included lack of energy (P=0.04), irritability (P=0.03), and drowsiness (P=0.02). Community-dwelling patients with advanced CHF experience numerous symptoms, significant symptom distress, and a compromised quality of life. Overall quality of life was strongly associated with symptom distress, psychological well-being and functional status. A focus on ameliorating prevalent physical symptoms and psychological distress, along with supportive measures that promote functional mobility, may lead to an improvement in the overall quality of life in this patient population.