ReviewHeart Failure in Older Adults
Section snippets
Multimorbidities
Advanced management of cardiovascular disease and improved survival has resulted in a more elderly HF population overall. More than a quarter of community-living patients with HF are ≥ 80 years of age; such patients often have multiple comorbid illnesses that complicate HF management.11 One recent study reported that 60% of elderly individuals with incident HF had 3 or more comorbidities, and only 2.5% had no associated comorbid illnesses. Hypertension was the most common associated comorbidity
Polypharmacy
Polypharmacy is defined as the chronic use of 5 or more medications and presents an underestimated challenge in the management of geriatric patients with HF. Leaving aside medications for symptom management such as diuretics or treatment directed at other chronic illnesses, guideline-recommended medical therapy for HFrEF includes β-blockers, angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, and mineralocorticoid antagonists. In selected patients, isosorbide dinitrate
Cognitive Impairment
Cognitive impairment (CI) is defined as “having trouble remembering or learning new things, concentrating, or making decisions.” Given the prevalence of complex multimorbidities and polypharmacy in elderly patients with HF, the potential impact of CI on management and outcomes is clear. Age is the greatest unavoidable risk factor for CI, which can range from mild impairment to severe advanced dementia. At least 25% of elderly patients with HF have some degree of CI,20 although the prevalence is
Decreased Functional Capacity
Decreased functional capacity is common in elderly patients with HF, especially after hospitalization. An objective evaluation of functional capacity can provide prognostic value in geriatric patients with HF. Symptom-limited cardiopulmonary exercise testing (CPET) is the gold standard modality, because it identifies the underlying mechanisms of exercise intolerance and provides several independent predictors of survival in patients with HF (eg, peak oxygen consumption and ventilatory
Disability and Frailty
In older patients, HF is associated with a progressive decline in function and high rates of institutionalization. More than half of patients ≥ 60 years of age with HF report some degree of mobility limitation, and many have difficulty with basic activities of daily living, such as bathing, eating, and dressing.11 Even at the time of HF diagnosis, 22% and 44% of older adults describe at least 1 impairment in basic and independent activities of daily living, respectively. Mobility and functional
Guideline-Based Medical Therapy in Elderly Patients With HF
Guideline-directed medical therapy (GDMT), as defined by the American College of Cardiology/American Heart Association and the Canadian Cardiovascular Society guidelines, refers to therapies with strong evidence from randomized trials to improve morbidity or mortality, or both, in patients with HF.12, 45 However, some uncertainty exists regarding the applicability of these guidelines to elderly patients with HF. Although there have been recent exceptions,46 few HF clinical trials have focused
Defibrillators and Cardiac Resynchronization in Elderly Patients With HF
Implantable cardiac defibrillators (ICDs) effectively prevent sudden cardiac death in symptomatic patients with HFrEF. However, elderly patients with HFrEF and multiple morbidities have a higher risk of nonarrhythmic death compared with their younger counterparts. In a large retrospective study from Spain, 15% of ICD recipients for primary prevention were ≥ 75 years of age and had attenuated mortality reduction resulting from competing risks of death at the time of ICD implantation.65 A
Nonpharmacologic Treatment in Elderly Patients With HF
As discussed earlier, physical limitations and frailty are emblematic features of HF in elderly patients. Exercise training interventions consistently improve measures of physical performance in frail older adults and hold promise for stabilizing or even partially reversing the frailty phenotype.70 A 2005 UK study of 200 stable patients with HFrEF demonstrated that a 24-week multidisciplinary cardiac rehabilitation program improved functional capacity and quality of life while reducing overall
Additional Comments
Decision-making in HF management begins with an open discussion of the disease prognosis, the goals of care, and the available treatment options and should take into account geriatric domains that affect the complexity and efficacy of care. The conventional viewpoint that elderly patients with HF value symptom control and quality of life over longevity is not always true. In 1 large study, three-quarters of elderly outpatients with HF were unwilling to trade any survival time for improved
Conclusions
The evaluation and treatment of the growing number of elderly patients with HF is often complicated by multimorbidities, polypharmacy, cognitive impairment, and functional deficits. Assessment of these geriatric domains can improve determination of prognosis and facilitate patient-centred management. Clinical trials with broader enrollment criteria and more efforts to specifically include elderly patients with HF, focusing on quality of life and functional measures in addition to mortality and
Funding Sources
S.L.H. is supported by NIH grants K23-HL109176 and R21-AG047939 and receives research funding from PurFoods, LLC.
Disclosures
The authors have no conflicts of interest to disclose.
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