Elsevier

Canadian Journal of Cardiology

Volume 32, Issue 9, September 2016, Pages 1140-1147
Canadian Journal of Cardiology

Review
Heart Failure in Older Adults

https://doi.org/10.1016/j.cjca.2016.05.005Get rights and content

Abstract

Heart failure (HF) is a leading cause of morbidity, hospitalization, and mortality in older adults and a growing public health problem placing a huge financial burden on the health care system. Many challenges exist in the assessment and management of HF in geriatric patients, who often have coexisting multimorbidity, polypharmacy, cognitive impairment, and frailty. These complex “geriatric domains” greatly affect physical and functional status as well as long-term clinical outcomes. Geriatric patients have been under-represented in major HF clinical trials. Nonetheless, available data suggest that guideline-based medical and device therapies improve morbidity and mortality. Nonpharmacologic strategies, such as exercise training and dietary interventions, are an active area of research. Targeted geriatric evaluation, including functional and cognitive assessment, can improve risk stratification and guide management in older patients with HF. Clinical trials that enroll older patients with multiple morbidities and HF and evaluate functional status and quality of life in addition to mortality and cardiovascular morbidity should be encouraged to guide management of this age group.

Résumé

L’insuffisance cardiaque (IC) est l’une des causes principales de morbidité, d’hospitalisation et de mortalité chez les personnes âgées, et constitue un problème de santé publique grandissant qui impose un énorme fardeau financier au système de soins de santé. Il existe de nombreuses difficultés d’évaluation et de prise en charge de l’IC chez les patients âgés en raison de la coexistence fréquente de la multimorbidité, de la polypharmacie, de la détérioration cognitive et de la fragilité. Ces « domaines gériatriques » complexes nuisent grandement à l’état physique et fonctionnel ainsi qu’aux résultats cliniques à long terme. D’importants essais cliniques sur l’IC ont montré une sous-représentation des patients âgés. Néanmoins, les données disponibles suggèrent que les traitements médicaux et à l’aide de dispositifs fondés sur les lignes directrices améliorent la morbidité et la mortalité. Les stratégies non pharmacologiques telles que l’entraînement à l’effort et les interventions portant sur le régime alimentaire constituent un domaine actif de la recherche. L’évaluation gériatrique ciblée, y compris l’évaluation fonctionnelle et cognitive, peut améliorer la stratification du risque et orienter la prise en charge des patients âgés atteints d’IC. Les essais cliniques qui recrutent des patients âgés atteints de multiples morbidités et d’IC, et évaluent l’état fonctionnel et la qualité de vie, en plus de la mortalité et de la morbidité cardiovasculaire, devraient être favorisés pour orienter la prise en charge des patients de ce groupe d’âge.

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.

References (88)

  • L.A. Hawkins et al.

    Cognitive impairment and medication adherence in outpatients with heart failure

    Heart Lung

    (2012)
  • J.A. Dodson et al.

    Cognitive impairment in older adults with heart failure: prevalence, documentation, and impact on outcomes

    Am J Med

    (2013)
  • K. Harkness et al.

    Screening for cognitive deficits using the Montreal Cognitive Assessment Tool in outpatients ≥65 years of age with heart failure

    Am J Cardiol

    (2011)
  • J.D. Cameron et al.

    Sensitivity and specificity of a five-minute cognitive screening test in patients with heart failure

    J Card Fail

    (2016)
  • R. Arena et al.

    Peak VO2 and VE/VCO2 slope in patients with heart failure: a prognostic comparison

    Am Heart J

    (2004)
  • D. Chiarantini et al.

    Lower extremity performance measures predict long-term prognosis in older patients hospitalized for heart failure

    J Card Fail

    (2010)
  • S.M. McNallan et al.

    Frailty and healthcare utilization among patients with heart failure in the community

    JACC Heart Fail

    (2013)
  • C.J. Chung et al.

    Reduced handgrip strength as a marker of frailty predicts clinical outcomes in patients with heart failure undergoing ventricular assist device placement

    J Card Fail

    (2014)
  • S.M. Dunlay et al.

    Frailty and outcomes after implantation of left ventricular assist device as destination therapy

    J Heart Lung Transplant

    (2014)
  • C.W. Yancy et al.

    2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

    J Am Coll Cardiol

    (2013)
  • F.A. Masoudi et al.

    Most hospitalized older persons do not meet the enrollment criteria for clinical trials in heart failure

    Am Heart J

    (2003)
  • J.M. Foody et al.

    Predictors of cardiologist care for older patients hospitalized for heart failure

    Am Heart J

    (2004)
  • J.Y. Kim et al.

    Utilization of evidence-based treatment in elderly patients with chronic heart failure: using Korean Health Insurance claims database

    BMC Cardiovasc Disord

    (2012)
  • V. Bhatia et al.

    Beta-blocker use and 30-day all-cause readmission in Medicare beneficiaries with systolic heart failure

    Am J Med

    (2015)
  • A. Ahmed et al.

    A propensity score analysis of the impact of angiotensin-converting enzyme inhibitors on long-term survival of older adults with heart failure and perceived contraindications

    Am Heart J

    (2005)
  • P.A. Heidenreich et al.

    Does age influence cardiac resynchronization therapy use and outcome?

    JACC Heart Fail

    (2015)
  • L. Bibas et al.

    Therapeutic interventions for frail elderly patients: part I. Published randomized trials

    Prog Cardiovasc Dis

    (2014)
  • D.W. Kitzman

    Exercise Training in heart failure with preserved ejection fraction: beyond proof-of-concept

    J Am Coll Cardiol

    (2011)
  • G.W. Moe et al.

    The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: focus on rehabilitation and exercise and surgical coronary revascularization

    Can J Cardiol

    (2014)
  • P.A. Ades et al.

    Cardiac rehabilitation exercise and self-care for chronic heart failure

    JACC Heart Fail

    (2013)
  • L. Sargento et al.

    Nutritional status of geriatric outpatients with systolic heart failure and its prognostic value regarding death or hospitalization, biomarkers and quality of life

    J Nutr Health Aging

    (2013)
  • S.L. Hummel et al.

    Dietary sodium restriction in heart failure: a recommendation worth its salt?

    JACC Heart Fail

    (2016)
  • K. Jefferson et al.

    Effect of a sodium-restricted diet on intake of other nutrients in heart failure: implications for research and clinical practice

    J Card Fail

    (2015)
  • R. Doukky et al.

    Impact of dietary sodium restriction on heart failure outcomes

    JACC Heart Fail

    (2016)
  • J.D. Wessler et al.

    Evaluating the safety and efficacy of sodium-restricted/Dietary Approaches to Stop Hypertension diet after acute decompensated heart failure hospitalization: design and rationale for the Geriatric OUt of hospital Randomized MEal Trial in Heart Failure (GOURMET-HF)

    Am Heart J

    (2015)
  • L.W. Stevenson et al.

    Changing preferences for survival after hospitalization with advanced heart failure

    J Am Coll Cardiol

    (2008)
  • M. Bakitas et al.

    Palliative care consultations for heart failure patients: how many, when, and why?

    J Card Fail

    (2013)
  • S.J. Goodlin

    Palliative care in congestive heart failure

    J Am Coll Cardiol

    (2009)
  • Heart and Stroke Foundation

    The Burden of Heart Failure

    (2016)
  • D. Mozaffarian et al.

    Heart disease and stroke statistics—2015 update: a report from the American Heart Association

    Circulation

    (2015)
  • J.V. Tu et al.

    National trends in rates of death and hospital admissions related to acute myocardial infarction, heart failure and stroke, 1994-2004

    CMAJ

    (2009)
  • P.A. Heidenreich et al.

    Forecasting the impact of heart failure in the United States: A policy statement from the American Heart Association

    Circ Heart Fail

    (2013)
  • C. Rodriguez-Pascual et al.

    Comprehensive geriatric assessment and 2-year mortality in elderly patients hospitalized for heart failure

    Circ Cardiovasc Qual Outcomes

    (2014)
  • L.A. Allen et al.

    Medication initiation burden required to comply with heart failure guideline recommendations and hospital quality measures

    Circulation

    (2015)
  • Cited by (90)

    • The Aged Heart

      2022, Emergency Medicine Clinics of North America
    View all citing articles on Scopus

    See page 1145 for disclosure information.

    View full text