Chronic Heart Failure Care Planning: Considerations in Older Patients

Abstract

In developed countries, it is estimated that 1-2 % of the adult population has heart failure (HF), with the prevalence increasing to more than 10 % in those aged >70 years.1 Despite advances in therapies for heart failure with reduced ejection fraction (HFrEF), it remains a condition associated with significant morbidity and mortality, punctuated by episodes of unplanned hospitalisation. 2HF is one of the commonest causes of unscheduled hospital admissions 3 and data consistently show a lower uptake of evidencebased investigations and therapies in adults >75 years as well as higher HF-related mortality.4 Mortality and rehospitalisation rates are higher amongst patients discharged to skilled nursing facilities than those going home. 5 Older patients more frequently experience comorbidities, frailty, polypharmacy and cognitive impairment and these factors have a significant impact on outcomes. These aspects require proper evaluation to best assess and plan patients' long-termcare needs.In this review, we examine HF-care planning in relation to older patients. While current guidance has its limitations, we offer here a pragmatic approach to care planning in this patient population. Care Planning in Skilled Nursing FacilitiesWhile the majority of older people live at home alone, or with carers, in the UK 16 % of people aged >85 years live in care homes. 6 The spectrum of care ranges from sheltered housing to a variety of assisted living facilities, residential and nursing homes. The reported prevalence of HF in nursing homes ranges from 20.0 to 37.4 %. 7The Heart Failure in Care Homes (HFinCH) study 8 found a higher prevalence of HF in UK care-facility residents aged 65-100 years than in community populations. Most cases were previously undiagnosed and three-quarters of previously recorded cases were unconfirmed using the latest European Society of Cardiology (ESC) guidelines, echocardiogram and brain natriuretic peptide measurements. AbstractIn developed countries, it is estimated that more than 10 % of adults aged over 70 years have heart failure (HF). Despite therapeutic advances, it remains a condition associated with significant morbidity and mortality. It is one of the commonest causes of unscheduled hospital admissions in older adults and data consistently show a lower uptake of evidence-based investigations and therapies as well as higher rates of HF hospitalisations and mortality than in younger adults. These rates are highest amongst patients discharged to 'skilled nursing facilities', where comorbidities, frailty and cognitive impairment are common and have a significant impact on outcomes. In this review, we examine current guidance and its limitations and offer a pragmatic approach to management of HF in this elderly population.

Frailty in Heart Failure: Implications for Management

“…25 The recognition of frailty is the first step for an accurate risk stratification and planning a tailored therapeutic plan. 26,27 However, several knowledge gaps exist. First, a unique definition of this syndrome in patients with HF is still lacking.…”

“…Several measurements have been proposed to assess frailty, and a huge variety of methods and instruments are available. 11,28,29 The most widely used tools to assess frailty are Fried's phenotypic definition of frailty and the frailty index, described in detail elsewhere. 3,11,30 There are also self-report questionnaires or instruments based on the assessment of single performances (i.e.…”

The Predictive Value of Plasma Brain Natriuretic Peptide and Galectin-3 in Elderly Patients Admitted for Heart Failure

“…Indeed, while in OPTIMIZE-HF [22] patients over 65 years old, the BNP plasma value adequately predicted 1-year mortality and hospital readmission, the meta-analysis of Troughton et al, [30] clearly demonstrated how the survival benefit of a BNP-guided therapy post-discharge seemed to be effective only in younger (<75 years old) HF patients. Elderly HF patients more frequently experience comorbidity, frailty, multiple therapies, and significant cognitive impairment that have a notable impact on outcomes [31] independent of levels of biomarkers. In a recent review on plasma biomarkers, Correale et al [32] stressed the fact that the role of biomarkers in elderly HF patients has been influenced by the presence of comorbidities.…”

Heart failure management of the elderly patient: focus on frailty, sarcopaenia, cachexia, and dementia: conclusions

“…In addition many confounding comorbidities make treatment more difficult; these include iron deficiency, 33 muscle wasting, 20 , 21 and frailty, many making drug side effects 18 more likely. Although we are beginning to address the specific problems of drug therapy in the elderly, much remains left to do to improve the quality and appropriateness of our care in this vulnerable group 34 such as by planning specific care plans for older or frail HF patients 35 …”