Heart failure in frail, older patients: We can do ‘MORE’
ABSTRACTA comprehensive approach is necessary in managing heart failure in frail older adults. To provide optimal care, physicians need to draw on knowledge from the fields of internal medicine, geriatrics, and cardiology. The acronym “MORE” is a mnemonic for what heart failure management should include: multidisciplinary care, attention to other (ie, comorbid) diseases, restrictions (of salt, fluid, and alcohol), and discussion of end-of-life issues.
KEY POINTS
- Not only does heart failure itself result in frailty, but its treatment can also put additional stress on an already frail patient. In addition, the illness and its treatments can negatively affect coexisting disorders.
- Common signs and symptoms of heart failure are less specific in older adults, and atypical symptoms may predominate.
- Age-associated changes in pharmacokinetics must be taken into account when prescribing drugs for heart failure.
- Effective communication among health professionals, patients, and families is necessary.
- Given the life-limiting nature of heart failure in frail older adults, it is critical for clinicians to discuss end-of-life issues with patients and their families as soon as possible.
WIELDING THE SCALPEL
A tenet of heart failure management is to correct the underlying cardiac structural abnormality. This often calls for invasive intervention along with optimization of drug therapy.
For example:
- Diseased coronary arteries may be amenable to revascularization, either by percutaneous coronary intervention or by the much more involved coronary artery bypass grafting, with the aim of enhancing cardiac function.
- Valves can be repaired or replaced in patients with valvular heart disease.
- A pacemaker can be implanted to remedy sick sinus syndrome, especially with concurrent use of heart-rate-lowering agents such as beta-blockers.
- Placement of an implantable cardioverter-defibrillator has been found to be effective in preventing death due to ventricular tachyarrhythmias in patients with an ejection fraction of less than 30%.9
- Cardiac resynchronization with a biventricular pacemaker may increase the ejection fraction and cardiac output by eliminating dyssynchronous contraction of the left and right ventricles.14
In frail older adults, consideration of these invasive therapies must be individualized. While procedures such as percutaneous coronary intervention and pacemaker placement may not be as physically taxing as bypass grafting or valve replacement, the potential for surgical complications must be seriously considered, particularly if the patient has diminished physiologic reserve. Case-to-case consideration is also crucial in cardioverter-defibrillator insertion, as the survival benefit may be diminished in older adults, who likely have coexisting illnesses that predispose them to die of a noncardiac cause.15,16
The bottom line is to contemplate multiple factors—severity of the heart failure, comorbidities, baseline functional status, and social support—when assessing the appropriateness of an invasive intervention.
BEYOND DRUGS AND DEVICES: WE CAN DO ‘MORE’
Much of the spotlight has been on the various drugs and devices used to treat heart failure, but of equal importance for frail elderly patients are complementary approaches that can be used to ease disease progression and boost the quality of life. The acronym MORE highlights these strategies.
M: Multidisciplinary management programs
Heart failure disease-management programs are designed to provide comprehensive multidisciplinary care across different settings (ie, home, outpatient, and inpatient) to high-risk patients who often have multiple medical, social, and behavioral issues.9 Interventions usually include intensive patient education, encouraging patients to be more aggressive participants in their care, closely monitoring patients through telephone follow-up or home nursing, carefully reviewing medications to improve adherence to evidence-based guidelines, and multidisciplinary care with nurse case management directed by a physician.
Studies have shown that management programs, which were largely nurse-directed and targeted at older adults and patients with advanced disease, can improve quality of life and functional status, decrease hospitalizations for both heart failure and other causes, and decrease medical costs.17–19
O: Other diseases
R: Restrictions
Specific limitations in the intake of certain dietary elements are a valuable adjunct in heart failure management.
Sodium intake should be restricted to less than 3 g/day by not adding salt to meals and by avoiding salt-rich foods (eg, canned and processed foods).24 During times of distressing volume overload, a tighter sodium limit of 2 g/day is necessary, and diuretics may be less effective if this restriction is not implemented.
Fluid restriction depends on the patient’s clinical status.25 While it is not necessary to limit fluid intake in the absence of retention, a limit of 2 L/day is recommended if edema is detected. If volume overload is severe, the limit should be 1 L/day.
Alcohol is a myocardial depressant that reduces the left ventricular ejection fraction.26 Abstinence is a must for patients with alcohol-induced heart failure; otherwise, a limit of 1 drink (8 oz of beer, 4 oz of wine, or 1 oz of hard liquor) per day is suggested.24
Calories and fat intake are both important to watch, particularly in patients with obesity, hyperlipidemia, hypertension, or coronary artery disease.
