Coexisting Frailty, Cognitive Impairment, and Heart Failure: Implications for Clinical Care
Implications for Clinical Care
A systematic assessment performed periodically using physical and cognitive measures that may identify prefrailty may be the best strategy for preventing further functional loss, limitations, and disability in persons with heart failure. Persons with heart failure ideally should be evaluated annually for physical function, since a decline has been consistently shown to be a strong predictor of adverse health outcomes, disability, and death [6,66]. Cognitive function should also be assessed routinely in persons with heart failure, particularly when first diagnosed, when changes in treatment regimen occur, and with worsening disease severity, since these events have been shown to occur before changes in cognition [31]. Incorporating geriatric performance-based measures in heart failure management would allow for more treatment strategies aimed at improving physical function, cognitive outcomes, and quality of life. Further, identifying frailty in heart failure is an important component of clinical decision-making when determining if a patient can tolerate therapies such as implantable defibrillators, cardiac resynchronization therapy, or left ventricular assist device placement.
In older adults, performance measures are well established and commonly used as part of geriatric assessment to evaluate physical and cognitive functioning. Performance-based measures may be particularly beneficial in older adults with heart failure to monitor serial changes in physical function. Performance measures in clinical settings require staff time but little training, space, equipment, or risk. As performance measures become more common in practice settings, MDC thresholds may need to be re-evaluated based on the characteristics of the population [67].
For persons with heart failure whose screening outcomes suggest MCI, more comprehensive neuropsychological testing should be available as well as provision of resources to optimize functional independence. Early identification of impaired cognition may lower risk of poor self-management through simplification of medication regimens or providing resources to help manage other regimens essential for optimal heart failure care. It is also important to recognize that depressive symptoms are common in persons with heart failure and are highly correlated with cognitive impairment in this population. Screening for depressive symptoms therefore, may also enhance identification of persons with heart failure at risk for frailty [4,28].
Conclusion
Effective appraisal and development of effective interventions are essential in older adults with heart failure who are at high risk for frailty and cognitive impairment. This will become increasingly important as the population ages and the incidence of heart failure rises proportionately. Although curative treatments for frailty and cognitive impairment are not available, interdisciplinary interventions such as exercise and comprehensive geriatric assessment may improve outcomes in older persons with heart failure [68]. Information gained from objective, simple, inexpensive physical performance measures, when used in combination with cognitive screening, may enhance the ability to evaluate change that signal onset of frailty or cognitive impairment [54,69,70]. The high morbidity and mortality associated with frailty and cognitive impairment indicate that it should be a priority for future research as a strategy to improve clinical outcomes, enhance quality of life, and lower health care costs in this growing population.
Corresponding author: Rebecca Gary, PhD, RN, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA 30322, ragary@emory.edu.
Funding/support: B. Butts was partially funded for this work through National Institutes of Health/National
Institute of Nursing Research Grant #T32NR012715.
