Littérature scientifique sur le sujet « Elderly, chronic heart failure, outpatient management »

Background Elderly patients are underrepresented in clinical trials but comprise the majority of heart failure patients. Data on age-specific use of heart failure therapy are limited. The European Society of Cardiology heart failure guidelines provide no age-specific treatment recommendations. We investigated practice-based heart failure management in a large registry at heart failure outpatient clinics. Design and methods We studied 8351 heart failure with reduced ejection fraction patients at 34 Dutch outpatient clinics between 2013 and 2016. The mean age was 72.3 ± 11.8 years and we divided age into three categories: less than 60 years (13.9%); 60–74 years (36.0%); and 75 years and over (50.2%). Results Elderly heart failure with reduced ejection fraction patients (≥75 years) received significantly fewer beta-blockers (77.8% vs. 84.2%), renin–angiotensin system inhibitors (75.2% vs. 89.7%), mineralocorticoid receptor antagonists (50.6% vs. 59.6%) and ivabradine (2.9% vs. 9.3%), but significantly more diuretics (88.1% vs. 72.6%) compared to patients aged less than 60 years ( Pfor all trends < 0.01). Moreover, the prescribed target dosages were significantly lower in elderly patients. Also, implantable cardioverter defibrillator (18.9% vs. 44.1%) and cardiac resynchronisation therapy device (14.6% vs. 16.7%) implantation rates were significantly lower in elderly patients. A similar trend in drug prescription was observed in patients with heart failure with mid-range ejection fraction as in heart failure with reduced ejection fraction. Conclusion With increasing age, heart failure with reduced ejection fraction patients less often received guideline-recommended medication prescriptions and also in a lower dosage. In addition, a lower percentage of implantable cardioverter defibrillator and cardiac resynchronisation therapy device implantation in elderly patients was observed.

As a permanent blockage of the pathogenetic chains of the disease prevents its progression and decompensation, medication adherence remains a cornerstone in the management of chronic heart failure. Poor adherence leads to an increase in chronic heart failure manifestations and frequent hospitalizations, resulting in quality of life deterioration. Aim. To characterize the quality of life in the elderly with chronic heart failure with preserved ejection fraction on the background of arterial hypertension and chronic kidney disease, and to determine the effect of medication adherence on the quality of life. Materials and methods. The prospective study included 122 patients aged 64 [62; 68] years with chronic heart failure on the background of arterial hypertension and chronic kidney disease. All participants underwent a clinical examination, a creatinine level determination with subsequent calculation of GFR EPI, a 6-minute walk test, an assessment according to the Minnesota Living with Heart Failure Questionnaire, and the Morisky Green Medication Adherence Scale. Based on the medication adherence level, the participants were divided into 2 groups. Results. Patients in both groups were comparable in age, sex, and ejection fraction. The patients in the non-adherent cohort had more comorbid diseases, greater systolic blood pressure and functional class according to NYHA, higher heart rate, a larger percentage of patients with lung crackles and GFR EPI less than 60 ml/min/1.73m2, lower GFR EPI, the shorter distance at 6-minute walk test, and the worse quality of life. The the quality of life was (the first figure – during hospitalization, the second - after 6 months, the third - after 12 months): 50 [39; 61], 42 [31; 50] and 40 [29; 50] scores among all the patients; 58.5 [48; 62], 47 [42; 52] and 47.5 [38; 54] scores – among non-adherent cohort; 41 [35, 53], 30 [28; 40] is the 29 [27; 40] scores - among the adherent patients. Conclusion. The quality of life of non-adherent patients was significantly worse in comparison with those who were more adherent to therapy. This difference was observed during both hospitalization and repeated outpatient observations. Medication adherence remained a significant quality of life predictor at all three visits: worsening in adherence level resulted in a quality of life deterioration. As the mediators causing the connection between medication adherence and the quality of life were patients' characteristics indicating poor diseases compensation.

This feature article for the thematic series on congestive heart failure (CHF) readmissions aims to outline important gaps in guidelines for patients with multiple comorbidities and the elderly. Congestive heart failure diagnosis manifests as a 3-phase journey between the hospital and community, during acute, chronic stable, and end-of-life (palliative) phases. This journey requires in variable intensities a combination of multidisciplinary care within tertiary hospital or ambulatory care from hospital outpatients or primary health services, within the general community. Management goals are uniform, ie, to achieve the lowest New York Heart Association class possible, with improvement in ejection fraction, by delivering gold standard therapies within a CHF program. Comorbidities are an important common denominator that influences outcomes. Comorbidities include diabetes mellitus, chronic obstructive airways disease, chronic renal impairment, hypertension, obesity, sleep apnea, and advancing age. Geriatric care includes the latter as well as syndromes such as frailty, falls, incontinence, and confusion. Many systems still fail to comprehensively achieve all aspects of such programs. This review explores these factors.

Abstract Background Many elderly people suffer from chronic health conditions and mobility limitations. Therefore, they may benefit from traditional rehabilitation or telerehabilitation interventions as an alternative for this type of services. Objective The purpose of this study was to compare the effectiveness of telerehabilitation interventions with traditional rehabilitation services for therapeutic purposes in the elderly. Methods This systematic review was conducted in 2018. The searched databases were Cochrane Library, PubMed, Scopus, Web of Science, Embase, and ProQuest. The search was conducted with no time or language limitation. The selected papers included the randomized clinical trial studies in which elderly people aged 60 and over used telerehabilitation services for treatment purposes. The quality of the studies was evaluated by using the physiotherapy evidence database (PEDro) scale. Data were extracted by using a data extraction form and findings were narratively synthesized. Results After screening the retrieved papers, eight articles were selected to be included in the study. According to the findings, telerehabilitation was used for the elderly after stroke, chronic obstructive pulmonary disease (COPD), total knee replacement, and in patients with the comorbidity of COPD and chronic heart failure. Overall, in most studies, there was no significant difference between the intervention and control groups and the level of improvements was similar for most outcomes. Conclusion Telerehabilitation services can be regarded as an alternative to traditional rehabilitation approaches to reduce outpatient resource utilization and improve quality of life. However, more rigorous studies are suggested to investigate the effectiveness of telerehabilitation services for specific diseases or health conditions.

Aim. To evaluate efficacy and safety of original ethylmethylhydroxypyridine succinate (Mexidol) in cardiological patients ≥75 year old.Material and methods. In the observational study, according to ethical standards of Khelsinki Declaration, with informed consent, 24 patients participated, age 75­88 y. o. Inclusion criteria: age ≥75 y. o.; already diagnosed coronary heart disease (CHD) and/or chronic heart failure (CHF); Mexidol usage. Exclusion criteria: absent informed consent, severe comorbidities. Mean age of the patients at inclusion 80,33±4,06 y. o.; 16 (66,7%) females and 8 (33,3%) males. Patients consequently visited office of cardiologist with the diagnoses: chronic CHD (I25.0­I25.9), CHF with preserved systolic function (I50.0­I50.9). All patients were consulted by neurologist, had an established diagnosis of cerebrovascular disease (I65­67). To reduce the symptoms of frailty, among the neurologist recommendations, with accordance to routine clinical practice, the original Mexidol was included. Mexidol was prescribed by a scheme of manufacturer: intravenous infusions 500 mg x 5 days, then per os 125 mg t. i.d.; overall treatment — 8 weeks.Results. Statistically significant results were noted in 6 months from the study start. There was significant increase of 6 minute walking distance in men from 304,00±87,09 to 388,63±92,28 m (р=0,01), in women from 346,06±56,81 to 427,69±76,87 m (р=0,003); also there were less signs of frailty. No one patient showed significant worsening of the condition; during the overall follow­up, patients did not call emergency or primary care physicians and did not hospitalize.Conclusion. In comorbidity patients aged ≥75 y. o. at Mexidol treatment, there was increase of 6­minute walking test distance, decrease of asthenia signs, that witness for the medication efficacy. All patients showed good tolerability of the drug that witness for safety. Obviously, there are broad trials needed to sum up a gerontological algorithm of CHD and CHF patient management in outpatient setting.

Background Telemonitoring-guided interventional management reduces the need for hospitalization and mortality of patients with chronic heart failure (CHF). Objective This study aimed to analyze the cost-effectiveness of usual care with and without telemonitoring-guided management in patients with CHF discharged from the hospital, from the perspective of US health care providers. Methods A lifelong Markov model was designed to estimate outcomes of (1) usual care alone for all postdischarge patients with CHF (New York Heart Association [NYHA] class I-IV), (2) usual care and telemonitoring for all postdischarge patients with CHF, (3) usual care for all postdischarge patients with CHF and telemonitoring for patients with NYHA class III to IV, and (4) usual care for all postdischarge patients with CHF plus telemonitoring for patients with NYHA class II to IV. Model inputs were derived from the literature and public data. Sensitivity analyses were conducted to assess the robustness of model. The primary outcomes were total direct medical cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER). Results In the base case analysis, universal telemonitoring group gained the highest QALYs (6.2967 QALYs), followed by the telemonitoring for NYHA class II to IV group (6.2960 QALYs), the telemonitoring for NYHA class III to IV group (6.2450 QALYs), and the universal usual care group (6.1530 QALYs). ICERs of the telemonitoring for NYHA class III to IV group (US $35,393 per QALY) and the telemonitoring for NYHA class II to IV group (US $38,261 per QALY) were lower than the ICER of the universal telemonitoring group (US $100,458 per QALY). One-way sensitivity analysis identified five critical parameters: odds ratio of hospitalization for telemonitoring versus usual care, hazard ratio of all-cause mortality for telemonitoring versus usual care, CHF hospitalization cost and monthly outpatient costs for NYHA class I, and CHF hospitalization cost for NYHA class II. In probabilistic sensitivity analysis, probabilities of the universal telemonitoring, telemonitoring for NYHA class II to IV, telemonitoring for NYHA class III to IV, and universal usual care groups to be accepted as cost-effective at US $50,000 per QALY were 2.76%, 76.31%, 18.6%, and 2.33%, respectively. Conclusions Usual care for all discharged patients with CHF plus telemonitoring-guided management for NYHA class II to IV patients appears to be the preferred cost-effective strategy.

Abstract Background Elderly individuals experience increased morbidity and mortality from acute respiratory infections (ARI), which are complicated by difficulties defining etiologies of ARI and risk-stratifying patients in order to guide care. A number of scoring tools have been developed to predict illness severity and patient outcome for proven pneumonia, however less is known about the use of such metrics for all causes of ARIs. Methods We analyzed risk factors, clinical course and major outcomes of individuals ≥60 years of age presenting to the emergency department with a clinical diagnosis of ARI over a 5-year period. Results Of the enrolled individuals 40 had proven viral infection and 52 proven bacterial infections, but 184 patients with clinically adjudicated ARI (67%) remained without a proven microbial etiology despite extensive workup. Age (71.5 vs. 65.9 years, P &lt; 0.001) and presence of cancer and heart failure were strongly predictive of illness severe enough to require hospital admission as compared with treatment in the outpatient setting. Of those with proven etiology, individuals with bacterial infection were more likely to require hospital and ICU admission (P &lt; 0.001). When applied to this study, a modified PORT score was found to correlate more closely with clinical outcome measures than a modified CURB-65 (r, 0.54 vs. 0.39). Jackson symptom scores, historically used for viral illness, were found to inversely correlate with outcomes (r, −0.34) and show potential for differentiating viral and bacterial etiologies (P = 0.02). Interestingly, a multivariate analysis showed that a novel scoring tool utilizing sex, heart rate, respiratory rate, blood pressure, BUN, glucose and presence of chronic lung disease and cancer was highly predictive of poor outcome in elderly subjects with all-cause ARI. Conclusion Elderly subjects are at increased risk for poor clinical outcomes from ARI and their clinical management remains challenging. However, modified PORT, CURB-65, Jackson symptom score, and a novel scoring tool presented herein all offer some predictive ability for all-cause ARI in elderly subjects. Such broadly applicable scoring metrics have the potential to assist in treatment and triage decisions at the point of care. Disclosures All authors: No reported disclosures.

BackgroundHeart failure (HF) and chronic obstructive pulmonary disease (COPD) lead to unplanned hospital activity, but our understanding of what drives this is incomplete.ObjectivesTo model patient, primary care and hospital factors associated with readmission and mortality for patients with HF and COPD, to assess the statistical performance of post-discharge emergency department (ED) attendance compared with readmission metrics and to compare all the results for the two conditions.DesignObservational study.SettingEnglish NHS.ParticipantsAll patients admitted to acute non-specialist hospitals as an emergency for HF or COPD.InterventionsNone.Main outcome measuresOne-year mortality and 30-day emergency readmission following the patient’s first unplanned admission (‘index admission’) for HF or COPD.Data sourcesPatient-level data from Hospital Episodes Statistics were combined with publicly available practice- and hospital-level data on performance, patient and staff experience and rehabilitation programme website information.ResultsOne-year mortality rates were 39.6% for HF and 24.1% for COPD and 30-day readmission rates were 19.8% for HF and 16.5% for COPD. Most patients were elderly with multiple comorbidities. Patient factors predicting mortality included older age, male sex, white ethnicity, prior missed outpatient appointments, (long) index length of hospital stay (LOS) and several comorbidities. Older age, missed appointments, (short) LOS and comorbidities also predicted readmission. Of the practice and hospital factors we considered, only more doctors per 10 beds [odds ratio (OR) 0.95 per doctor;p < 0.001] was significant for both cohorts for mortality, with staff recommending to friends and family (OR 0.80 per unit increase;p < 0.001) and number of general practitioners (GPs) per 1000 patients (OR 0.89 per extra GP;p = 0.004) important for COPD. For readmission, only hospital size [OR per 100 beds = 2.16, 95% confidence interval (CI) 1.34 to 3.48 for HF, and 2.27, 95% CI 1.40 to 3.66 for COPD] and doctors per 10 beds (OR 0.98;p < 0.001) were significantly associated. Some factors, such as comorbidities, varied in importance depending on the readmission diagnosis. ED visits were common after the index discharge, with 75% resulting in admission. Many predictors of admission at this visit were as for readmission minus comorbidities and plus attendance outside the day shift and numbers of admissions that hour. Hospital-level rates for ED attendance varied much more than those for readmission, but the omega statistics favoured them as a performance indicator.LimitationsData lacked direct information on disease severity and ED attendance reasons; NHS surveys were not specific to HF or COPD patients; and some data sets were aggregated.ConclusionsFollowing an index admission for HF or COPD, older age, prior missed outpatient appointments, LOS and many comorbidities predict both mortality and readmission. Of the aggregated practice and hospital information, only doctors per bed and numbers of hospital beds were strongly associated with either outcome (both negatively). The 30-day ED visits and diagnosis-specific readmission rates seem to be useful performance indicators.Future workHospital variations in ED visits could be investigated using existing data despite coding limitations. Primary care management could be explored using individual-level linked databases.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Background. Lo scompenso cardiaco (SC) è un problema di salute pubblica globale che interessa circa 38 milioni di persone nel mondo. La storia naturale dello SC è caratterizzata da frequenti riospedalizzazioni, tanto che, nei pazienti di età superiore ai 65 anni, lo SC acuto rappresenta la prima causa di ospedalizzazione. E’stato dimostrato che l’immediato post-dimissione dopo un ricovero per SC acuto rappresenta un periodo vulnerabile per il paziente, caratterizzato da un aumentato rischio di andare incontro a deterioramento delle condizioni cliniche generali, riospedalizzazione e morte. Materiali e metodi. All’interno di questo studio osservazionale di coorte retro-prospettico, sono stati arruolati tutti i soggetti afferiti presso la Unità Scompenso Cardiaco appartenente alla Struttura Oraganizzativa Dipartimentale Geriatria-Unità di Terapia Intesiva Geriatrica (SOD Geriatria-UTIG), del Dipartimento ad Attività Integrata (DAI) Medico-geriatrico dell’AOU Careggi (Firenze) di età maggiore o uguale di 60 anni, con diagnosi di SC di qualunque tipo, diagnosticato secondo i criteri delle linee guida ESC 2016, che avessero sottoscritto il consenso informato. In prima visita e a 12 mesi sono state raccolte variabili cliniche cardiologiche e geriatriche (Basic Activities of Daily Living-BADL, Instrumental ADL, Mini-Mental State Examination, Geriatric Depression Scale, Short Physical Performance Battery, Charlson-Age Index), bioumorali ed ecografiche (ecocolorDoppler cardiaco, ecografia polmonare). Sono state considerate le seguenti misure di esito a 12 mesi: mortalità per tutte le cause; numero di ospedalizzazioni nell’anno successivo alla presa in carico, rispetto a quelle registrate nell’anno precedente. Risultati. Dei 137 pazienti valutati in prima visita dal Novembre 2016 al Dicembre 2018, 14 non soddisfavano i criteri di eleggibilità. Il campione risultava quindi costituito da 103 pazienti di età media pari a 82.0  8.1 anni, 46 (44.7%) dei quali di sesso femminile. Di questi, 12 (11.7%) sono deceduti nel primo anno di follow-up. In analisi multivariata sono risultati predittori indipendenti di morte per tutte le cause: l’EVEREST Score (OR 1.32, 95% CI 1.02-1.70 per ogni punto; p=0.035); la Pressione Arteriosa Diastolica - PAD (OR 0.90, 95% CI 0.81-0.99 per ogni mmHg; p=0.032); la disabilità BADL ( OR 1.88, 95% CI 1.11-3.19 per ogni item perso; p=0.020); la presenza di stenosi aortica almeno moderata (OR 14.92, 95% CI 1.65-134.91; p=0.016) e il valore del Tricuspid Annular Plane Systolic Excursion – TAPSE (OR 0.68, 95% CI 0.51-0.90 per ogni mm; p=0.007). Per quanto riguarda l’outcome secondario, analizzando il campione dei pazienti vivi ad 1 anno, il numero medio di ospedalizzazioni per SC per paziente si riduceva da 1.23 ± 1.14 nei 12 mesi precedenti a 0.13 ± 0.40 nei 12 mesi successivi alla presa in carico (p < 0.001). Conclusioni. Rispetto a quanto riportato in letteratura in studi su pazienti di ogni età dimessi dopo ricovero per SC, abbiamo osservato una mortalità ad 1 anno nettamente inferiore (11.7% rispetto a 20-25%). Tale risultato è ancora più rilevante, dal momento che il nostro campione è costituito da soggetti molto anziani (età media circa 82 anni), con grave comorbosità (Charlson Age medio circa 7) e SC considerato ad alto rischio di instabilizzazione. Alcuni risultati sono in linea con quelli già presenti in letteratura: infatti la PAD, il TAPSE, la stenosi aortica moderata-severa sono già stati descritti come predittori indipendenti di morte in pazienti dimessi per SC. L’EVEREST Score, in precedenza validato e utilizzato alla dimissione da ricovero ospedaliero per SC, ha dimostrato per la prima volta un valore predittivo anche quando applicato in regime ambulatoriale. Infine, la valutazione dell’autonomia funzionale secondo i test geriatrici (BADL) si è dimostrata più efficace della classe funzionale NYHA nel predire l’outcome principale. Questo risultato è di particolare interesse, perchè aiuta a dirimere una problematica clinica di grande rilievo nella gestione del paziente anziano con SC. Infatti, la classe funzionale NYHA, che si basa sulla misura della dispnea in relazione allo sforzo fisico, mal si adatta alla popolazione ultra75enne multimorbosa e sedentaria dei pazienti che afferiscono ai reparti e agli ambulatori di Geriatria, Cardiologia e Medicina Interna. Il risultato forse più stimolante tra quelli qui riportati è, tuttavia, quello relativo all’outcome secondario: la gestione multidisciplinare del paziente all’interno di una USC dedicata sembra efficace nel ridurre il numero di ospedalizzazioni per SC nei 12 mesi successivi la presa in carico. Tali dati supportano la necessità di potenziare la presenza di strutture dedicate alla gestione del paziente anziano con SC, di fronte al quale le sole abituali competenze cardiologiche possono risultare insufficienti.

Acute heart failure (AHF) is a potentially life-threatening condition that requires rapid evaluation and treatment and usually results in hospitalization of the patient. The in-hospital management of AHF may be divided into three phases: a first phase of acute care, a second phase of stabilization, and a third phase of discharge. In the first phase, the main goals are the rapid management of life-threatening conditions; the effective resolution of congestion and/or peripheral hypoperfusion with stabilization of patient haemodynamics; and protection of vital organ function. In the second phase, the main goals are the transition from intravenous to oral medications; the initiation, reinstitution, or titration of disease-modifying medications; any further cardiac assessments and treatments; and the identification and management of co-morbid conditions. Finally, the third phase includes the assessment of the readiness for discharge; the development of a chronic disease management plan; and the transition to outpatient care.

Chronic heart failure (CHF) is a complex clinical syndrome characterised by the inability of the heart to provide sufficient perfusion to meet the body’s metabolic demands. It occurs primarily in the elderly and currently affects 64.3 million people worldwide. Heart failure is associated with significant morbidity and mortality as well as with prohibitive utilization of healthcare resources. Novel technologies that would improve patient management and reduce the burden of HF on healthcare resources are thus urgently needed. We assessed the performance of machine learning algorithms for predicting decompensation in CHF using heart sound data obtained by two different setups. The most accurate model was a decision tree classifier that achieved accuracy, precision, recall, F1 score, and area and the receiver operating curve of 0.896, 0.797, 0.812, 0.801, and 0.898, respectively. We also identified the most relevant predictor features extracted from different frequency bands of the recordings. Our analysis suggests that the low-frequency abnormal heart sounds do not play a critical role in detecting decompensation episodes in CHF patient cohort.

In the last sixty years, there has been an increase in life expectance especially in females and in industrialized countries. This, along with the reduction of population growth, is leading to a reversal of the population pyramid: a narrow base of adults has to maintain a wide top of elderly people. Old people are often affected by multi-pathologies and comorbidities. Furthermore, the changes in family’s structure, particularly the reduction of the central rule of the Ancients, contribute to create the “frail elderly syndrome.” Geriatric frailty is found in 20-30% of the elderly population over 75 and increases with advancing age. It was reported to be associated with long-term adverse health-related outcomes such as increased risk of geriatric syndromes, dependency, disability, hospitalization, institutional placement, and mortality. Obviously, it is also associated with an increase in healthcare costs. Telemedicine is an innovative healthcare system capable of ensuring both higher efficiency and better cost-effectiveness. It has wide variety of services, relative simplicity of use and moderate-low costs. Currently there is clinical evidence of telemonitoring impact on management of several clinical conditions such us chronic heart failure, arrhythmias, pacemaker and ICD controls, cardiac rehabilitation programs, and cardiovascular risk factors.

Abstract Hypertension, especially isolated systolic hypertension, is common in older people. White coat hypertension is also very common in older individuals making ambulatory blood pressure monitoring (ABPM) essential to confirm the diagnosis of hypertension. Hypertension is a major risk factor for cerebrovascular accidents, coronary artery disease, heart failure, retinopathy, chronic renal disease, and cognitive impairment. The benefits of treating hypertension including isolated systolic hypertension in the elderly has been demonstrated conclusively. Overtreatment can be harmful and caution is advocated in the very old. Non-pharmacological approaches are an integral part of management. Management can be challenging because of side effects especially postural hypotension, polypharmacy, frailty, and coexisting multiple chronic conditions.

Rheumatoid arthritis (RA), the commonest inflammatory arthritis, is a debilitating disease leading to decreased functional capacity, social disability and reduced quality of life. RA affects multisystems with chronic inflammatory disease characterized by destructive synovitis and muscular dysfunction leading to premature musculoskeletal aging, which has been coined with many terms including myopenia, sarcopenia, cachexia, muscle failure and muscle wasting. Myopenia is described as the presence of clinically relevant muscle wasting due to any illness at any age, associated with impaired muscle function, increased morbidity and mortality. RA myopenia has significantly less muscle mass compared to the general population muscle loss showing preservation or slight increase in fat mass. RA myopenia is unique compared to chronic disease-related myopenia in cancer, chronic heart failure, kidney disease and chronic infection as it is rarely accompanied by a net weight loss. RA myopenia has younger-age onset compared to elderly primary sarcopenia, while higher-grade inflammation has been considered as the pathophysiology of muscle wasting. Research, however, indicates that inflammation itself cannot fully explain the high prevalence of muscle wasting in RA. This chapter aims to review the literature on the casual relationships among RA myopenia, premature musculoskeletal aging and management strategies to delay musculoskeletal aging.