OPTIMAL MANAGEMENT OF ELDERLY HEART FAILURE PATIENT. Dr Eilidh Hill ST7 Geriatric Medicine Glasgow Royal Infirmary

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1 OPTIMAL MANAGEMENT OF ELDERLY HEART FAILURE PATIENT Dr Eilidh Hill ST7 Geriatric Medicine Glasgow Royal Infirmary

2 OUTLINE Epidemiology Why the older HF patient is different What s the evidence base? Co-morbidities Comprehensive Geriatric Assessment

3 EPIDEMIOLOGY HEART FAILURE 1-2% general population UK 10-20% in >80 yrs High prevalence undetected HF in long term care residents % 62.7% HFpEF, 37.3% LVSD Hancock et al. Eur J Heart Failure 2013;15:158

4 EPIDEMIOLOGY Mean age 1st admission Age at first admission by sex! 76yrs men 80yrs women! Number of patients Age group Men Women

5 MORTALITY MORTALITY <75 >75 Fig 23: Three-year post-discharge survival by age ( ) In-hospital 4.7% 12% 30-day 3.6% 7.7% 1 year 17% 33% % Survived Days after discharge

6 AGE DIFFERENCES Therapies on discharge more diuretics, less ACEi/BB/MRA Specialist input both as inpatient and on follow-up

7 WHY IS THE OLDER (HF) PATIENT IS DIFFERENT?!! DIFFICULTY DIAGNOSING Atypical presentations 1/3 proven HF pts had none usual signs [ Oudejans et al. Eur J HF 2011] Non-specific complaints generalised weakness, anorexia, reduced BMI, fatigue, insomnia up to half present with deterioration in function Co-morbidities mask /confound the dx

8 COMORBIDITY OF HF POPULATION Non-cardiac comorbidities Braunstein JB. J Am Coll Cardiol 2003;42: ,630 pts > 65yr with HF only 4% had HF alone 40% >5 non-cardiac comorbidites = 81% total inpatient hospital days experience by all HF patients highest risks for preventable hospitalisations and mortality = COPD/bronchiectasis, renal fx, diabetes, depression High rates readmission after acute HF hospitalisation 23% within 30 days Ross et al. Circ Heart Fail 2010;3:97

9 CO-MORBIDITIES Retrospective review elderly HF patients None had HF as only medical problem! Polypharmacy (>4 meds) 90% musculoskeletal problems 41% psychological problems 39% AMT<7 38% Barthel <16 35% Chest disease 30% Incontinence 29%! Lien et al. Eur J Heart Fail 2002;4:91

10 IMPACT OF CO-MORBIDITY DIAGNOSIS MANAGEMENT OUTCOME Expectation of illness?

11 HFPEF Elderly patients hospitalised for acute HF more likely to have higher EF and higher prevalence HFpEF LVEF not as strong a predictor of mortality in >80 comorbidity more important.

12 UNDER REPRESENTATION IN CLINICAL TRIALS Table 1 Selected main practice-changing heart failure trials Trial Year Study treatment a No. of Age (years) b Key age-related inclusion patients criteria... SOLVD 1991 Enalapril Age,80; EF 35% DIG (main trial) 1997 Digoxin EF 45% RALES 1999 Spironolactone EF 35% CIBIS II 1999 Bisoprolol Age 18 80; EF 35% ATLAS 1999 Low-dose vs. high-dose lisinopril EF 30% COPERNICUS 2001 Carvedilol EF 25% BEST 2001 Bucindolol EF 35%. EPHESUS 2001 Eplerenone EF 40% Val-HeFT 2002 Valsartan ACEi, no ACEi EF 40% MADIT II 2002 ICD EF 30% COMET 2003 Carvedilol vs. metoprolol (11 4) c EF 35% CARE HF 2005 CRT vs. medical therapy alone (59 72) no CRT, 67 (60 73) CRT c EF 35% MADIT-CRT 2009 CRT-D vs. ICD EF 30% SHIFT 2010 Ivabradine EF 35% EMPHASIS 2011 Eplerenone EF 35% Selected landmark heart failure trials, mean or median age of population enrolled, and key age-related inclusion criteria representing a potential age-related selection bias.

13 TRIALS IN ELDERLY study drug mean age conclusion SENIORS nebivolol 76 PEP-CHF perindopril 76 HR 0.9 primary outcome composite all-cause mortality or CV hospital admission Well tolerated no improved outcome in HFpEF (Insufficient power for primary endpoint but trend of fewer hospitalisations) I- PRESERVE irbesartan 73 no improved outcome in HFpEF LIVE:LIFE ivabradine 76.6 Primary endpoint to assess effect ivabradine on QoL

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16 COGNITIVE IMPAIRMENT Estimated prevalence in HF-REF 30-80% (*heterogeneity case mix/study design/cognitive assessments used) Associated with poorer clinical outcomes (*longer hospital admissions, increased inpatient mortality and increased 1 year mortality) & nonparticipation in self-care /mx programmes Cognitive impairment associated with 5 fold increase in mortality DELIRIUM : 17% HF hospitalisations Zuccala G et al American J Med 2003;115:97-103

17 TREATMENT IMPLICATION OF CI IN HF Significantly lower self-care mx Poorer adherence with: dietary/lifestyle modification self monitoring complex & varying drug regimens biochemical surveillance appointments

18 COGNITIVE SCREENING IN HEART FAILURE SERVICES Informal assessment cognition by a cardiologist insufficiently sensitive 3 in 4 HF pts with CI not recognised in routine consultations from the EFICARE Study! Hanon O et al Am J Cardiol 2014;113;1205

19 COGNITIVE IMPAIRMENT Screening AMT4 1. year 2. where are we 3. age 4. DoB NICE advise a clinical assessment cognitive status as part of the clinical review of HF patient Cutoff of <3 for AMT4! sensitivity 80 (75-85)% specificity 88 (84-91)% More detailed cognitive assessments +/- referral to Old Age psych AMT 10 MMSE MOCA

20 TREATMENT IMPLICATIONS No evidence that standard HF therapies are harmful Acetylcholinesterase inhibitors caution as excessive cholinergic stimulation, bradycardia, sick sinus syndrome, QT prolongation IDENTIFICATION** is key Early use of compliance aids Early involvement family / carers Systems of care / multidisciplinary team

21 FALLS Multifactorial (orthostatic hypotension, postural instability, visual impairment, arrhythmias) Fractured Neck of Femur 35% mortality 1year, high rates institutionalisation Symptomatic OH 43% elderly women admitted with HF ASK ABOUT Sx OH essential to measure L/S BP MDT input - refer to Community Falls Prevention Programme

22 CONTINENCE therapeutic competition 35-50% HF patients Affects compliance Worse with NYHA III/IV Consider once daily dosing (lowest compatible with stability) +/- flexibility in timings fluid restrictions, avoid caffeinated drinks,? stress incont from cough assoc ACEi old people can do pelvic floor exercises too!

23 POLYPHARMACY Mean no. drugs on discharge in Glasgow following HF decomp = 9 If on >4 increased risk of falls >10 meds, 90% probability ADR Evidence base comorbid elderly HF patient is lacking Remember ageing affects pharmacokinetics/pharmacodynamics Systems for medication review essential

24 AAARGH! HOW DO WE MANAGE CO-MORBIDITY IN ELDERLY PATIENT WITH HEART FAILURE?! 1. Specialist MDT eg stroke unit NNT 20 for one extra independent survivor 2. Realistic patient-centred medicine

25 REALISTIC MEDICINE CMO REPORT Evidence based guidelines developed for people with single diseases should not be extrapolated to mx patients with multiple conditions result over-treatment, over-complex medication regimes

26 TREATMENT GOALS QoL & symptoms functional capacity reduced hospitalisations life prolongation

27 SYSTEMATIC REVIEW OF RANDOMISED TRIALS OF MULTIDISCIPLINARY STRATEGIES MCALISTER ET AL. F/U by specialist MDT reduced mortality, (RR 0.75), HF hospitalisation (RR 0.74) & all cause hospitalisation (RR 0.81) $$ saving too People with chronic heart failure are cared for by a multidisciplinary heart failure team led by a specialist

28 European Society of Cardiology Heart Failure Association Standards for delivering heart failure care European Journal of Heart Failure Volume 13, Issue 3, pages , 18 FEB 2014 DOI: /eurjhf/hfq221

29 COMPREHENSIVE GERIATRIC ASSESSMENT Coordinated multidisciplinary assessment process Identification/documentation of medical, functional,social,psychological problems Development of a plan of care including appropriate treatment, rehabilitation and follow-up **Rationalising medication Formation of patient-centred goals Regular multidisciplinary review of progress/goals Discharge planning

30 COCHRANE CGA in hospitalised elderly, 12 month f/u increased chance being alive and in own home after emergency admission when stratified according to need & admitted to CGA ward : NNT 6 to be alive and in own home 6/12, NNT 13 to be alive and in own home 1 year

31 APPLYING CGA TO PROGNOSTICATE OLDER PEOPLE WITH DECOMPENSATED HF Poor score on simple CGA tool (ADL, mobility, comorbidity, cognitive decline, no. medications) associated with worse prognosis 1 point increase CGA score assoc with 19% higher mortality in 2 yr f/u Rodriguez-Pascual et al.

32 SUMMARY Geriatric conditions are common in older HF patients A disease orientated focus medical care does not adequately address their needs Try to practice Realistic Medicine Coordinating care with specialist MDT input improves outcomes

33 ANY QUESTIONS?

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35 Environment Personnel Process

36 AGE DIFFERENCES 1. THERAPY Table 28: Treatment on discharge for LVSD by age Medication <75 years (%) ACE inhibitor ARB ACE and/or ARB Beta blocker MRA ACEI and/or ARB, beta blocker and MRA Loop diuretic Thiazide diuretic 7 4 Digoxin years (%) Prescribed at discharge (%) Age Group ACEi and/or ARB Beta blocker ACEi Loop MRA ARB

37 Table 9: HF specialist input by age AGE DIFFERENCES 2. SPECIALIST INPUT <75 years (%) 75 years (%) Consultant cardiologist Heart failure nurse specialist Other consultant with interest in heart failure Any HF specialist Other clinician Input from HF MDT Table 33: Referral to follow-up services on discharge by age Service <75 years (%) 75 years (%) Cardiology follow-up Heart failure nurse follow-up Cardiac rehabilitation 15 8

38 COMORBIDITY OF HF POPULATION Medical History LVSD (%) No LVSD (%) p-value Ischaemic heart disease (IHD) <0.001 Atrial fibrillation <0.001 Acute myocardial infarction (AMI) <0.001 Valve disease <0.001 Hypertension <0.001 Chronic renal impairment Diabetes Asthma 8 10 <0.001 Coronary obstructive pulmonary disease (COPD) <0.001

39 DRUG PRESCRIBING IN ELDERLY Physiological age-related changes influence drug pharmacokinetics and pharmacodynamics decreased volume distribution and creatinine clearance Co-morbidities increase risk ADRs - renal dysfunction, orthostatic hypotension, bradycardias conflicting treatment recommendations (eg OH and falls) polypharmacy - drugs that worsen HF (NSAIDs) or increase risk of drug-drug interactions (antidepressants and antiarrhythmics)

40 COGNITIVE IMPAIRMENT Predicts poor self-care in HF patients 93 consecutive pts Self Care of Heart Failure Index assessment 75% had Mild Cognitive Impairment with significantly lower self care management (p<0.01) Cameron J et al Eur J Heart Fail 2010;12:508

41 HFREF ACEinhibitors - M+M benefits similar >80 cf <60. SAGE study: retrospective cohort frail elderly (mean = 85) ACEi = 10% reduction mortality, reduced rate of functional decline Beta-blockers - SENIORS 4.2% ARR reduction in composite of all-cause mortality & CV hospital admissions (but lower magnitude than other BB trials & not statistically significant >75) MRAs - no specific elderly trials. EMPHASIS-HF (mean age 68.7) significant reduced rates composite cardiac death /hospitalisation. CRT/ICDs - higher operative mortality, 2 small observational studies only : older patients CRT derive similar benefits (improvement symptoms, exercise tolerance, QoL) cf younger therefore authors advised shouldn't exclude elderly if meet usual criteria.

42 SENIORS

43 IS THE NH POPULATION WORTH A SPECIAL MENTION? Hancock study higher than usual point prevalence high levels misdiagnosis and missed diagnoses Shibata study (Eur J HF 2005) poor levels of prescribing in institutionalised elderly even where no clear contraindication or advanced directives basics really poorly done, weights not monitored, only 11% followed salt restriction, 3.8% had fluid restrictions caveats to all of this may still be that we are appropriately stratifying and providing patient centred care (ie focusing on their goals of therapy) but not sufficiently evidenced in this paper

44 HFPEF Diuretics Prevent ischaemia Ix/Rx underlying causes AF: controlling HR (lose atrial kick so less well tolerated) HTN: prevalent 74% >80yo., maintaining BP<150 has M+M benefits >75, HYVET study. benefits apparent w/i 1 year. BUT J-shape curve

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46 Considering when drugs become inappropriate eg severe cognitive impairment, NH resident Inappropriate drugs in elderly patients with severe cognitive impairment: results from the shelter study. Colloca G; Tosato M; Vetrano DL; Topinkova E; Fialova D; Gindin J; van der Roest HG; Landi F; Liperoti R; Bernabei R; Onder G; SHELTER project. PLoS ONE [Electronic Resource]. 7(10):e46669, [Journal Article. Research Support, Non-U.S. Gov't]

47 RESULTS: LIVING AT HOME

48 RESULTS: LIVING AT HOME

49 RESULTS: LIVING AT HOME

50 DEPRESSION Prevalence 24-42% in CHF Underdiagnosed (sx fatigue, low energy levels, sleep disturbance attrib to CHF alone) Significantly related to: reduced compliance reduced functional status higher readmission rates increased mortality

51 CHRONIC LUNG DISEASE All HF HF+COPD COPD only(194) Neither (405) Only(33) (50) (128) Mean (SD) age 73(5.3) 74(5.9) 73.7(5.3) 73.3(5.0) 71.8(5.5) Male IHD HBP DM Dyspnoea Orth/PND Fatigue NB Cochrane : no adverse effects from use of cardioselective beta-blockers in COPD patients