Heart Failure in the Elderly Challenges in Management

The clinical trials on which drug management strategies are based have under-representation of elderly population especially those in their seventies and eighties.
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Heart failure (HF), is a common problem globally with at least 1% of the population being affected. Elderly population constitute more than half of them and differ from their younger counterparts in that they have higher rates of co-morbidities. Like frailty, cognitive impairments and higher chances of poly pharmacy. They are also liable to get adverse effects of medications.

The clinical trials on which drug management strategies are based have under-representation of elderly population especially those in their seventies and eighties. For this reason, there is no consensus and management has to be individualised.

Presentation of Heart Failure:

Shortness of breath, swelling of the feet or body, fatigue, abnormally pulsating veins of the neck. The basic problem being the reduction in the performance of the heart. Heart basically is a pump meant to supply an adequate amount of nourishment to different parts of the body. The common causes in elderly population are high BP and damaged heart because of recent or old heart attacks.

Diagnosis of Heart Failure:

The methods of diagnosis of HF remain the same irrespective of age. Echocardiography is an important test. It differentiates between Heart failure with reduced function (HF ref) and that with normal pumping function or preserved function (Hf pef). It is important because the drugs used are different. Besides this there are a range of tests like electrocardiography and X Ray Chest. Blood tests which include haemoglobin estimation, kidney function tests like serum creatinine and important biomarkers like NT pro BNP and BNP (natriuretic peptides) which get released in blood in response to stress on heart chambers due to HF. These peptides are very useful in diagnosing the severity and also to see the response to treatment by drugs and other methods like pacemakers.

Pharmacotherapy for HF with emphasis in elderly population:

HF is a serious disease with a limited life span and treatment which is standardized needs to be started early. HF with poor heart function (HF ref) has got 4 pillars as drugs in the guidelines . These prolong life and also reduce hospitalizations. In elderly however careful considerations need to be given because of comorbidities, side effects of medications and polypharmacy. In view of limited life span therapies which improve the quality of life may be given priority. The side effects of these agents and lowering of BP and electrolyte issues can lead to falls and injuries in the senior citizens with HF. So smaller doses and frequent monitoring is essential. HF being a chronic disease, long term adherence of the medication regimens is needed. It can be a challenge for the elderly. It is therefore important to focus on regimen simplification and education which is most effective to get best results than just writing a prescription. The co-morbidities in fact can provide opportunities to rationalise treatments and provide a positive impact for other body systems. Examples being drugs like dapagliflozin / empagliflozin which are important HF treatment agents also reduce blood sugar levels in diabetics and a dual advantage can be taken. Similarly drugs like enalapril which also protect kidneys can be taken advantage of in patients with HF and early kidney disease. A holistic approach of patient care can therefore harness the multiple actions of different drugs for co-morbid conditions to optimise patient outcomes and minimize polypharmacy.

Emphasis on Non-Drug treatment:

These assume immense importance in the elderly. Salt restriction to < 2 gm per day. Exercise training in stable patients with poor heart function. This is important for improving the quality of life and reducing hospitalisations. Reduced muscle mass is a common accompaniment and gentle regular exercise is a good way to improve it.

Restriction of fluids to < 1.5 litres per day is important, given the harm by excessive fluid intake leading to water logging and congestion and aggravation of HF. Individualised fluid restriction should be encouraged. It can help in reducing water pill reduction, an important cause of producing weakness and sodium loss.

Palliative Care:

HF is a progressive disease and mortality rates up to 40% in a year are known after first hospitalisation. When adverse effects of drugs predominate, downscaling them should be considered. Focus of treatment should be on pain relief and reducing shortness of breath. Adequate communication with the patient and family and avoiding futile interventions is the key. Symptom control should be given the priority.

Take Home Message:

Older patients with HF often have several co-morbidities, frailty, polypharmacy and impaired cognition. Although all effort should be made to give evidence based drugs, an individualised approach to treatment should be given priority. Potential benefits and harm should be weighed and aligned with good care.

Disclaimer: The views and opinions expressed in this article are the personal opinions of the author.

The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK

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