Heart Failure Among Very Old Individuals
Heart Failure Among Very Old Individuals
Background: Increasing prevalence, use of health services, and number of deaths have made congestive heart failure (CHF) a new epidemic in the United States. Yet there are no adequate data to guide treatment of the more typical and complex cases of patients who are very old and frail.
Methods: Using the SAGE database, we studied the cases of 86,094 patients with CHF admitted to any of the 1492 long-term care facilities of 5 states from 1992 through 1996. We described their clinical and functional characteristics and their pharmacologic treatment to verify agreement with widely approved guidelines. We evaluated age- and sex-related differences, and we determined predictors of receiving an angiotensin-converting enzyme (ACE) inhibitor by developing a multiple logistic regression model.
Results: The mean age of the population was 84.9 ± 8 years. Eighty percent of the patients 85 years of age or older were women. More than two thirds of patients underwent frequent hospitalizations related to CHF in the year preceding admission to a long-term care facility. Coronary heart disease and hypertension were the most common causes. Half of the patients received digoxin and 45% a diuretic, regardless of background cardiovascular comorbidities. Only 25% of patients had a prescription for ACE inhibitors. The presence of cardiovascular comorbidity, already being a recipient of a large number of medications, a previous hospitalization for CHF, and admission to the facility in recent years were associated with an increased likelihood of receiving an ACE inhibitor. The presence of severe physical limitation was inversely related to use of ACE inhibitors, as were a series of organizational factors related to the facilities.
Conclusions: Patients in long-term care who have CHF little resemble to those enrolled in randomized trials. This circumstance may explain, at least in part, the divergence from pharmacologic management consensus guidelines. Yet the prescription of ACE inhibitors varies significantly across facilities and depends on organizational characteristics.
The incidence and prevalence of congestive heart failure (CHF) escalate with age, and because most women outlive most men, the absolute number of cases is highest among older women. These epidemiologic observations together with the substantial mortality and morbidity associated with it have made CHF a new epidemic in the United States. The magnitude of the problem is expected to increase because more adults survive into old age as a result of reduced mortality from coronary heart disease and stroke. Heart failure is a major cause of disability. It erodes quality of life and necessitates frequent hospital admissions and subsequent placement in a long-term care facility.
Landmark clinical trials have established that appropriate pharmacologic therapy can prolong survival while reducing morbidity among patients with CHF. Consensus guidelines based on the results of these trials have been released in United States and in Europe. However, many studies have shown a very slow introduction or even no adoption of the recommendations from the trials, infrequent use of certain drugs, especially angiotensin-converting enzyme (ACE) inhibitors, use of lower than suggested dosages, and poor compliance with prescriptions. Age and sex bias consistently appear to explain some of these findings.
Despite the epidemiologic relevance of CHF among older persons, there is a paucity of data to elucidate optimal therapeutic strategies for the more typical patients with CHF. Heart failure trials have almost invariably excluded elderly patients, especially the oldest ones, and have greatly underrepresented women. Entry criteria have screened out complex and frail patients and have usually prioritized mortality end points. Issues such as comorbidity, polypharmacy, and cognitive loss, pertinent to the treatment of patients with CHF remain poorly explored.
We conducted a cross-sectional study involving patients with CHF living in long-term care facilities. The aims of our study were to (1) describe patients' clinical and functional characteristics, (2) characterize specific pharmacologic regimens and the extent to which they vary depending on comorbid conditions, and (3) evaluate predictors of appropriate pharmacologic care (use of ACE inhibitors), including specific facility characteristics.
Background: Increasing prevalence, use of health services, and number of deaths have made congestive heart failure (CHF) a new epidemic in the United States. Yet there are no adequate data to guide treatment of the more typical and complex cases of patients who are very old and frail.
Methods: Using the SAGE database, we studied the cases of 86,094 patients with CHF admitted to any of the 1492 long-term care facilities of 5 states from 1992 through 1996. We described their clinical and functional characteristics and their pharmacologic treatment to verify agreement with widely approved guidelines. We evaluated age- and sex-related differences, and we determined predictors of receiving an angiotensin-converting enzyme (ACE) inhibitor by developing a multiple logistic regression model.
Results: The mean age of the population was 84.9 ± 8 years. Eighty percent of the patients 85 years of age or older were women. More than two thirds of patients underwent frequent hospitalizations related to CHF in the year preceding admission to a long-term care facility. Coronary heart disease and hypertension were the most common causes. Half of the patients received digoxin and 45% a diuretic, regardless of background cardiovascular comorbidities. Only 25% of patients had a prescription for ACE inhibitors. The presence of cardiovascular comorbidity, already being a recipient of a large number of medications, a previous hospitalization for CHF, and admission to the facility in recent years were associated with an increased likelihood of receiving an ACE inhibitor. The presence of severe physical limitation was inversely related to use of ACE inhibitors, as were a series of organizational factors related to the facilities.
Conclusions: Patients in long-term care who have CHF little resemble to those enrolled in randomized trials. This circumstance may explain, at least in part, the divergence from pharmacologic management consensus guidelines. Yet the prescription of ACE inhibitors varies significantly across facilities and depends on organizational characteristics.
The incidence and prevalence of congestive heart failure (CHF) escalate with age, and because most women outlive most men, the absolute number of cases is highest among older women. These epidemiologic observations together with the substantial mortality and morbidity associated with it have made CHF a new epidemic in the United States. The magnitude of the problem is expected to increase because more adults survive into old age as a result of reduced mortality from coronary heart disease and stroke. Heart failure is a major cause of disability. It erodes quality of life and necessitates frequent hospital admissions and subsequent placement in a long-term care facility.
Landmark clinical trials have established that appropriate pharmacologic therapy can prolong survival while reducing morbidity among patients with CHF. Consensus guidelines based on the results of these trials have been released in United States and in Europe. However, many studies have shown a very slow introduction or even no adoption of the recommendations from the trials, infrequent use of certain drugs, especially angiotensin-converting enzyme (ACE) inhibitors, use of lower than suggested dosages, and poor compliance with prescriptions. Age and sex bias consistently appear to explain some of these findings.
Despite the epidemiologic relevance of CHF among older persons, there is a paucity of data to elucidate optimal therapeutic strategies for the more typical patients with CHF. Heart failure trials have almost invariably excluded elderly patients, especially the oldest ones, and have greatly underrepresented women. Entry criteria have screened out complex and frail patients and have usually prioritized mortality end points. Issues such as comorbidity, polypharmacy, and cognitive loss, pertinent to the treatment of patients with CHF remain poorly explored.
We conducted a cross-sectional study involving patients with CHF living in long-term care facilities. The aims of our study were to (1) describe patients' clinical and functional characteristics, (2) characterize specific pharmacologic regimens and the extent to which they vary depending on comorbid conditions, and (3) evaluate predictors of appropriate pharmacologic care (use of ACE inhibitors), including specific facility characteristics.
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