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European Journal of Heart Failure 2002 4(1):91-98; doi:10.1016/S1388-9842(01)00200-8
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© 2002 European Society of Cardiology

Heart failure in frail elderly patients: diagnostic difficulties, co-morbidities, polypharmacy and treatment dilemmas

Christopher T.C. Liena, Neil D. Gillespiea,*, Allan D. Struthersb and Marion E.T. McMurdoa

a Ageing and Health, Department of Medicine, Ninewells Hospital and Medical School Dundee DD1 9SY, UK
b Department of Clinical Pharmacology and Therapeutics, Ninewells Hospital and Medical School Dundee DD1 9SY, UK

* Corresponding author. Tel.: +44-1382-632436; fax: +44-1382-660675. E-mail address: n.d.gillespie{at}dundee.ac.uk


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 Acknowledgments
 References
 
Background: Heart failure (HF) is difficult to diagnose and treat in older patients. Symptoms may be non-specific and the presence of co-morbidities and polypharmacy complicate treatment strategies. There are, however, few data to quantify the extent of these problems in the very elderly.

Methods: A retrospective study of 116 patients (median age 86; range 65–98) with an established diagnosis of HF during their hospital admission. Main outcome measures: the accuracy of diagnosis of heart failure according to the European Society of Cardiology (ESC) definition. The aetiology and frequency of associated co-morbidities and the nature of drug treatment.

Results: The specificities of clinical signs, chest X-rays and abnormal ECGs for heart failure (ESC definition) were 50%, 20% and 9%, respectively. Only 28% of patients were admitted for worsening symptoms which could be attributed to HF. None of the patients had HF as their only medical problem. Co-morbidities included chest disease (30%), incontinence (29%), cerebrovascular disease (26%), musculoskeletal problems (41%). Barthel (activities of daily living) score was ≤16/20 in 35%. Mental state questionnaire (MSQ) score was ≤7/10 in 38%. Ninety percent were taking four or more different medications. Thirty-nine percent were on psychotropic drugs. On discharge, a total of 88% of patients returned home to live independently and 35% were monitored by regular day hospital attendance.

Conclusion: Heart failure in frail elderly patients is often compounded by other major illnesses and polypharmacy which have a profound impact on their functional status. This has implications for the most effective targeting of evidence based treatment.

Key Words: Heart failure • Elderly • Co-morbidities • Polypharmacy • Day hospital

Received May 4, 2001; Revised July 26, 2001; Accepted September 19, 2001


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 Acknowledgments
 References
 
Heart failure is common in older patients and is a major cause of morbidity and mortality [1,2]. Hospitalisation for heart failure among the elderly also increases the risk of subsequent mortality, readmission for heart failure [3], re-hospitalisation for any reason and greater functional decline [4].

Studies have shown that heart failure in older patients may have an insidious onset. Symptoms may be non-specific and signs may be obscured by the presence of multiple co-morbidities, making chronic heart failure (CHF) in the frailer elderly a difficult disease to diagnose [5–7]. In addition, CHF in older patients may also be difficult to treat because of the multiple co-morbidities, the presence of polypharmacy and a greater prevalence of adverse drug effects [8,9]. These therapeutic difficulties may explain why doctors may be reluctant to use the full range of available therapeutic options in older heart failure patients [10–12]. Importantly, however, there are few data to quantify the extent of these underlying problems in frail older patients who are not usually included in the major heart failure clinical trials.

This study set out to provide some quantitative data on the extent of these diagnostic and therapeutic problems among frailer elderly patients across a needs-related Medicine for the Elderly service. After all, it could, for example, turn out that the underuse of ACE-inhibitors [11] and beta-blockers [12] is not only entirely appropriate, but may in fact be only one of several therapeutic options that need to be re-considered due to a high frequency of recognised contraindications and co-pathologies.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 5. Conclusion
 Acknowledgments
 References
 
Patients were identified retrospectively from a computerised database containing detailed discharge summaries of patients admitted to the Medicine for the Elderly assessment and rehabilitation wards in Dundee. Casenotes of consecutive patients who were either discharged with frusemide for heart failure or had an ICD-10 coded diagnosis of heart failure were reviewed by medical staff shortly after discharge, using a standardised questionnaire, over a nine month period.

This retrospective study used data captured on structured documentation sheets. Parameters such as symptoms, signs, blood pressure, the abbreviated Mental State Questionnaire (MSQ), discharge Barthel Index (a standardised assessment tool to record basic activities of daily living), co-morbidities and medication prescribed are recorded as part of routine practice. Chest X-ray (CXR) findings were obtained from formal X-ray reports or by review of the X-ray films by CL. The New York Heart Association (NYHA) Classification during admission was inferred from the documentation of symptoms in the casenotes. Electrocardiographs (ECG) were collected and separately analysed according to the Minnesota Criteria [41] by CL.

Echocardiography was provided by a centralised cardiology service and was reported by consultant cardiologists. LV systolic dysfunction was diagnosed on the basis of a visual assessment of global LV function and fractional shortening and the ejection fraction were calculated when possible. Diastolic dysfunction was considered when there were symptoms and signs of heart failure associated with normal systolic function together with objective evidence of left ventricular filling abnormalities. The definition of heart failure by the Task Force on Heart Failure of the European Society of Cardiology (ESC) [13] requires objective evidence of cardiac dysfunction in addition to the presence of symptoms or signs. A response to treatment should also be taken into consideration. The accuracy of the diagnosis of heart failure in this frail elderly cohort was assessed using the ESC criteria.

The Mann–Whitney (MW) test was used to analyse differences between non-parametric data, and the chi-square ({chi}2) test was used to compare categorical data.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 5. Conclusion
 Acknowledgments
 References
 
One hundred and sixteen consecutive patients (31 men, 85 women) were included in the analysis. The median age was 86 years (range 65–98), and 82% (95/116) were aged 75 years and above. The median discharge Barthel score was 18/20 (range 0–20) and median MSQ was 9/10 (range 0–10).

Echocardiography was available for 76% (88/116) of patients. Frailer patients were less likely to be investigated. Those who did not have echocardiography were older (median age 89 years, P<0.005 [MW]), had a lower MSQ (median MSQ 7, P<0.05 [MW]) and a lower median Barthel score on discharge (16, P<0.001 [MW]) compared with those who had echocardiography (age 84 years, MSQ 9 and Barthel 18). ECGs were available for 94% (109/116) of patients and were abnormal in 95% (103/109). CXRs were available in 80% (93/116) of patients.

Patients were distributed across all NYHA classes. Symptoms (NYHA Class II–IV) were present in 86% (100/116) of patients and signs of heart failure were noted in 76% (92/116) (Table 1a). Among patients with available CXRs, 75% (70/93) had CXR evidence of heart failure (cardiomegaly, pleural effusion, pulmonary oedema or upper lobe diversion) (Table 1b)


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  		Table 1 (a) Signs of heart failurea and (b) CXR evidence of HFb

 
3.1. Echocardiography
Among patients with echocardiography, 55% (48/88) had evidence of LV systolic dysfunction. Forty-two percent (37/88) were found to have significant valvular abnormalities, but a murmur was noted in only 51% of them (19/37). Diastolic dysfunction was reported in 22% (19/88) of patients. Eighty-one percent (71/88) had ‘objective’ evidence of cardiac dysfunction, and 73% (64/88) fulfilled the ESC criteria for a diagnosis of heart failure.

3.2. Asymptomatic patients
Fourteen percent (16/116) of patients did not have any symptoms of heart failure (NYHA Class I), but 44% (7/16) of these patients had clinical signs (basal crackles or leg oedema) and among the eight patients with CXRs, all had some evidence to suggest underlying cardiac disease. Fifty percent (8/16) had Barthel activities of daily living score of ≤16/20, suggesting that there may be other factors which limit mobility, functional state and the ability to exert. Among the 81% (13/16) of asymptomatic patients who had an echocardiogram, 85% (11/13) had some objective evidence of cardiac dysfunction which included 46% (6/13) with LV systolic dysfunction and 62% (8/13) with significant valvular disease. Although a significantly greater proportion of patients with symptoms of heart failure had clinical signs of heart failure, more importantly, there was no significant difference in CXR or echocardiographic evidence of cardiac dysfunction between the asymptomatic and symptomatic patients (Table 2).


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  		Table 2 Comparing asymptomatic and symptomatic patients

 
3.3. Diagnostic accuracy
Symptoms and signs that were of high specificity in diagnosing heart failure by the ESC definition included paroxysmal nocturnal dyspnoea, orthopnoea and an elevated JVP. These parameters were, however, of low sensitivity and of poor negative predictive value. CXR findings were unhelpful in predicting the presence of heart failure. An abnormal ECG was of high sensitivity but low specificity, had a positive predictive value of 75% (60/80) and a negative predictive value of only 33% (2/6). Objective (usually echocardiographic) evidence of cardiac dysfunction is an integral part of the ESC definition for heart failure, which explains the high sensitivity (64/64) and negative predictive value (17/17) of echocardiography. However, the definition excludes patients without symptoms and this compromises its specificity (71% or 17/24) and positive predictive value (90% or 64/71) (Table 3).


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  		Table 3 Accuracy of diagnosing heart failure (ESC definition) on the basis of symptoms, signs, X-rays, ECG and echocardiogram

 
3.4. Reasons for admission
Only 28% (n=33) of admissions were predominantly due to worsening symptoms of breathlessness due to underlying heart failure. A further 10% of patients (n=12) presented with breathlessness but this was thought to be due to underlying chest disease. Six patients were admitted for chest pain. The majority (48%) of patients (n=56) were admitted for problems associated with deteriorating mobility and problems with self-care (which included those with falls, dizzy turns, lethargy, confusion, collapse, gout and constipation). Three patients were admitted for rehabilitation post stroke.

3.5. Co-morbidities
None of the patients had chronic heart failure as their only medical problem. Chest disease was present in 30% (36/116) of patients. Patients with pre-existing chest disease were more likely to have signs of lung crepitations or rhonchi on clinical examination [78% (28/36) compared to the 55% (44/80) with no underlying chest disease; {chi}2=5.5, P<0.05]. Twenty-two percent of patients had treated hypothyroidism and 26% had a known history of cerebrovascular disease. There was a high prevalence of cognitive impairment. On the 10-point abbreviated mental state questionnaire score, 38% had an MSQ≤7 (and 49% an MSQ of ≤8). Thirty-nine percent of patients were on medication for a variety of psychological problems: 28% (n=32) took a night-time sedative; 12% (n=14) were on anti-depressants (of which 10/14 were in NYHA Class III–IV); and 8% (n=9; 5/9 in NYHA Class III–IV) required medication for agitation or anxiety. Forty-one percent of patients required analgesia for a variety of musculoskeletal problems. On discharge from hospital, 29% (34/118) of patients were either incontinent or had a urinary catheter as a result of intractable incontinence (Table 4).


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  		Table 4 Co-morbidities in elderly heart failure patients

 
3.6. Treatment and polypharmacy
Ninety-one percent (105/116) of patients were on a loop diuretic, and doses (equivalent to frusemide) ranged from 20 to 120 mg a day. Patients not on frusemide (n=11) included five patients with atrial fibrillation who improved symptomatically from rate control with digoxin and three patients who had their diuretics discontinued (Table 5).


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  		Table 5 Polypharmacy in elderly heart failure patients

 
Among those with systolic dysfunction diagnosed on echocardiography (n=48), 71% (34/48) were prescribed an ACE-inhibitor. Doses used were lower than target doses in clinical trials in 85% (29/34). ACE-inhibitor treatment was withdrawn due to side-effects (postural hypotension) in only one patient. Among those with LV systolic dysfunction who were not on an ACE-inhibitor, only 4/14 (29%) had absolute contra-indications (two with severe aortic stenosis and two with renal failure). Digoxin was prescribed to 53% (15/28) of patients who had LV systolic dysfunction and were in NYHA Class III–IV. Five patients were on a beta-blocker, but not specifically for heart failure. Polypharmacy was a feature in many of our patients. Ninety percent of patients were on four or more medications (median=six different medications; range: 0–14).

3.7. Discharge and follow-up
Despite the presence of significant multiple co-morbidities and of cognitive dysfunction, 88% (104/116) of the patients in this cohort returned home to live independently (including four patients with an MSQ of three and who had LV systolic dysfunction and were not offered an ACE-inhibitor). Nine percent (10/116) were discharged to a nursing home or NHS continuing care wards, and 3% (4/116) to a residential home for the elderly. Thirty-five percent (36/102) of patients discharged home continued with regular attendances at the Medicine for the Elderly day hospital.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
5. Conclusion
 Acknowledgments
 References
 
This retrospective study highlights some of the difficulties associated with diagnosing and treating heart failure in frail older patients, a group who are poorly represented in the major clinical trials. The data collected in this study is from routine clinical practice, and as such, has significant limitations. Nevertheless, it provides us with some novel information about the frail elderly heart failure patients seen in day to day practice in a Scottish Medicine for the Elderly Service. In this group, many patients had poor functional capacity; 38% had a degree of cognitive impairment (MSQ≤7), 26% had cerebrovascular disease and 35% had a Barthel activities of daily living score of 16 or less. A Barthel score of less than 16 implies that the patient may encounter difficulties if trying to live independently in the community.

4.1. Diagnostic difficulties
The difficulties in diagnosing heart failure on clinical grounds are well described [5,14] and this study suggests that the difficulties are particularly evident in frailer patients. Specific symptoms such as paroxysmal nocturnal dyspnoea and orthopnoea were present in too few patients to be sufficiently sensitive to make a reliable diagnosis of heart failure by the ESC definition. The detection of these symptoms also depends on patients being able to give an accurate history, which can prove difficult in the presence of cognitive impairment. Musculoskeletal problems and low levels of fitness together with cerebrovasular disease may prevent the patient from ever reaching a level of activity at which breathlessness may be precipitated. Indeed, just only a quarter of these patients were admitted initially with heart failure as the main indication for admission. Consequently, the diagnosis of heart failure in the older patient relies more on objective assessments of cardiac performance and response to treatment rather than clinical signs and symptoms. This is one of the reasons why echocardiography is so important in older patients. Other reasons why echocardiography is so crucial include the high level of background valvular disease and the likelihood of a dilated left atrium [15], which has implications for treatment with anticoagulants.

4.2. Reasons for admission and multiple co-morbidites
Only 28% of patients in this cohort were admitted to hospital as a result of worsening symptoms of their heart failure. The majority (47%) were admitted for problems associated with mobililty and self care. This is a common feature in elderly medicine, where patients are often admitted for different reasons which lead to an inability to cope at home [16]. This reminds us that CHF in frailer patients can be concealed by other predominant medical reasons which result in hospital admission. This could even strengthen the argument for screening for heart failure among elderly in-patients with natriuretic peptides [17,18]. In addition, among patients who present with symptoms which can be attributed to underlying chest disease (10% in this case), it is important not to overlook any associated underlying cardiac dysfunction, even if any response to treatment could be masked by alternative causes of breathlessness. In the presence of multiple pathology, the treatment of heart failure may only lead to modest improvements in effort tolerance, but the effect of these small improvements on various aspects of self-care and on quality of life are likely to be very important in individual patients.

4.3. Prescribing diuretics and the problem of urinary incontinence
Most patients (91%) were on a loop diuretic, though not all patients required this on discharge. There is evidence to suggest that diuretics may be discontinued in some patients with heart failure [19]; although when diuretics are stopped, those patients with depressed left ventricular ejection fraction and atrial fibrillation usually require treatment to be instigated at some point in the future. Heart failure with normal systolic function is increasingly being recognised in older patients [20], but the long-term requirements of diuretic therapy and other treatment modalities in this group of patients is currently unclear. Urinary incontinence is an important factor to consider (present in 29% of these patients) when prescribing diuretics. The dosage of diuretic should be adjusted to the minimum dose possible. If the patient or their carer is able to self-medicate, it may be possible to spread out the dose of diuretic on alternate days [21] so that inconvenience is minimised. A cause for incontinence should always be sought as it may be easily remedied. Other potential ways of reducing the need for diuretics include optimum control of ventricular rate in patients with atrial fibrillation, optimising the ACE inhibitor dosage and treating associated anaemia or thyroid dysfunction. Elderly patients with heart failure require particularly close supervision of their electrolytes and those patients with hyponatraemia may be more likely to have hypotension when treated with ACE inhibitors [22].

4.4. Use of ACE-inhibitors
ACE-inhibitor usage among patients with LV systolic dysfunction was relatively high (71%) [23,24], but most (85%) did not receive the target doses identified in the major survival trials. There may be good reasons for this including a high level of postural hypotension among elderly in-patients [25]. Although the major clinical trials show that ACE-inhibitor usage in patients with LV systolic dysfunction improves symptoms, prevents hospitalisations [26] and prolongs survival [27], there is little data on the use of maximum doses of ACE inhibitors in frail older patients. However, despite the caution with ACE-inhibitor dosage, the incidence of side effects in this cohort was low, which is in keeping with previous reports [28]. None of the patients developed a deterioration of their renal function and only one patient (1/35 or 3%) had postural hypotension and required the discontinuation of ACE-inhibitor treatment. During the time of this study, further evidence for the use of beta-blockers [29] in the treatment of heart failure has emerged. Their tolerability in the frail older patient is yet to be established.

4.5. Polypharmacy, falls and compliance
Ninety percent of patients were on four or more different medications. This has important treatment implications, particularly when the patient leaves hospital where the level of close supervision diminishes. In a systematic evaluation of drugs and falls in older patients, subjects reporting the use of three or four psychotropic, cardiac or analgesic drugs were at an increased risk of recurrent falls [30] in the community and falls in the older patient are a major source of morbidity and mortality [31]. Therapeutic options in patients with significant symptoms from LV systolic dysfunction now include the addition of digoxin [32] and spironolactone [33]. Their potential benefit needs to be put into the context of the existing polypharmacy, which in itself can lead to non-compliance [34]. A community based nurse [35] or pharmacist may be able to monitor the patients when they are discharged from hospital. Polypharmacy may also be addressed and monitored by follow up of the patient at Day Hospital where facilities include interdisciplinary management and access to investigations and laboratory tests.

4.6. Cognitive impairment, depression, anxiety and insomnia
Cognitive impairment (MSQ≤7) was present in at least 38% of patients. A recent larger study revealed that 56% of elderly patients with chronic heart failure have a mini-mental state examination score (MMSE) of less than 24 [36]. This is the level at which patients with Alzheimer's disease may derive treatment with an acetylcholinesterase inhibitor. Patients with cognitive impairment may not remember their symptoms and may also be unable to register changes in their symptoms, until they become severely unwell with frank pulmonary oedema. Recent evidence suggests that hospital admissions for heart failure may be reduced by prompt tailoring of the therapeutic regime when the clinical condition deteriorates [37]. Early detection of a deterioration may prove difficult in the frail older patient who may attribute fatigue, breathlessness or lethargy to merely their age. The ability to bring to medical attention any ongoing problems with side-effects of therapy may also be compromised.

The association of heart failure with depression is increasingly recognised [38]. Twelve percent of patients in this study were on an anti-depressant and of these 71% were in NYHA Class III–IV. More importantly, 28% of patients were on a benzodiazepine for insomnia. Symptoms such as nocturnal dyspnoea or orthopnoea could be disguised as a need for night-time sedation, which may be a valuable clue for cardiac decompensation.

4.7. Multi-disciplinary care and day hospitals
All patients in this study were managed within a multi-disciplinary environment directed towards the needs of frail older persons, and received concurrent rehabilitation in addition to medical treatment. In this environment, there is the opportunity for nursing and therapy staff to pay particular attention to the less conventional manifestations of heart failure and its treatment. Issues of polypharmacy, medication compliance, ease of toileting, ability to fit into footwear and appropriate community support measures to maintain independence were routinely addressed.

Eighty-eight percent of patients were discharged back to their own homes and 35% of those discharged continued to return to day hospital for weekly assessment, monitoring and further rehabilitation. There is evidence to show that such multi-disciplinary interventions in heart failure improve quality of life [39] and together with a skilfully planned discharge package with appropriate maintenance interventions, successfully limit readmissions [40]. These nurse-led North American models have parallels in the United Kingdom within Geriatric Day Hospitals where key-workers (usually a member of the multi-disciplinary team) are accustomed to being in frequent contact with patients and care-givers, and where patient diaries can be used to monitor and record parameters such as weight and symptoms.


   5. Conclusion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
Acknowledgments
 References
 
This retrospective study highlights some of the diagnostic and management difficulties associated with heart failure in the frail older patient. Although the numbers studied are relatively small and the data collected were from routine daily practice, the study illustrates a number of important issues in the very old heart failure patient. Although the majority of the findings are not new, the study provides quantitative data on polypharmacy, incontinence, cognitive dysfunction and depression in the elderly heart failure patient. Awareness of the extent and implications of these associated factors may facilitate optimum management.


   Acknowledgments
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 Acknowledgments
References
 
We are grateful to Dr J.L. Hanslip, Dr L. Ramage, Dr J.M. Watson, Dr W.J. Mutch and Ms A. Maher for their helpful comments and support, Mrs L. Irving for the initial statistical analysis, Dr R.L. Chen for statistical advice and also to the SHOs and secretarial staff in Ashludie, Royal Victoria and Ninewells Hospitals who assisted in collecting the information required. The authors acknowledge the financial support of the clinical effectiveness and audit committee of the Dundee Healthcare (NHS) Trust.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 Acknowledgments
 References
 

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