Sleep Apnea
Sleep apnea is common among patients with HF. A study of adults with chronic HF treated with evidence-based therapies found that 61% of participants had central or obstructive sleep apnea.39 In elderly patients, sleep apnea is further complicated by insomnia and disturbance of sleep cycle that often occur with the aging process.
It is crucial to differentiate central sleep apnea from obstructive sleep apnea, because the treatment approaches differ. Central sleep apnea is associated with poor prognosis in patients with HF.40 Adaptive servo ventilation for central sleep apnea uses a noninvasive ventilator to delivering servo controlled inspiratory pressure support on top of expiratory positive airway pressure. Adaptive servo ventilation for central sleep apnea is associated with higher all-cause mortality and CV mortality.41 Continuous positive airway pressure for obstructive sleep apnea improves sleep quality, reduces the apnea-hypopnea index, and improves nocturnal oxygenation.42
Depression
Clinically significant depression occurs in 21% of patients with HF, and the relationship between depression and poor HF outcomes is consistent and strong across several endpoints. However, in a randomized, 12-week study, the selective serotonin reuptake inhibitor sertraline did not improve depression symptoms or clinical status among patients with HF.43 Depression symptoms might overlap with fatigue and low energy expenditure experienced by oldest old patients with HF who do not have depression.
Furthermore, studies describing depression treatments among patients with HF are too small and heterogeneous to permit definitive conclusions about intervention effectiveness. These results identify areas requiring further development, raise questions regarding the association between depression and clinical outcomes in patients with HF, and provide information on depression prevalence that may help researchers design studies with appropriate depression measures and adequately powered sample sizes.
Frailty
Although frailty is prevalent in the elderly and is independently associated with poor outcomes, there is no standardized definition for frailty. The Fried Frailty Index is a widely used scale that incorporates criteria including weakness, slowness, exhaustion, and low physical activity in the diagnosis of frailty.44 However these symptoms are common among patients with advanced HF with and without depression or frailty.
Frailty should be defined collaboratively by the clinician and the patient and should include multidimensional aspects of health, function, and well-being. The treatment goal for patients with HF with frailty is to establish patient-centered goals based on preferences of care.45
Discussion
Although several novel approaches to improve outcomes of patients with HF have been developed, it continues to be the leading cause of cardiovascular death among older patients and the leading cause of hospital admissions.46 About 50% of newly diagnosed patients with HF die within 5 years.47 Current guidelines for managing HF are based on clinical trials that either include few or completely exclude patients aged > 80 years, minorities, and patients with comorbidities clinicians encounter daily in clinical practice.
Furthermore, most clinical trials are designed with mortality as the primary endpoint, which might be as important to our patients with advanced age as their ability to function with a reasonable QOL and less dependence on caregivers.
Decision making in managing HF in our oldest patients should start with an open discussion of the disease and its prognosis, goals of care, and available treatment options. The discussion should also cover all dimensions of suffering, including physical, spiritual, and psychosocial domains. Interviews of patients dying of HF and their caregivers conducted in the United Kingdom identified several communication and transition of care challenges specific to treating this population.48 The study revealed in most cases, patients did not recall receiving any written information about the severity of their disease and often did not understand the association among symptoms, such as shortness of breath, edema, and HF. Patients and caregivers did not feel involved in the decision-making process regarding their illness.
The concurrent presence of comorbidity, frailty, and cognitive impairment in our aging population with HF might add to the burden of the primary condition. Care often is perceived as fragmented. Polypharmacy negatively impacts HF management by increasing risk of drug nonadherence, drug interactions, and AEs in an already vulnerable population. There is a need for more effective interpersonal and easy to understand communication and resources.
In many situations, support services might be best facilitated by a dedicated palliative medicine team with significant experience in managing patients with HF.Although palliative medicine should always be considered for patients with HF with advanced age,consultations often are not obtained unless the patient decides to forgo medical treatment or until the last month of life.49It is important to note that older adults are not a homogeneous group, and the conventional viewpoint that all patients with HF value symptom control and QOL over longevity may not be true. In a large study three-fourths of elderly outpatients with HF were not willing to trade survival time for improved QOL; and their preferences changed over the course of illness.50
Although not all end-of-life symptoms can realistically be palliated, earlier involvement of multidisciplinary palliative medicine specialists may improve symptom control, functional status, and QOL. The team may help patients and caregivers cope with uncertainty, and make informed decisions that are person centered based on value system and beliefs.51