Domain Management Approach to Heart Failure in the Geriatric Patient

Abstract

Heart failure (HF) is a quintessential geriatric cardiovascular condition, with more than 50% of hospitalizations occurring in adults age 75 years or older. In older patients, HF is closely linked to processes inherent to aging, which include cellular and structural changes to the myocardium, vasculature, and skeletal muscle. In addition, HF cannot be considered in isolation of physical functioning, or without the social, psychological, and behavioral dimensions of illness. The role of frailty, depression, cognitive impairment, nutrition, and goals of care are each uniquely relevant to the implementation and success of medical therapy. In this paper, we discuss a model of caring for older adults with HF through a 4-domain framework that can address the unique multidimensional needs and vulnerabilities of this population. We believe that clinicians who embrace this approach can improve health outcomes for older adults with HF.

Integrating assessment of cognitive status in elderly cardiovascular care

“…Among community‐based older adults with HF, cognitive impairment has complex cross‐sectional associations with physical frailty, sleep disorders, and mood disorders including depression, anxiety, and hopelessness . Cognitive impairment has been linked to a variety of poor outcomes including worse health‐related quality of life, increased spousal/caregiver distress, increased disability, worse cardiovascular outcomes at 180 days, and increased mortality risk . A common link, which has immense practical implications for clinicians caring for older adults with HF, is that cognitive impairment in this population is associated with worse self‐management, self‐care, and self‐confidence .…”

“…Cardiovascular clinicians should adopt a common approach to management of geriatric syndromes in older adults with cardiovascular disease that includes: (a) awareness, (b) screening, (c) incorporation into decision‐making, and (d) leveraging team‐based care by referring to and collaborating with appropriate colleagues. These approaches have been discussed in detail elsewhere as they relate to older adults with cardiovascular disease and HF …”

“…[14][15][16][17] Cognitive impairment has been linked to a variety of poor outcomes including worse health-related quality of life, increased spousal/caregiver distress, increased disability, worse cardiovascular outcomes at 180 days, and increased mortality risk. 18,19 A common link, which has immense practical implications for clinicians caring for older adults with HF, is that cognitive impairment in this population is associated with worse self-management, self-care, and self-confidence. 20 A high index of suspicion is warranted as patients with cognitive impairment are less likely to seek assistance.…”

Perspectives on Implementing a Multidomain Approach to Caring for Older Adults With Heart Failure

“…Consequently, the majority of the HF population is older than 75 years and typically contends with age‐related medical conditions and challenges, such as cognitive impairment and frailty. The complexity of caring for older adults with HF was the subject of a recent review article by the American College of Cardiology (ACC) Geriatric Cardiology Section Leadership Council . In this review, the council proposed a “domain management” approach that outlined four key domains that warrant routine assessment in older adults with HF—medical, mind and emotion, physical function, and social environment (Figure ).…”

Frailty in TOPCAT: a deep dive into the deficit index approach for defining frailty

“…Heart failure with preserved ejection fraction (HFpEF) disproportionately affects older adults, making HFpEF a common disease treated by geriatric cardiologists. Incorporating frailty measures into our understanding of older adults with HFpEF is recommended, but little data currently exist to guide clinicians. While frailty can be conceptualized as the cumulation of physiologic deficits over time that results in vulnerability to stressors, HFpEF can be considered a disease borne out of the accumulation of both age and key co‐morbid illnesses such as obesity, hypertension, diabetes, and atrial fibrillation .…”