Heart Failure in people over 65

Cardiac Failure is predominantly a disease of older persons:

• It occurs in 1 in 10 of the over 65's.
• 5% to 10% of people in their 80's are affected.

Both the incidence and prevalence of chronic cardiac failure are rising, because of better care of coronary events, and hence better survival, more emphasis on preventative medicine, with respect to vascular risk factors in the ageing population, and more older people in the population (currently, around one quarter of the population is over 60 in the UK, but by 2030, this will have risen to one third).

The causes are usually coronary heart disease, especially in the Caucasian population, whereas hypertension (high blood pressure) is likely to be a predisposing factor in the Afro-Caribbean population. Older patients with chronic heart failure are more likely to be female, with pre-existing high blood pressure, and preserved left ventricular function; diastolic dysfunction is also a prominent feature, especially those with a history of high blood pressure.

Other causes of heart failure in older patients are:

• Degenerative heart valve disease,
• Arrhythmias,
• Pulmonary hypertension (e.g. as a result of COPD - chronic obstructive pulmonary disease),
• High cardiac output states (e.g. as a result of anaemia, Paget's Disease and thyroid disease),
• Cardiomyopathy.

Diagnosis may be difficult, because of other co-existing disease, possible multiple medications and their effects, and complicating factors such as dementia.

Because of age-related changes in the cardiovascular and other organ systems in the older person, there is the likelihood of increased severity of symptoms, possible complication in the management, and a worsened prognosis, as well as the increased likelihood of developing cardiac failure. Also, the dosage of many of the medications including those for cardiac failure should be the lowest effective dose, because kidney and liver function may be reduced, older patients often receive multiple drugs for multiple conditions, and there are drug interactions and adverse effects of which to be aware.

Chronic cardiac failure is an important cause of chronic disability in older adults with physical and psychological effects of:

• Breathlessness,
• Poor exercise tolerance,
• Reduction in activity,
• Isolation,
• Depression and anxiety,
• Possible poor cognitive state.

The management of cardiac failure in older patients is similar to that of younger patients; however cardiac failure in the older person is best treated using a co-ordinated multidisciplinary team approach. A full medical management plan should follow Consultant Cardiologist assessment and involve the GP and/or a Specialist Cardiac Failure Nurse at a heart failure follow-up clinic or a day hospital. with particular facilities for older people, and/or those who are frail.

Important factors, which would be monitored, are:

• Medication supervision and adjustment of medication according to the NICE Guidelines (National Institute for Health and Clinical Excellence), bearing in mind side-effects and drug interactions,
• Lifestyle factors, such as nutrition, alcohol intake, exercise (Tai Chi has documented physical and psychosocial benefits and is used in some cardiac rehabilitation programmes),
• Treating the cause, if possible (for example, corrective operation for aortic stenotic valvular disease or treatment for atrial fibrillation),
• Addressing social factors, including isolation, inability to attend follow-ups, the need for social support or a carer,
• Cognitive assessment and assessment for depression. (Frequently used tests are the Mini Mental State Examination, the Abbreviated Mental Test Score, the Clock Drawing and Mini- Cog and the Geriatric Depression Scale).