Defining the role of palliative care in older adults with heart failure
Introduction
Older adults shoulder the population burden of heart failure. Approximately 80% of all cases of heart failure in the United States occur in persons aged 65 years and older [1] and as many as 6–10% of people in developed countries over the age of 65 have heart failure [2]. Heart failure is the leading cause of hospital admissions in people aged 65 years and older [2] and heart failure admissions are increasing in all industrialized countries [3].
Heart failure causes worsened health status, shortened survival, and a high risk of hospitalization among older adults. Despite therapeutic advances, population-based outcomes for heart failure have not improved substantially over the past decade [4], possibly reflecting an increasing complexity of the population of older adults with heart failure.
Older adults with heart failure differ substantially from those enrolled in randomized clinical trials of heart failure therapy [5]. Half of all older Medicare patients in the United States discharged from an acute care hospital with a principal diagnosis of HF have preserved left ventricular ejection fractions, one-third have chronic obstructive pulmonary disease, and 40% have diabetes [6]. Polypharmacy is the rule rather than the exception in older patients with heart failure; on average, elderly Medicare beneficiaries hospitalized with heart failure are discharged on more than 11 chronic medications [7]. These characteristics of the older population challenge clinicians, patients, and their families to formulate effective strategies of care to improve both longevity as well as the quality of life.
While palliative care is often thought of as only being applicable to dying patients, its focus on symptom alleviation, patient function, and quality of life has much to offer older adults with chronic heart failure. The primary aim of this article is to discuss how palliative care strategies may be implemented to meet the needs of older persons with heart failure. We define the need for palliative care and use a case example to illustrate how this type of care might benefit a heart failure patient. We conclude with a research agenda for palliative care in heart failure. Our objective is to help define the role of palliative care in the treatment of older adults with heart failure, providing clinicians with strategies that acknowledge the complexity of older persons with heart failure and have the potential to improve outcomes for these patients.
Section snippets
Case: Mrs. J
Mrs. J is a 73 year-old retired administrative assistant with coronary artery disease, diabetes, gastroesophageal reflux disease, hypertension, urinary incontinence, and ischemic cardiomyopathy with an ejection fraction of 0.25. She has persistent NYHA Class III heart failure on maximally tolerated doses of ACE-inhibitor, beta-blocker, and diuretic therapy. She takes 12 medications and has an implanted cardioverter-defibrillator/biventricular pacemaker. She visits her cardiologist monthly and
What is palliative care?
Palliative care is “patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and facilitating patient autonomy” [43]. Thus, palliative care expands the traditional medical goals of curing illness and prolonging life to emphasize the patient-centered goals of reducing symptom burden, enhancing function,
Case: Mrs. J, continued
The palliative care specialist targeted her depression and symptoms. Her symptoms could have been related to heart failure, side effects of heart failure or other medicines, or her depression/anxiety. Her shortness of breath was treated with opiates, constipation with bowel stimulants, dry mouth with oral rinses and sugarless hard candy, neck pain (thought to be muscular in origin) with heat and muscle relaxation techniques. Her anxiety and fears were addressed with supportive communication,
Research agenda for palliative care in heart failure
We have reviewed evidence for palliative and supportive care needs in patients with heart failure, described a conceptual framework that depicts measurable outcomes for palliative care programs and interventions, and suggested how palliative care might benefit patients with heart failure and their families. Important unanswered questions remain [51].
First, what are the critical elements of a palliative care intervention, and can the intervention be standardized so that it is replicable across
Conclusion
The health status burden of heart failure in older patients will require increasing attention from heart failure care providers over the next 20 years as the number of older adults grows and the oldest old (those over 85) become an ever greater proportion of the population. Failure to integrate a palliative care approach for these patients, whose disease in ultimately incurable and whose health status is poor, would be a profound disservice. By integrating pharmaceutical and behavioral
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