Heart failure is one of the most common causes of disability in
the elderly and is the most common hospital discharge diagnosis
for the elderly. More than 75% of patients with heart failure
are older than 65 years.36 Among the factors that have contributed
to the increased numbers of older people with heart
failure are the improved therapies for ischemic and hypertensive
heart disease. Thus, persons who would have died of acute
myocardial disease 20 years ago are now surviving, but with
residual left ventricular dysfunction. Similarly, improved blood
pressure control has led to a 60% decline in stroke mortality
rates, yet these same people remain at risk for CHF as a complication
of hypertension. In addition, advances in treatment
of other diseases have contributed indirectly to the rising prevalence
of heart failure in the older population.
Coronary heart disease, hypertension, and valvular heart
disease (particularly aortic stenosis and mitral regurgitation)
are common causes of heart failure in older adults.36,37 Although
the pathophysiology of heart failure is similar in younger and
older persons, elderly persons tend to experience cardiac failure
when confronted with stresses that would not produce failure
in younger persons. There are four principal changes associated
with cardiovascular aging that impair the ability to
respond to stress.36 First, reduced responsiveness to β-adrenergic
stimulation limits the heart’s capacity maximally to increase
heart rate and contractility. A second major effect of aging is increased
vascular stiffness, which results in an increased resistance
to left ventricular ejection (afterload) and contributes to
the development of systolic hypertension in the elderly. Third,
in addition to increased vascular stiffness, the heart itself becomes
stiffer and less compliant with age. The changes in diastolic
stiffness result in important alterations in diastolic filling
and atrial function. A reduction in ventricular filling not only
affects cardiac output, but also produces an elevation in diastolic
pressure that is transmitted back to the left atrium, where
it stretches the muscle wall and predisposes to atrial ectopic
beats and atrial fibrillation. The fourth major effect of cardiovascular
aging is altered myocardial metabolism at the level of
the mitochondria. Although older mitochondria may be able
to generate sufficient adenosine triphosphate to meet the normal
energy needs of the heart, they may not be able to respond
under stress.
Manifestations
The manifestations of heart failure in the elderly often are
masked by other disease conditions. Nocturia is an early symptom
but may be caused by other conditions such as prostatic
hypertrophy. Dyspnea on exertion may result from lung disease,
lack of exercise, and deconditioning. Lower extremity
edema commonly is caused by venous insufficiency.
Among the acute manifestations of heart failure in the elderly
are increasing lethargy and confusion, probably the result
of impaired cerebral perfusion. Activity intolerance is common.
Instead of dyspnea, the prominent sign may be restlessness.
Impaired perfusion of the gastrointestinal tract is a common
cause of anorexia and profound loss of lean body mass.
Loss of lean body mass may be masked by edemaThe elderly also maintain a precarious balance between the
managed symptom state and acute symptom exacerbation.
During the managed symptom state, they are relatively symptom
free while adhering to their treatment regimen. Acute
symptom exacerbation, often requiring emergency medical
treatment, can be precipitated by seemingly minor conditions
such as poor compliance with sodium restriction, infection,
or stress. Failure promptly to seek medical care is a common
cause of progressive acceleration of symptoms.
Diagnosis and Treatment
The diagnosis of heart failure in the elderly is based on the history,
physical examination, chest radiograph, and ECG findings.
However, the presenting symptoms of heart failure often
are difficult to evaluate.
Treatment of heart failure in the elderly involves many of
the same methods as in younger persons. Activities are restricted
to a level that is commensurate with the cardiac reserve.
Seldom is bed rest recommended or advised. Bed rest causes
rapid deconditioning of skeletal muscles and increases the risk
of complications, such as orthostatic hypotension and thromboemboli.
Instead, carefully prescribed exercise programs can
help to maintain activity tolerance. Even walking around a
room usually is preferable to continuous bed rest. Sodium restriction
usually is indicated.
Age- and disease-related changes increase the likelihood of
adverse drug reactions and drug interactions. Drug dosages and
the number of drugs that are prescribed should be kept to a
minimum. Compliance with drug regimens often is difficult;
the simpler the regimen, the more likely it is that the older
person will comply. In general, the treatment plan for elderly
persons with heart failure must be put in the context of the person’s
overall needs. An improvement in the quality of life may
take precedence over increasing the length of survival.