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Treatment for heart failure is not straightforward for any patient. Add in up to seven comorbidities and possible cognitive impairment and nutritional problems, and you get an idea of the complexity of treating older patients. Doctor Pascal de Groote (CHU de Lille – Institut Coeur Poumon, Lille, France), a speaker at Saturday’s symposium ‘Very old patient, very new problems’ talks about the challenges of treating the elderly, which, in today’s world, means patients over the age of 80 years.
“Before any treatment is administered, a geriatric assessment must be conducted alongside the medical evaluation so that the patient’s frailty can be judged. The results of this assessment will guide management strategies and so it is an absolute necessity for all patients. The test should include evaluation of cognitive impairment, of depression, of mobility and should identify any financial, nutritional or social problems that may influence management. Sometimes, we need the help of geriatricians for the geriatric evaluation.
In terms of treatment, elderly patients in good health can receive drugs and/or devices. Unfortunately, given the lack of randomised trials in elderly patients, we have to rely on registry evidence regarding which drugs used in younger patients will have similar efficacy in older individuals. The most important message to remember when treating this age group is to do no harm. It is vitally important that we balance the efficacy of a treatment with the possible consequences of side effects, which, in older patients can be life threatening.
For example, we need to avoid exposing older patients to the risks of worsening renal failure with angiotensin-converting enzyme inhibitors, dehydration with diuretics and potentially devastating falls associated with orthostatic hypotension as a result of excessive blood pressure reduction. Unlike heart failure with reduced ejection fraction, for which there are established treatment pathways, there is still no clear picture of the best drugs to use for heart failure with preserved ejection fraction, in younger as well as older patients. For these individuals, treatment should focus on managing symptoms.
When a patient is not in good health, treatment should be kept to a minimum and there should be a conversation with the patient and family about possible palliative care. As a note of caution here, although the medical community understand that ‘palliative care’ can last for months or even years, the term can be alarming for the general population, who associate it with imminent death. We need to be aware of this in our interactions with patients and care givers. The cardiologist and palliative care physician should work together to provide a management plan that will enable the patient to enjoy their remaining time without pain or distress.
Primary prevention is an important aim for all individuals, including the elderly, but we need to be realistic in our recommendations and mindful of the risks. With any age group, blood pressure, cholesterol, weight and diabetes should be managed, and individuals should be strongly advised not to smoke. All but the frailest older individual should be encouraged to do some sort of exercise every day. But this is a good example of where we need to be careful. Walking outside is not suitable if the conditions may cause the person to fall. These sorts of nuances must be clearly explained. Ideally, prevention plans should be tailored to the individual.
The elderly patient deserves to be treated as well as patients of other ages. If we know their frailty status and are aware of the risks associated with different treatment approaches, we should be able to effectively manage elderly patients and ensure they enjoy a good quality of life.”
Would you give it to your grandmother? - Primary prevention in the elderlyTuesday, 08:30 – 10:00; London – Village 2
Pick of the posters today:
Impact of frailty status on 30-day mortality in patients with valvular heart disease undergoing percutaneous transcatheter valve interventions (P3723)08:30 – 12:30; Poster Area
Older patients with atrial fibrillation and comorbidities are less likely to be treated with oral anticoagulation: insights from a nationwide study (P4774)14:00 – 18:00; Poster Area
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About ESC Congress 2019
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