To the Editor,
It was with great interest that I read the article by Miró O et al1 on "short-term prognostic factors for the elderly treated for acute heart failure in emergency rooms", which highlights the importance of a functional assessment of elderly patients with heart failure. I would like to reflect on different aspects of evaluating elderly patients with heart failure.
Geriatric assessment2 is the basic technique used by professionals trained in care of the elderly. Based on clinical, functional, cognitive, affective, and social aspects of care, this screening requires just 15 minutes, whether as a baseline of normal healthy status or when health problems present themselves.
Geriatric assessment has been shown to be useful in different medical settings2 including hospital emergency services, and for different conditions, including heart failure.3 They are consistently used by geriatric specialists, and are on the rise among internists and general practitioners at different types of medical centres2,3, not only at nursing homes and geriatric care units as the authors stated.
Several factors that may have an effect on the prognosis of heart failure in the elderly were not mentioned in the article: polypharmacy, adherence to treatment,4 social problems,5 delirium and depressive, cognitive,6 and functional status at the time of coming to the ER.
It is interesting to note that despite the advanced mean age of patients in this analysis (80 [7] years), the rates of dementia are very low (6.3%), while up to 56% of heart failure patients older than 65 years have cognitive deterioration.6 This fact may be secondary to an underdiagnosis of dementia or to the possibility that fewer elderly patients with dementia come to the emergency room due to heart failure.
The authors mention that they did not include nutritional and anthropometric variables that may have provided more information about the elderly patient's fragility. However, the most widely-accepted criteria for fragility (Fried LP, 2001) require at least 3 of the following factors: weight loss, slow walking, little physical activity, sense of exhaustion, and lack of grip strength in the hand. In elderly patients with coronary disease or severe heart failure, the prevalence of fragility is 50% and fragility increases mortality and risk of cardiovascular events.7
All of these variables which are related to the prognosis of heart failure in fragile elderly patients have not been sufficiently studied and should be considered in clinical practice. This is all the more true now that we have seen that current drugs for treating diastolic heart failure in patients older than 80 may not be associated with better survival rates.8
The Canadian Cardiovascular Society and the French Society of Cardiology recommend the following for the elderly patient with heart failure: geriatric assessment, fragility screening, assessments for delirium, depression, cognitive decline and treatment adherence, and referring the fragile elderly to a geriatric specialist.9
In summary, geriatric assessment is a fundamental step in geriatric patient care in the emergency room and for fragile elderly patients with heart failure. Forming multidisciplinary teams may contribute to improving the management of elderly patients with heart failure.