8. Community Management of HF
The management of HF should be delivered within an integrated system of care on the basis of chronic disease management and prevention principles.[559] This system must meet and anticipate the evolving goals and complexity of aging patients throughout their entire journey with HF, and provide access to specialized services, community supports, and end of life care according to patient needs and preferences.
8.1 Patient-level considerations
Clinical complexity, cognitive impairment, and frailty. Aging patients with HF often develop additional medical and psychiatric comorbidities, geriatric syndromes, and associated symptoms. Cognitive impairment, which is more common among patients with HF, is associated with impaired self-care capacity and greater risks of functional decline, rehospitalization, and mortality.[321],[564]–[567] Similarly, frailty affects up to 50% of older patients with HF, in whom it is associated with nonspecific clinical features, acute care utilization, poor quality of life, worse outcomes from concomitant conditions, and mortality.[568]
Recommendations regarding HF therapy apply to older patients and should not be restricted on the basis of age alone.[180],[182],[569]–[576] Frail patients are vulnerable to side effects due to the polypharmacy inherent to the treatment of HF and other comorbidities. To avoid side effects such as falls, care must be taken when optimizing medications toward target doses.[564],[577] Orthostatic hypotension is frequent among frail older patients, but if recognized, can be managed to allow for greater use of evidence-based HF therapies.[564],[578],[579]
Frailty has important ramifications on the organization of HF care. It is central to defining patient goals and thus to decision-making related to ACP, surgical treatments, implantable device therapy, medication deprescribing, or other treatments not compatible with these goals.[580],[581] Frailty is more common with age, but can occur in persons who are relatively young chronologically. There is currently no agreement on a single standard frailty measure.[580] Instruments that address key underlying factors related to frailty might be more clinically useful than performance measures, including the Edmonton Frail Scale,[582] the Clinical Frailty Scale,[583] and scales embedded with the interRAI instruments broadly implemented across multiple care sectors in Canada.[580],[584]
An international multidisciplinary working group established, through consensus, Acknowledge, Routinely Profile, Identify, Support, and Evaluate Heart Failure (ARISEHF),[567] a framework to optimize health outcomes for patients with HF. The framework includes acknowledging the importance of multimorbidity, profiling multimorbidity using standardized protocols, and identifying individual patientcentred goals.
Recommendation
168. We recommend that patients with known or suspected HF should be assessed for multimorbidity, frailty, cognitive impairment, dementia, and depression, all of which might affect treatment, adherence to therapy, follow-up, or prognosis (Strong Recommendation; High-Quality Evidence).
Practical Tip
Depression in older patients with HF should be suspected when chronic physical complaints persist despite optimal HF therapy.[560]
Measuring orthostatic vital signs might identify individuals at risk of falls.
Manage fall risk related to orthostatic hypotension:
- Minimize use of diuretics and other vasodilators by optimizing first-line HF therapy; Consider a medication review with a pharmacist; and Promote physical activity, which might reduce the risk of orthostatic hypotension
Screening, prevention, and management of delirium is a standard of care for all acutely ill older patients, including those with HF.[561]
Cognitive impairment, even when mild, might interfere with HF self-care.
Patients older than the age of 65 years with HF should be screened for cognitive impairment.[562],[563]
If cognitive impairment is identified, a capable substitute decision-maker should be designated.
HF therapies in frail or older patients should be similar to those in younger patients.
In frail older patients, HF medications may be introduced at lower doses and titrated more slowly.
Clinicians should be alert for drug-drug, drug-disease interactions, and therapeutic competition, in cases when the care of one comorbidity is exacerbated by the care of another.[577]
For patients prescribed many medications or those with cognitive impairment, consider adherence aids, such as “blister packs,” to reduce medication errors.
Although the course of HF in individual patients can be unpredictable, a high symptom burden and high mortality rates should be anticipated, and ACP discussions should be initiated early in the course of illness.[564],[585]–[589] These discussions should focus on the values and goals of the individual patientdwhat they find valuable and important in their lives and what they hope for in the future (eg, attending an important upcoming family event). This is an ongoing conversation to pursue after important clinical events, when considering invasive therapies, or when requested by the patient. Many local, provincial, or federal organizations have excellent tools for helping patients and families in decisionmaking (www.myspeakupplan.ca).
Patients with HF suffer from a substantial burden of physical and psychiatric symptoms (Table 37).[590],[591] Palliative care is the promotion of physical and psychosocial health, regardless of diagnosis or prognosis (Table 38).[592] Thus, the delivery of palliative care interventions should be triggered by patient needs and not arbitrarily on the basis of a score on a particular instrument. Several HF-specific and generic quality of life tools have been validated to assess the symptoms of patients with HF, and several are freely available online (Table 39).[584],[593]–[604] Informal caregivers of patients with advanced HF should be evaluated for coping and degree of caregiver burden. Although several tools exist, there is no clear evidence to recommend one tool over another. Management options for symptoms of advanced HF are outlined in Table 40.[585]–[589],[605]–[614]
Recommendation
169. We recommend that clinicians caring for patients with HF should initiate and facilitate regular, ongoing, and repeated discussions with patients and family regarding advance care planning (Strong Recommendation; Very Low-Quality Evidence).
170. We recommend that the provision of palliative care to patients with HF should be on the basis of a thorough assessment of needs and symptoms, rather than on individual estimates of remaining life expectancy (Strong Recommendation; Very Low-Quality Evidence).
171. We recommend that the presence of persistent advanced HF symptoms despite optimal therapy be confirmed, ideally by an interdisciplinary team with expertise in HF management, to ensure appropriate HF management strategies have been considered and optimized, in the context of patient goals and comorbidities (Strong Recommendation; Very Low-Quality Evidence).
Practical Tip
The timing of advance care planning (ACP) discussions should take into consideration the high mortality rate in the year after a first HF hospitalization.
The substitute decision-maker should be involved in ACP discussions.
Engage patients and families in open and honest discussion about the prognosis of HF, including possible modes of death (sudden, progressive HF, or from a comorbidity).
Care preferences and goals of care should be regularly discussed with patients and documented, with emphasis shifting from quantity to quality of life.
As HF symptoms advance, ACP should be reviewed, and the possible deactivation of implantable defibrillators or cessation of invasive therapies such as MCS or hemodialysis discussed, particularly when these no longer align with goals of care.
Symptoms and psychosocial burden (eg, depression, fear, anxiety, social isolation, home supports, and need for respite care) should be regularly evaluated, and a palliative care referral considered.
Informal caregivers of patients with advanced HF should be evaluated for coping and degree of caregiver burden.
8.2 Clinical practice considerations
Multidisciplinary HF management programs have been shown to lead to better symptom control, less acute care utilization, and lower mortality including among older frail persons with multimorbidity.[622]–[623] Similarly, multidisciplinary palliative care programs for adults with advanced chronic illness can improve patient and caregiver outcomes, reduce health service utilization, and increase the chances of dying at home.[624]–[627]
Recommendation
172. We recommend that a HF specialist or clinic should have the capacity to accept referrals, transition of care, or arrange for transfer to a tertiary care centre within the recommended CCS benchmarks (Strong Recommendation; Very Low-Quality Evidence).
173. We recommend that specialized outpatient HF clinics or disease management programs provide access to an interprofessional team ideally including a physician, a nurse, and a pharmacist with experience and expertise in HF (Strong Recommendation; High-Quality Evidence).
174. We recommend that all patients with recurrent HF hospitalizations, irrespective of age, multimorbidity, or frailty, should be referred to a HF disease management program (Strong Recommendation; High-Quality Evidence).
Practical Tip
Patients with HF should have regular follow-up assessments, with their intensity and frequency tailored according to individual risk and stability (Table 41).
Follow-up assessments should include symptoms, function, quality of life, physical examination, medication reconciliation and review, and a review of updated laboratory results and diagnostic test results (Fig. 12). Emerging needs, such as disability, other health concerns (Table 42), caregiver burden, and advance care plans should be reviewed as well.
Follow-up methods might include telemonitoring, structured telephone support, or home visits, all of which have variable evidence to support this and should be localized.[615],[616]
HF management includes coaching patients and informal caregivers on self-care skills, through experiential learning, practice, and support.[617],[618]
Self-care includes knowledge, skills, and confidence about HF treatments, exercise, dietary measures, symptom-, and weight-monitoring. It also includes an action plan to address exacerbations early and determine if actions were helpful to circumvent further deterioration. This plan should facilitate rapid access, either in person, by phone, or other modes of communication or technology, to HF clinic staff for assistance.[619]
Home-based HF management, which can include hospital-at-home care, might be beneficial for highly selected patients.[620],[621]
8.3 Systems-level considerations
Integration is a system-wide process of combining social and health services to meet the needs of the patients with chronic disease through alignment of financial and administrative modalities, with the clinical practices of multidisciplinary care teams.[628]–[630] Care coordination is integral to the Chronic Disease Management model, which has been recommended as the preferred model for care delivery for CVD by the Canadian Heart Health Strategy Action Plan.[631] Patient assessments throughout their journey with HF should continuously be linked with updated management plans, through seamless communication between the patient, primary to tertiary care, palliative care, and with community care resources.[632] Clinical trials of community-based integrated systems of care for frail seniors have shown better care quality, coordination, and continuity, better health outcomes, and equal or reduced overall costs.[632]–[636] Further, integration of multidisciplinary palliative care services in the care of patients with advancing HF can reduce symptom burden and health system utilization.[637]–[639] Features of an integrated care model for patients with HF are described in Table 43.[640]
Proper execution of care transitions from hospital to the community is particularly important, because patients with HF have high rates of readmission. Older patients with multimorbidity, frailty, and previous HF hospitalizations are at increased risk for readmission.[641] Important elements of successful transitional care programs have been identified and should be considered on the basis of local resources, which are outlined in section 8.3 of the Supplementary Material.[642]–[648]
Recommendation
175. We recommend that care for patients with HF be organized within an integrated system of health care delivery in which patient information and care plans are accessible to collaborating practitioners across the continuum of care (Strong Recommendation; Moderate-Quality Evidence).
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