{"id":128938,"date":"2023-01-09T16:45:43","date_gmt":"2023-01-09T16:45:43","guid":{"rendered":"https:\/\/ccs.ca\/?post_type=guideline&p=128938"},"modified":"2023-04-12T04:59:49","modified_gmt":"2023-04-12T04:59:49","slug":"chapter-8-community-management-of-hf","status":"publish","type":"guideline","link":"https:\/\/ccs.ca\/guideline\/2017-heart-failure-management-of-hf\/chapter-8-community-management-of-hf\/","title":{"rendered":"8. Community Management of HF"},"content":{"rendered":"\n

The management of HF should be delivered within an integrated system of care on the basis of chronic disease management and prevention principles.[559]<\/a><\/sup> 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.<\/p>\n\n\n\n

8.1 Patient-level considerations<\/h2>\n\n\n\n

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]<\/a>,[564]<\/a>–[567]<\/a><\/sup> 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]<\/a><\/sup><\/p>\n\n\n\n

Recommendations regarding HF therapy apply to older patients and should not be restricted on the basis of age alone.[180]<\/a>,[182]<\/a>,[569]<\/a>–[576]<\/a><\/sup> 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]<\/a>,[577]<\/a><\/sup> 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]<\/a>,[578]<\/a>,[579]<\/a><\/sup><\/p>\n\n\n\n

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]<\/a>,[581]<\/a><\/sup> 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]<\/a><\/sup> Instruments that address key underlying factors related to frailty might be more clinically useful than performance measures, including the Edmonton Frail Scale,[582]<\/a><\/sup> the Clinical Frailty Scale,[583]<\/a><\/sup> and scales embedded with the interRAI instruments broadly implemented across multiple care sectors in Canada.[580]<\/a>,[584]<\/a><\/sup><\/p>\n\n\n\n

An international multidisciplinary working group established, through consensus, A<\/strong>cknowledge, R<\/strong>outinely Profile, I<\/strong>dentify, S<\/strong>upport, and E<\/strong>valuate H<\/strong>eart F<\/strong>ailure (ARISEHF),[567]<\/a><\/sup> 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.<\/p>\n\n\n

\n
\n
\n <\/i>\n <\/div>\n
\n

Recommendation<\/p>

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).<\/p>\n <\/div>\n <\/div>\n<\/div>\n\n\n

\n

Practical Tip<\/p>

Depression in older patients with HF should be suspected when chronic physical complaints persist despite optimal HF therapy.[560]<\/a><\/sup><\/p>\n

Measuring orthostatic vital signs might identify individuals at risk of falls.<\/p>\n

<\/p>\n

Manage fall risk related to orthostatic hypotension:<\/p>\n

<\/p>\n