ENFOQUE’MULTIDIMENSIONAL’DE’ … · 2020. 6. 21. · European’Journalof Heart’Failure’(2013)’15,’717–723’ Heart’failurein’ elderly’paents : disncJve ’featuresand’

ENFOQUE MULTIDIMENSIONAL DE LA FALLA CARDIACA EN EL ADULTO

MAYOR DIANA CAROLINA MORALES BENAVIDES

MEDICA INTERNISTA Y GERIATRA UNIVERSIDAD DE CALDAS

GRUPO DE GERIATRIA Y CUIDADO PALIATIVO GERIATRICO FUNDACION SANTA FE DE BOGOTA

2016

JUEVES 19 DE MAYO DE 2016

07:00 – 18:00 INSCRIPCIONES

SALÓN SANTA FE 1

CURSO 1 Metodología de investigación. Bases de datos longitudinales en el campo delenvejecimiento.

Coordinador: Rafael Samper, BogotáHorario: 09:00 - 13:00

Presentación del cursoRafael Samper, BogotáMetodología de investigación. Bases de datos longitudinales en el campo delenvejecimientoRebeca Wong, USAAlejandra Michaels, BogotáResultados de investigación con los estudios ELPS y ELCARafael Santos, Bogotá

SALÓN SANTA FE 2

CURSO 2 Papel del gerontólogo en la humanización y en los servicios de cuidado socio-sanitario en la vejez

Coordinador: Fabián Ricardo Villacis, BogotáHorario: 09:00 - 13:00

Presentación del cursoFabián Ricardo Villacis, BogotáPapel del gerontólogo en la humanización y los sistemas de cuidados en la vejezDerechos y participación de las personas adultas mayoresRoberto Angarita, BogotáModelo participativo de salud mental comunitaria en personas adultas mayores.Elizabeth Machado, SincelejoHogar san Vicente de Paul, un lugar de apropiación y vínculos.Diana Fernanda Bermúdez, ArmeniaCalidad y humanización en la atención socio sanitaria a las personas adultas mayoresClaudia Janeth Ladino, Armenia

SALÓN SANTA FE 3 (AB)

CURSO 3 Enfermedad terminal: un desafío y una oportunidad integralExpositora: Nidia Aristizabal, BogotáHorario: 09:00 - 13:00

Enfermedad terminal: un desafío y una oportunidad integral

CONTENIDO

•  Contexto epidemiológico: prevalencia de falla cardíaca en el adulto mayor

•  Cambios fisiológicos con el envejecimiento •  Enfoque mul>dimensional •  Falla cardíaca y grandes síndromes geriátricos: fragilidad, mul>morbilidad, deterioro cogni>vo

•  Conclusiones

Falla cardíaca: prevalencia •  Causal de 59 000 muertes

en 2005 en US •  Causas primarias.

CORONARIA-‐HIPERTENSIVA •  Prevalencia: 5-‐10% entre

65-‐69 años •  18% en mayores de 85 años •  IMPACTO NEGATIVO para

lograr envejecimiento exitoso

ENVEJECIMIENTO Y SISTEMA CARDIOVASCULAR

European Journal of Heart Failure (2013) 15, 717–723 Heart failure in elderly paJents: disJncJve features and unresolved issues

Reducción en número y función de miocitos (apoptosis)

ARTERIOESCLEROSIS: aumento de la poscarga

Alteración en la regulación del calcio Cambios en las proteínas contrác>les Menor eficacia en la u>lización de ATP

PREDOMINIO DE FALLA CARDIACA DE FRACCION DE EYECCION CONSERVADA

ACORTAMIENTO TELOMERICO: presbicardia: aumento del contenido colágeno en inters>cio: FIBROSIS

Precipitado por: hiperac>vación del eje RAA, ROS, INFLAMAGING

TENDENCIA A LA HIPERTROFIA DEL VI Trastorno de relajación

European Journal of Heart Failure (2013) 15, 717–723 Heart failure in elderly paJents: disJncJve features and unresolved issues

overall survival after HF onset has substantially improved with con-temporary therapies,9 this benefit is less evident in older agegroups.15,16 Advanced age remains a strong predictor for poor out-comes in patients with chronic17 or acute HF,11 and it is included inseveral prognostic models for mortality after hospitalization.18

Pathophysiology of the ageingheartSeveral specific changes in cardiac structure and function are asso-ciated with cardiac ageing, and they may explain a number ofpathophysiological and phenotypic features typical of the elderly.Among these, particularly important is the greater predispositionof the elderly to develop HF, particularly HF with preserved ejec-tion fraction (HFpEF)4,12,19 (Figure 1).

With age, there is a decrease both in number and in function ofmyocytes, which occurs even in subjects without evidence of car-diovascular disease.20 The underlying mechanisms of such changesinclude enhanced necrosis and apoptosis,21 and a reduced regen-erative capacity of cardiac progenitor cells. This prevents adequatereparation for myocyte loss either caused by ageing, or secondaryto myocardial injury and ischaemia.21 The loss of functioning

cardiomyocytes is compensated by the hypertrophy of the remain-ing cells.20

Alterations in the function of myocytes associated with ageinclude impaired calcium metabolism and regulation, which reflectsan alteration of processes of contraction and relaxation.22 In add-ition, contractile proteins change with age similarly to the altera-tions seen in hypertrophic hearts.23 Finally, ATP utilization is lessefficient in the ageing heart. These abnormalities may providethe substrate for worsening cardiac function in the setting of ex-acerbating conditions, even in otherwise healthy hearts.22

Another potential mechanism associated with the higher risk of de-velopment of HF in advancing age is the shortening of telomeres,which has been suggested as a marker of biological and cellularageing and associated with development of HF.21,24

Simultaneously with the reduced number, function, and com-pensatory hypertrophy of myocytes, the senescent myocardiumis affected by an imbalance of extracellular matrix metabolism,with a subsequent detrimental increase in myocardial collagencontent and development of fibrosis.25 Myocardial fibrosis is pro-moted by several mechanisms26 known to be up-regulated in HF atany age, and which are constitutively activated in the elderly. Theyinclude the up-regulation of the renin–angiotensin–aldosteronesystem,25 enhanced inflammatory activity,27 and oxidative stress.25

Figure 1 Suggested pathophysiological mechanisms predisposing to the development of diastolic dysfunction and heart failure in otherwisehealthy ageing hearts.

V. Lazzarini et al.718

Impacto en calidad de vida: FUNCIONALIDAD

Impacto en cuidadores: AGOBIO

Adherencia al tratamiento Riesgo de hospitalización

Interacción con la mulJmorbilidad

Costos para el sistema

DIMENSION DE LA FALLA CARDIACA EN EL ADULTO MAYOR

DIMENSION DE LA FALLA CARDIACA EN EL ADULTO MAYOR

85% marcapasos 61% CDI 53% CABG

51% ICP 60% cambio valvular 75%

endarterectomías

COSTOS. En los mayores de 65 años se realizan:

ABORDAJE MULTIDIMENSIONAL DE LA FALLA CARDIACA EN EL ADULTO MAYOR

Condición índice: FALLA

CARDIACA

FRAGILIDAD Y FALLA CARDIACA

•  Falla cardíaca en el adulto mayor: más allá del modelo orientado en la enfermedad

•  Enfoque desde la FRAGILIDAD •  Ayuda a es>mar:

CliniCal MediCine insights: Cardiology 2014:8(s1) The Biologic Syndrome of Frailty in Heart Failure

Riesgo de mortalidad , toma de decisiones

Potencial riesgo de eventos adversos

Riesgo de hospitalizaciones

COMO MEDIR LA FRAGILIDAD? ÍNDICE DE FRAGILIDAD

EDAD BIOLÓGICA/ EDAD CRONOLÓGICA: Canadian Study of Health and Aging “Es>mar el acúmulo de déficit se relaciona con la edad biológica”

COMO MEDIR LA FRAGILIDAD? CUESTIONARIO FRAIL

•  CUESTIONARIO FRAIL •  Evaluación subje>va de 5 puntos. •  Ha demostrado correlación con riesgo de discapacidad, baja velocidad de marcha, mortalidad y menor desempeño en SPPB

•  FRAGIL 3 A 5 PUNTOS •  PRE FRAGIL 1 A 2 PUNTOS •  NO FRAGIL 0 PUNTOS.

• 

A SIMPLE FRAILTY QUESTIONNAIRE (FRAIL) PREDICTS OUTCOMES IN MIDDLE AGED AFRICAN AMERICANS

J Nutr Health Aging. 2012 July ; 16(7): 601–608.

FATIGA. En las úlJmas 4 semanas qué tanto se ha senJdo cansado o faJgado? Respuestas 1 y 2: 1 punto. Demás 0 puntos

1.   Todo el Jempo 2.   La mayoría del Jempo 3.   Algunas veces 4.   Muy pocas veces 5.   Nunca

RESISTENCIA. Presenta alguna dificultad para caminar 10 pasos sin descansar sin ayuda de disposi>vos ni de otra persona?

1.  Si 2.  No

DEAMBULACION. Sin uso de ayudas, >ene alguna dificultad para caminar mas de 100 metros?

1.  Si 2.  No

Número de enfermedades 0 a 4: 0 puntos 5 a 11: 1 punto

PESO. Cuál es su peso actual y cuál era su peso hace 1 año?

Porcentaje de cambio > 5% 1 punto Porcentaje de cambio < 5% 0 puntos.

Estrategia clínica de falla cardíaca Fundación Santa Fe

1.  Paciente adulto mayor llega a consulta o interconsulta hospitalaria a clínica de falla cardíaca

2.  Aplicación de cues>onario FRAIL por el servicio de cardiología

3.  Cumple criterios para fragilidad o además presenta:

•  Polifarmacia •  Comorbilidad

MÉDICOS

•  Demencia •  Depresión moderada/severa

PSÍQUICOS •  Discapacidad moderada-‐severa

FUNCIONALES

•  InsJtucionalización • Agobio del cuidador

SOCIALES

-‐ Valoración Geriátrica mulJdimensional

728 F. Cacciatore et al.

© 2005 Blackwell Publishing Ltd, European Journal of Clinical Investigation, 35, 723–730

mobility with a tendency to fall, polipharmacy, comorbidity,low social status, cognitive impairment and nutritionalimpairment [30–32]. Several attempts have been made tograde frailty [30,31], which was recently resolved accordingto the results of two tests of physical ability involving rapidwalking and standing from a sitting position: subjects ableto perform one of these tests were considered moderatelyfrail and those unable to perform either were consideredseverely frail [33]. However, that method considers onlythe physical domain. This study considers that its gradingmethod is more consistent with the complexity of frailty,which utilizes a short approach focused on selected tests ofvision, hearing, arm and leg function, urinary incontinence,mental status, instrumental and basic activities of dailyliving, environmental hazards and social support systems [13].

Relationship between frailty and CHF in the elderly

Newman et al. in the Cardiovascular Health Study deter-mined that persons with a history of CHF were more likelyto be frail [17]. In a prospective study of 178 patientsdependent in at least one basic activity of daily living andhospitalized with cardiovascular disease, primarily CHFand acute coronary syndromes, there was an increased riskof further functional decline after 1 year [34]. Chronic heartfailure is associated with increased health service care [35]and institutionalization [36], both of which are products offrailty. Patients with functional decline are at increased riskof hospitalization for CHF [37].

These data demonstrate that frailty is more predictive ofmortality in elderly subjects with CHF than in those withoutCHF. None of the CHF subjects, in this study, with advancedfrailty survived after 9 years’ follow up, whereas those inNYHA class IV are still alive. Why does frailty influence themortality of elderly patients with CHF in such a way? Thereare several possible reasons for this intriguing phenomenon.In this sample the high grade of frailty, when compared withNYHA class IV, represents the highest value of comorbidity

(5·4 vs. 5·2), of drugs used (5·1 vs. 4·9), and the lowest scoreof MMSE (18·7 vs. 22·6). More importantly, disability inADL affects 83% of frail subjects but only 25% of NYHAclass IV subjects. The use of vasodilators, such as nitrates,known to influence the prognosis of CHF, progressivelydecreases with frailty (from 42% to 11%). These findingsare particularly significant in understanding how to managethe care of frail CHF elderly patients.

Considered singularly, each of the characteristics of frailtyis highly prevalent and is a predictor of poor prognosis inelderly patients with CHF. The Charlson comorbidity indexscore closely correlates with early hospital readmission ordeath in patients with CHF [38,39]. Rich et al. have dem-onstrated that iatrogenic CHF, i.e. CHF precipitated bymedications or excessive fluid administration, characterizesthe poor prognosis of debilitated older patients showing lesssevere premorbid cardiac disease, but more marked non-cardiac disease and longer hospital stays [40]. In this regard,the declining use of nitrates, observed in our study, mightreflect a greater risk of side-effects (hypotension leading tofalls) in the frail elderly. However, it could not be excludedthat the reduced use of nitrates could reflect the lowprevalence of ‘typical’ CHF symptoms compared with‘atypical’ presentations in the frail elderly (assuming nitrateswere primarily prescribed to treat typical CHF symptoms)[9]. The prevalence of CHF in cognitively impaired subjectsis high and the risk of developing cognitive impairmentwas 1·96-fold greater in subjects with CHF [11], and it isassociated with a fivefold increase in mortality after adjust-ing for several potential confounders [12]. A recent studyon cardiovascular diseases as determinants of disabilityshowed that the prevalence of disability was 22·6% in menand 37·3% in women with CHF. After the cerebrovasculardiseases, CHF was the most powerful predictor of disabilityin men [41]. Poor social support has also been described asa marker for patients with CHF [38]. In 292 elderly subjectswith CHF, after adjustment for demographic factors,clinical severity, comorbidity and functional status, socialties and instrumental support, the absence of emotionalsupport remained associated with a significantly higher risk

Figure 1 Cox regression adjusted survival curve in subjects with (a) CHF (n = 120) and without (b) CHF (n = 1139) chronic renal failure (CHF) stratified by frailty.

European Journal of Clinical Inves9ga9on (2005) 35, 723–730 Frailty predicts long-‐term mortality in elderly subjects with chronic heart failure

OBJETIVO: rol predic>vo de la fragilidad en mortalidad en pacientes con ICC N: 1139 >65 años en comunidad. 129 con ICC. Seguimiento a 12 años Campania, Italia. FRAGILIDAD: perfil de Linda Fried MORTALIDAD: ICC + FRAGILIDAD= 94.4% ICC sin FRAGILIDAD= 70%

•  90% de los pacientes con falla cardíaca >enen más de 2 comorbilidades

•  La ERC y EPOC son predictores de riesgo de hospitalización y reingresos en falla cardíaca

•  2010. Medicare. 27% de pacientes con falla cardíaca tenían deterioro cogni>vo

MulJmorbidity in Older Adults with Heart Failure

Clin Geriatr Med 32 (2016) 277–289

FALLA CARDIACA Y MULTIMORBILIDAD

EL PROBLEMA… contexto clínico


Clin Geriatr Med 32 (2016) 277–289 exist, one can simply start by asking patients if they can do what is asked of them, andif so, at what cost?70 Their responses should be used to prioritize the conditions worthaddressing and the specific strategies used. Reducing polypharmacy is one relativelyeasy way to decrease treatment burden and may improve quality of life without otheradverse effects.72

Enhance Care-Coordination

Care coordination and multidisciplinary team-based care has been shown to improveoutcomes in older multimorbid patients at high risk for hospitalization. For example,Medicare demonstration projects successful in lowering preventable hospitalizationsthrough improved care coordination had the following common features: (1) frequentin-person meetings between care coordinators and patients; (2) in-person meetingsbetween care coordinators and health providers; (3) supplemental educational ses-sions for patients and caregivers; (4) medication management services; and (5) timelyand comprehensive transitional care after hospitalization.73 Similarly, reductions inreadmission after hospitalization for HF have been achieved through use of multi-pronged strategies delivered by multidisciplinary teams of physicians, nurses, socialworkers, pharmacists, physical therapists, and care managers both during and afterhospitalization.74–76 The most successful hospitals have used a large number of stra-tegies designed to integrate hospital and postacute care77 and have successfullyreduced readmissions from the full range of medical conditions to which older patientswith HF are vulnerable after hospital discharge.78

SUMMARY

Multimorbidity is a common feature of HF that impacts diagnosis, management,and outcomes. It is therefore critical that providers caring for older patients withHF adopt broad patient-centered perspectives rather than focus exclusively on car-diovascular conditions. Treatment strategies should be closely aligned to patients’specific health goals and well-calibrated to the workload they wish to expend. Withthis perspective, benefits of treatment can be maximized while minimizing poten-tially harmful consequences.

REFERENCES

1. Chamberlain AM, St Sauver JL, Gerber Y, et al. Multimorbidity in heart failure: acommunity perspective. Am J Med 2015;128:38–45.

Box 1Typical burden of an older person with heart failure and multimorbidity

! Has 4 other chronic conditions in addition to heart failure1

! Takes 10 or more medications a day47

! Spends about 2 hours per day on health-related activities80

! Attends 15 or more outpatient appointments with physicians each year81

! Needs assistance with at least one activity of daily living5,82

! Experiences hospitalizations for multiple conditions7,8

All are best estimates based on the available published literature, but burden is likely to varywidely across individual patients.

Data from Refs.1,5,7,8,47,80–82

Dharmarajan & Dunlay284

•  90% de los estudios excluyen pacientes con mul>morbilidad

•  1/3 de los estudios fase 3: excluyen pacientes con discapacidad, deterioro cogni>vo, ins>tucionalizados o comorbilidad crónica

•  Ejemplos: CHARM y PRESERVE excluyeron pacientes con expecta>va de vida menor de 3 años.

•  Desenlaces primarios en geriatría: mareo, inestabilidad, caídas, calidad de vida, descompensación de comorbilidad (?)

EL PROBLEMA… nivel de evidencia



patients’ lives by advances in heart failure management. Analysis

of trends in comorbidities and drug use from 1988 to 2008 shows

an increase in the proportion of octogenarians with heart failure

(from 13.3% to 22.4%) along with an increase in the number of

patients with five or more comorbidities (from 42% to 58%) and

number of daily prescription medications from 4.1 to 6.4 drugs

[5]. Comorbidities unrelated to heart failure (e.g., dementia and

hip fracture) are more prevalent in above 86 age group [6].

Comorbidities affect the quality of life and survival in heart failure

patients—the more the comorbidities, the more the hospitaliza-tion and mortality. Noncardiac comorbidities are found to be more

prevalent in patients with heart failure with preserved ejection

fraction compared to those with heart failure with reduced ejec-

tion fraction, leading to higher non-HF hospitalization rate. The

impact of these comorbidities in both groups is, however, the

same [7].

Previous data on the presence and effect of comorbidities on

CHF were derived from geographically limited studies of relatively

small numbers of patients such as the Framingham cohort [8].

More recent studies have utilized databases to examine the impact

of comorbidity in larger groups of elderly patients with CHF.

Utilizing data from 27,477 Scottish morbidity records listing CHF,

Brown and Cleland [9] reported 11.8% of CHF admissions were

associated with chronic airway obstruction, 8.3% with chronic or

acute renal failure, and 5.3% with cerebrovascular accident. The

National Heart Failure project, from the Centres for Medicare and

Medicaid Services in the USA, previously reported comorbidities

among 34,587 Medicare patients aged >65 years who were hospi-talized with a principal diagnosis of CHF [10]. About a third had

chronic obstructive pulmonary disease (COPD), 18% had a his-

tory of stroke, and 9.2% had dementia. A retrospective cohort

study of 1,363,977 elderly Medicare beneficiaries hospitalized

with heart failure from 2001 to 2004 described comorbid condi-

tions including diabetes mellitus (36.8%), renal failure (18.5%),

and dementia or major psychiatric disorders (13.5%) [11].

Braunstein et al. identified 122,630 individuals aged >65 yearswith CHF through a 5% random sample of all US Medicare ben-

eficiaries. Nearly 40% of patients with CHF had >5 noncardiaccomorbidities, and this group accounted for 81% of the total

inpatient hospital days experienced by patients with CHF. The

risk of hospitalization and potentially preventable

hospitalizations strongly increased with the number of chronic

Figure 1 Interaction of noncardiac comorbidities in chronic heart failure (CHF). Solid lines toward centre: Comorbidities contributing to CHF; Solid lines

away from centre: Sequelae of CHF; Blue boxes: Direct contributors to worsening CHF; Yellow boxes: Indirect contributors to worsening CHF; Curved

arrows: Interaction between comorbidities.

ª 2015 John Wiley & Sons Ltd Cardiovascular Therapeutics 33 (2015) 300–315 301

V. H. Chong et al. Management of Comorbidities in Heart Failure

Management of Noncardiac ComorbidiJes in Chronic Heart Failure Cardiovascular Therapeu>cs 33 (2015) 300–315

•  UK. Clínica de falla cardíaca: 74% de los pacientes con clase funcional NYHA II-‐ IV tenían puntajes de MOCA test entre 17-‐25 puntos

•  SOLVD-‐ WHAS I: hallazgos similares

FALLA CARDIACA Y DETERIORO COGNITIVO

CogniJve impairment in heart failure paJents Journal of Geriatric Cardiology (2014) 11: 316−328

Atención Velocidad de procesamiento

Síndrome disejecuJvo Memoria de trabajo

Recomendación de American Geriatric Society: aplicar tamizaje cogniJvo ANUAL a pacientes con ICC

RECOMENDACIONES PARA TENER EN CUENTA



1. ENFOQUESE EN LOS DESENLACES GLOBALES EN SALUD

IdenJfique síntomas: dolor, disnea, faJga Evalúe calidad de vida Determine el estado funcional MEBE-‐ AVD Procure reducir CUALQUIER CAUSA de hospitalización no solo por falla cardíaca Discuta pronósJco

2. EVALUE FORMALMENTE COGNICION Y AFECTO

MOCA-‐ MMT-‐ Mini Cog-‐ Yesavage-‐ PHQ2

3. APLIQUE TRATAMIENTOS NO FARMACOLOGICOS

Ac>vidad usica-‐ rehabilitación cardíaca Medidas generales para ortosta>smo

4. MINIMIZE EL AGOBIO POR LA ENFERMEDAD

Pregúntele al paciente cuál es le principal síntoma que lo agobia Des-‐prescripción Disminuya el número de citas médicas

5. COMUNIQUESE CON LOS OTROS ESPECIALISTAS QUE TRATAN AL PACIENTE

Plan interdisciplinario INTEGRADO

CONCLUSIONES •  La transición demográfica lleva a mayor carga de enfermedad

cardiovascular en el mundo •  Es más frecuente la ICC de fracción de eyección preservada en el

adulto mayor •  Existe alta prevalencia de fragilidad en adultos mayores con ICC •  La fragilidad es un predictor de desenlaces adversos •  La presencia de comorbilidad genera un impacto nega>vo en

índices de pronós>co y calidad de vida en el adulto mayor con ICC •  Existe una relación directamente proporcional entre la severidad

de ICC y la presencia de deterioro cogni>vo •  Es necesario realizar tamizajes de deterioro cogni>vo en

pacientes con ICC

Documents

ENFOQUE’MULTIDIMENSIONAL’DE’ … · 2020. 6. 21. · European’Journalof Heart’Failure’(2013)’15,’717–723’ Heart’failurein’ elderly’paents : disncJve ’featuresand’