Heart failure in the elderly

Review

10.1586/14779072.3.1.99 © 2005 Future Drugs Ltd ISSN 1477-9072 99

CONTENTS

Pathophysiology & epidemiology

Features of aging & relevance to heart failure care

Issues in diagnostic approaches

Issues in heart failure management in the elderly

Geriatric issues

Decision making in elderly heart failure patients

Expert opinion

Five-year view

Key issues

Information resources

References

Affiliation

www.future-drugs.com

Heart failure in the elderlySarah J Goodlin

Palliative Care-Heart Failure Education And Research Trials (PC-HEART), 681 East 17th Avenue, Salt Lake City, UT 84103, USATel.: +1 801 442 3081Fax: +1 801 442 [email protected]

KEYWORDS: elderly, geriatric problems, heart failure, management

Heart failure is the most common reason for hospitalization among older adults in the USA, and impacts five million people. Most people with heart failure are elderly, but in older people the management of the disease is complicated by comorbid conditions. Common problems in the elderly, such as dementia, frailty and depression, are more common in the elderly heart failure population. This review discusses an approach to identifying and managing these problems while managing heart failure. A suggested approach to older people with heart failure addresses the screening and integration of common geriatric problems into heart failure care.

Expert Rev. Cardiovasc. Ther. 3(1), 99–106 (2005)

Heart failure (HF) affects five million peoplein the USA, 80% of whom are elderly [1]. Thegrowth in people with HF is largest in the agegroup over 75 years, and almost 10% of peopleover the age of 75 years in the USA haveHF [101]. HF is the most common hospitaliza-tion diagnosis (diagnosis related group [DRG])under Medicare payment, is a common cause ofreadmission to hospital and presents a significantfinancial healthcare burden worldwide [2,3]. Ageis an important predictor of 30-day and 1-yearmortality in HF [4]. Older people with HF havenot been well studied, and are generally notincluded in trials of therapies for HF [5].

The population over the age of 65 is increasingexponentially, so that soon all adult medicinewill largely involve care of the eldely. Thenumber of people over 65 years of age, andparticularly the numbers of very old (over85 years of age) people, are increasing. By theyear 2030, 22% of the population of the USA(or 65.6 million people) will be over the ageof 65, and those aged 85 years and older, themost rapidly expanding segment of the olderpopulation, are expected to nearly triple to8.8 million [6].

Pathophysiology & epidemiologyHF in the elderly is primarily due to hyper-tension or ischemic heart disease (coronaryartery disease). The pathophysiology of HF in

the elderly seems to differ according to race:HF is more commonly associated with hyper-tension and diabetes in African–Americans,and with coronary artery disease in Whites [7].African–Americans tend to develop HF at ayounger age than Whites. Racial differencesin response to treatment also suggest differ-ences in the underlying pathophysiology.African–Americans with HF are less responsiveto angiotensin-converting enzyme (ACE) inhib-itors than other racial groups [8], but showequivalent benefit when administered a combi-nation of an ACE inhibitor combined withcarvedilol to Whites [9]. With increasing age, theproportion of women with HF increases.

Diastolic HF (HF with preserved systolicfunction) is increasingly recognized as a signifi-cant health issue; it predominates in womenand represents a different process from left ven-tricular (LV) systolic dysfunction, but is associ-ated with similar neuroendocrine abnormalitiesto HF associated with systolic dysfunction [10].People with diastolic HF have a worse progno-sis than those with reduced LV ejection fraction(LVEF). Approximately half of those with HFhave preserved systolic function, and most ofthem are elderly [11].

Comorbid conditions are common in mostHF patients over the age of 60 years, andbecome more common with increasingage [12]. Related cardiac conditions, including

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Goodlin

100 Expert Rev. Cardiovasc. Ther. 3(1), (2005)

atrial fibrillation, hypertension, valvular heart disease andcoronary artery disease, coexist in the elderly HF population.Three-quarters of people with HF have antecedent hyperten-sion; improving hypertension control reduces HF prevalence inthe elderly [13].

Uncontrolled-rate or new-onset atrial fibrillation can precipitateor worsen HF [14]. Rate control is as effective as conversion tonormal sinus rhythm in reducing morbidity and mortality inpatients with atrial fibrillation and HF [15]. Type II diabetesmellitus increases in prevalence with increasing age, affectingmore than one in eight people aged 70 years or over [16]. Diabe-tes is associated with alterations in LV filling and function(assessed by myocardial performance index) in the absence ofcoronary artery disease [17].

Features of aging & relevance to heart failure careAging is associated with LV systolic stiffness, diastolic dysfunction,arterial stiffness and increasing LV mass [18]. With every 10-yearincrease in age, older people have less ability to increase cardiacoutput or ejection fraction and maximal heart rate in responseto increased demand, such as exercise. In addition to a limita-tion in systolic reserve in the elderly, blood pressure lability isincreased, causing blood pressure to become increasingly sensi-tive to filling pressures and load [19]. The combination of ven-tricular and arterial stiffening contributes to the developmentof pulmonary congestion in response to increased volume orpressure load, particularly in people with HF. Bone marrowendothelial progenitor cell numbers decline with increasingage, as does their ability to give rise to cardiac myocytes [20].These changes in the aging heart and body result in a decreasedability to respond to insult and injury with advancing age.

Age-related changes in body composition include a decreasein lean or muscle tissue compared with fat. In both obesity andmalnutrition, the proportion of muscle mass is lower in the eld-erly compared with young patients [21]. Muscle mass can bepreserved to some extent by regular aerobic exercise. Exerciseclearly improves muscle strength, maintains the speed of ambu-lation and reaction time in elderly people and decreases disabil-ity [22]. When maintained on a regular exercise program, lowerextremity strengthening reduces the incidence of falls in elderlypatients living in the community. Individuals who exercise reg-ularly maintain young patterns of heart rate and blood pressurevariability. Total body water decreases with increasing age.Thirst is generally diminished in elderly people, as is taste sen-sation, which may result in an increased sodium intake by eld-erly people. Older people tolerate and may respond well tosodium restriction for blood pressure reduction [23]; althoughthis is recommended, no studies have demonstrated benefit inHF patients [24].

A further manifestation of decreased reserve is the decline inrenal function. Although there is significant variationbetween older people, in general they have a decreasedglomerular filtration rate, reduced tubular transport and thusless maximally dilute urine and renal retention of aminoacids and glucose. Renal insufficiency correlates with the

presence of HF in people over the age of 70 years [25]. Renaldysfunction is associated with poor prognosis in HF and limitsuse of appropriate medications.

Altered body composition and decreases in renal and hepaticmetabolism may increase drug or metabolite levels in the eld-erly. Although there is individual variation in the elderly pop-ulation as a whole, the ‘start low, go slow’ principle is advo-cated for the initiation of therapies: begin with low doses andtitrate up slowly, monitoring the effects. Drug concentrations(and adverse effects) may be increased in people withimpaired clearance.

The difficulties with compliance and polypharmacy aredilemmas in the elderly population that mandate strategies tooptimize adherence:

• Scheduling calls from family to remind the individual to takea given dose of medication

• Simplifying regimens whenever possible

• Monitoring compliance

The potentials for drug–drug interactions, adverse effects andnoncompliance increase markedly when patients are prescribedmore than a few medications [26]. Current guidelines andevidence recommend up to nine medications to treat HF [27].

Orthostatic hypotension (a fall in systolic blood pressure of20 points or more from lying to standing) is present in approx-imately a third of people over the age of 65 years. [28] Auto-nomic dysfunction, either with age or from illness and medica-tions contribute to the etiology of orthostatic hypotension inelderly people.

The elderly have an increased rate of anemia compared withyounger people; anemia is more prevalent in the elderly withHF than in those without [29]. The rate of anemia in older HFpatients is 17% or more [30]. The mortality rates of HF patientswith anemia (hemoglobins less than 11 mg/dl) are greater thanthose for patients with normal hemoglobin levels [31]. LVhypertrophy increases with hemoglobin values of less than12.1 mg/dl.

Issues in diagnostic approachesThe hallmark of HF diagnosis is the documentation of symptomsand clinical findings of HF. Symptoms of dyspnea, fatigue andedema in the absence of supporting diagnostic studies are oftenmisleading and, in one series, resulted in 50% or more ofpatients being misdiagnosed with HF [32]. A surprisingly highproportion of elderly patients diagnosed with HF do not have ameasure of LV function. In one study of people over the age65 years discharged from the hospital with a principal diagnosisof HF, over 40% did not have measurement of LV function,and measurements were taken less frequently with increasingage [33]. Symptoms of fatigue and decreased endurance are com-mon among elderly people, complicating the diagnosis of HF.Fatigue and decreased endurance may be independently causedby sleep-disordered breathing, anemia and general functionaldecline, as well as in association with HF. Therefore, diagnosisof HF in the elderly requires a meticulous assessment of fluid

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status and cardiovascular function. B-type natriuretic peptidemay be a helpful addition to a careful clinical assessment offluid status, although it has limited diagnostic utility in theabsence of dyspnea [34].

Issues in heart failure management in the elderlyLimitations in the evidence base for heart failure management in the elderlyOlder people have generally not been included in randomizedclinical trials for HF treatment perhaps, in part, owing to the factthat trials generally exclude people with comorbid conditions.Therefore, the application of available evidence for the manage-ment of HF to the elderly is more uncertain than for middle-aged men. Despite these limitations, older people with LV dys-function seem to tolerate and benefit from β-blockers [35]. ACEinhibitors are underprescribed in older people with HF but,when given, are associated with lower 1-year mortality in peoplewith systolic dysfunction [36]. The response to β-blockers andACE inhibitors in the elderly predicts prognosis, and some olderpeople show a significant improvement in ejection fraction withthese drugs [37]. Both ACE inhibitors and β-blockers must becarefully titrated to standing blood pressure in the elderly toavoid precipitating dizziness and falls. Renal dysfunction requirescareful monitoring of laboratory values with the use of ACEinhibitors and aldosterone antagonists.

One study of invasive assessment of hemodynamic status inolder people identifies those who responded to unloading ther-apy; people with no response to unloading had poor prognosisand renal dysfunction at hospital admission [38]. Impedance car-diography may offer a noninvasive means of assessing benefitfrom, and titrating medications [39].

Comorbid conditionsHospital admission in elderly HF patients is common, yet HFmay only represent part of the reason for hospitalization [40], orreadmission to the hospital [41]. Coexisting illnesses are presentin most older people with HF, and these problems are fre-quently the reason for hospitalization. Coexisting illness canalso precipitate exacerbation of HF.

Sleep-disordered breathingSleep-disordered breathing occurs in approximately half ofindividuals with advanced HF, and results in decreasesd exercisecapacity, ventricular arrhythmias and poor prognosis [42]. Treat-ment with continuous positive airway pressure (CPAP) improvesthe mechanical function of the LV [43], and CPAP (and perhapsto a lesser extent, oxygen supplementation) reverses the adverseneurohormonal activation for patients with sleep apnea and withCheynes–Stokes respiration [44]. Sleep-disordered breathing iscommon in the elderly in the absence of HF [45].

Team or disease managementInterdisciplinary team, specialized nurse, home-care or telephone-management programs have been successful in improving qual-ity of life and the use of guideline-recommended medications

and decreasing hospital admissions, readmissions, emergencydepartment visits, hospital stay and cost of care [46]. An edu-cational program for low literacy people with a mean age of60 years improved self care, including daily weight assess-ment and diuretic titration [47]. The cost of these programsmandate that they be targeted to patients with a high like-lihood of readmission or decompensation; telephone nursecare management provided no benefit to elderly HF patientswho had not been frequently readmitted to hospital or whohad hemodynamic instability [48].

Geriatric issuesIssues common to aging people impact their management andoutcomes of treatment in HF care. Any healthcare provider car-ing for the elderly should be aware of these geriatric-specificproblems, and have a basic knowledge of their identification, aswell as their impact on HF care.

Hospital mortality and intensive care unit outcomes dependon the functional, cognitive and physiologic status of thepatient; intervening to address geriatric issues such as cognitiveor functional impairment, falls and malnutrition significantlydiminishes the 6-month mortality in people with recognizeddeficits [49].

Recognition of specific geriatric problems can alter theapproach to patients. At minimum, care can be tailored tocompensate for the deficits. Recognition of geriatric problemsmay also direct care. Predictive models integrate nutritional,cognitive and functional status to identify inhospital mortal-ity for seriously ill people [50]. Clinicians who recognizepatients at risk of poor outcomes may choose to direct themto a more conservative management, avoiding interventionssuch as surgery.

The management of HF is also impacted by the managementof several specific conditions. Identification of these conditionscan facilitate the management of HF in elderly patients. Dataconcerning HF in the elderly should be generated from studiesthat include older people and incorporate the evaluation ofspecific conditions and comorbidities.

ArthritisOsteoarthritis increases in frequency with increasing age.Symptomatic arthritis is present in 50 to 65% of older people,and 80% of people over the age of 65 years show radiographicevidence of degenerative joint disease [51]. Over 40% of peoplewho died from HF in the Study to Understand Prognosis andPreferences for Outcomes and Risks of Treatment (SUPPORT)were perceived to have pain at the end of life, presumably fromarthritis [52].

The mainstay of treatment for osteoarthritis, nonsteroidalanti-inflammatory drugs (NSAIDs), act on renal cyclooxygen-ases (COXs) and prostaglandins to alter renal blood flow andhandling of sodium and water, therefore must be avoided inHF. Many NSAIDs are available without prescription, so athorough review of nonprescription medications is imperative.COX-2 inhibitors have been promoted for their reduced potential

Goodlin


to cause gastrointestinal ulceration and bleeding; however, theirrenal effects are equivalent to other NSAIDs. NSAIDs alsoworsen renal toxicities associated with ACE inhibitors.

Practitioners caring for people with HF and arthritis mustoffer alternative therapies to manage pain. Of the medicationsavailable to treat pain, low-dose opioids are effective withoutsignificant toxicity in older people with arthritis [53]. Althoughtheir precise effects on the kidney and in HF is uncertain, thenonacetylated salicylates such as salsalate and trilisate offer painrelief and anti-inflammatory action without the potentialadverse effects on sodium and water retention of NSAIDs.Serum salicylate levels should be monitored with these medica-tions as their toxicities parallel those of aspirin including tinni-tus, dizziness, dysarthria and confusion. The exception is thatnonacetylated salicylates do not affect platelet function orbleeding time.

Topical agents, including over-the-counter topical salicylatesand capsacin cream may reduce pain and muscle ache. Lidocainepatches applied for 12 h/day are effective at reducing localizedpain and muscle spasm for some patients. Small amounts of lido-caine may be systemically absorbed, although data concerningblood levels of lidocaine are not readily available.

Nonpharmacologic therapies are particularly important inthe management of arthritis in the elderly. Physical therapyevaluation and treatment of gait disorders with a focus on adap-tive techniques, muscle strengthening (particularly for back,hip and knee pain), and assistive devices are all effectiveinterventions to reduce pain and improve function. Ice fol-lowing exercise may decrease inflammation and associatedpain. Nonspecific exercise, in contrast, may exacerbate pain.

Cognitive impairmentDementia, the acquired, persistent impairment of cognition,carries enormous healthcare and societal costs. The prevalenceof cognitive impairment rises exponentially with increasing age,but cognitive impairment is more common in people with HFthan in the population at large. This may reflect the combinedetiologies of cognitive impairment in HF:

• Vascular disease

• Multi-infarct disease

• Alzheimer’s disease

• Lewy Body disease

• HF-specific dementia

HF-specific dementia seems to relate to perfusion, as cognitionimproves following heart transplantation. People with HF havebeen shown to have specific regions of gray matter loss on mag-netic resonance imaging (MRI) compared with people withoutHF. However, these were not correlated with cognitive func-tion, but did correlate with sleep-disordered breathing [54]. Car-diovascular risk factors strongly correlate with the developmentof deficits in memory, and affect executive function (the inte-gration and sequencing of information) [55]. Diabetes mellitusand hypertension, in particular, are strongly associated withmulti-infarct dementia.

Cognitive impairment presents several potential issues in themanagement of patients with HF. Memory loss and cogni-tive impairment significantly impact compliance with HFtreatment. Recognition of memory impairment permits pro-viders to set up systems to enhance compliance such asorganized pill boxes or delivery systems with daily remindersabout medications.

Cognitive impairment is the major risk factor for delirium oracute confusion. Delirium in hospitalized patients is associ-ated with a 30% mortality. Medications are a major cause ofdelirium, and β-blockers are a recognized culprit, as is dig-oxin. In contrast, ACE inhibitors, angiotensin receptor block-ers (ARBs) and diuretics have not been implicated in delir-ium. Identification of dementia should direct carefuladministration of medications, and serial exams to detectaltered mental status when a new medication is started. Otherconditions common in HF such as dehydration,hyponatremia and hypoxia may precipitate delirium.

Dementia and its predecessor, mild cognitive impairment,are grossly under-recognized in primary care practice, with asmany as 91% of mild cases and 67% of total cases beingmissed [56]. Recognition of dementia is best achieved with abrief screening of older people as routine practice. Several shortscreens can reliably be performed by nonphysicians, and cantherefore be integrated into office practice using nursing orother clinical staff [57]. Management of dementia can bereferred to a geriatrician, neurologist or psychiatrist; however,once cognitive impairment is recognized, the HF clinicianshould re-evaluate cognition to detect delirium or other adverseeffects that might ensue with changes in medications or in HFmanagement. Optimizing cardiac function may improve cogni-tive function; impaired patients awaiting heart transplantationdemonstrated improved cognitive function following successfultransplantation [58].

FrailtyOver the past 20 years, clinicians and researchers have recognizeda clinical syndrome, frailty, which is associated with high mor-bidity and mortality. Frail patients have a loss of physical func-tional reserve, sarcopenia (low muscle mass), weakness,cachexia and neurohormonal and cytokine dysregulation. Mus-cle is lost at the expense of other tissues in malnutrition, andprotein-calorie malnourished elderly people preserve serumalbumin at the expense of muscle, except in acute illness. Frailpatients have diminished strength as well as decreased func-tional reserve. Frailty is highly associated with HF [59], althoughit also exists in its absence. HF patients have muscle atrophyand altered muscle metabolism [60]. Studies of older peoplewith HF who are and are not frail are needed to understand thedistinction of muscle dysfunction with HF from frailty.

Recognition of frailty assists with prognostication. Dependencein three or more of the basic activities of daily living is associ-ated with a 50% 6-month mortality [61], and functional impair-ment evident with clinical assessment is associated with hospi-tal mortality, 1-year mortality and with nursing home



admission [62,63]. Recognition of frailty in HF patients shoulddirect decision-making away from interventions dependent onphysiologic reserve for success.

Interventions to reduce frailty have largely been directed atsarcopenia. Directed resistance exercise of the lower extremitieswill have a dramatic benefit in improving muscle strength, andmay alter markers of neurohormonal dysregulation in the eld-erly. Strengthening of lower extremities improves maximumventilation of oxygen in the elderly and in middle-aged patientswith HF [64,65].

Functional impairment is associated with the need for assistancewith care. The caregivers of older people with heart disease areoften elderly themselves; approximately a quarter of caregiversare spouses, a third are adult children, few are grandchildrenand approximately a third are paid or unpaid nonrelatives [66].Caregivers feel isolated, worry about doing something wrongand lack training and support in giving care [67]. Social workand other resources should be employed to support caregiversand caregivers should be included in all education provided tothe patient about their HF care. Written materials and writteninstructions should supplement oral instructions to patientand caregivers.

DepressionRates of depression in older people increase every 10 years over65 years of age, and are as high as 25% for patients aged 80 to100 years. HF has also been associated with elevated rates ofdepression and, in turn, depression has been identified as amarker of higher mortality in HF patients [68,69]. Studies ofdepression in HF to date have generally used screening tools todiagnose depression; however, a recent study using more sophisti-cated tools correlated depression with overall health status andillness burden in elderly people with HF [70].

Treatment of elderly people with antidepressants should becautious. Tricyclic antidepressants have fallen out of voguebecause of their side-effect profile and relatively slow onset ofaction, but they are an effective treatment for depression.Nortriptylene and desipramine have less significant anti-cholinergic effects such as orthostatic hypotension than other tri-cyclics. The selective serotonin reuptake inhibitors (SSRIs) maycause orthostatic hypotension, and as well cause hyponatremia insome elderly patients. The hyponatremia is presumed to be dueto stimulation of antidiuretic hormone release by serotonin [71].The onset of hyponatremia varies from weeks to months afterinitiation of the SSRI, hence all older people on an SSRI shouldhave sodium level checked periodically.

Decision making in elderly heart failure patientsPrognostication for an individual patient with HF is difficult,but the overall mortality rate is high, particularly for the elderly.Overall survival is poorer for men than women, but in all groups1-year death rates approach 20%. The prognosis for womenwith coronary artery disease is worse than for other groups [72].Women with HF may also receive less survival benefit fromACE inhibitor therapy [73].

Most patients and families prefer to be involved in decision-making and desire honest information about what to expect inthe course of their illness, and how to respond in an emergency.Patients and families also identify maximizing the quality oftheir lives as a major need [74]. Although cultural approaches tomedical care and beliefs vary, all patients and their familiesshould be informed that HF is a life-limiting illness. The highrates of sudden death or progressive frailty with progressive HFmandate that patient’s preferences for an attempt at resuscita-tion be solicited in the context of what they can reasonablyexpect. Physical frailty or significant cognitive impairmentargue against interventions designed to prevent sudden death,as the alternative is progressive functional and cognitive declinewith associated burden for both patients and families.

Family caregivers are often an elderly spouse or adult child,and most provide daily care with significant impact on the care-giver [75]. Caregivers worry about doing something wrong, lacktraining about care, and need assistance in providing care [76].Patient outcome improves with HF education that engages thefamily, and intergrating family care providers into the patientcare results in less distress [77]. Decreasing family distress is a keyto improving patient physical and mental quality of life [78].

Expert opinionCare for elderly heart failure patientsThe initial assessment of an elderly patient should include abrief screen of physical function such as the ‘get up and go’ testand a screen of cognitive function such as the mini-cog or themini-mental state exam. A screen for pain at that time shouldinclude asking the patient whether they have had pain in thepast week or two and if so, how frequent and how severe thepain is, as well as how much it interferes with usual activities.Depression screening should be incorporated into the initialassessment. Initial blood pressure should be measured supineand standing; if orthostatic hypotension is present, standingblood pressure should be followed with changes in medication.Strategies to address recognized problems must be built into themanagement of HF.

HF treatment should incorporate management of functionaland cognitive disabilities and pain. An exercise prescription withphysical therapy guidance is appropriate as a treatment for bothfrailty and pain. Cognitive disability requires careful titration ofmedication and reassessment of cognitive status when medicalregimens change. Antidepressants require ongoing surveillanceof sodium, orthostatic hypotension and other side effects of thedrugs. All patients with HF should be placed on an ACE inhibi-tor (or ARB if they have cough) and β-blocker, with dosesadjusted if needed to maintain standing blood pressure suchthat the patient avoids symptomatic light-headedness.

Five-year viewMost patients with HF are elderly. The number of elderlypeople with HF will increase as both the elderly populationincreases and as we improve care for people with HF and theylive longer.

Goodlin


Medical management of HF in the elderly will need to addressthe complexity of medications and the dilemmas of polyphar-macy. Simplified regimens and once-daily dosing are desirable.In addition, research studies will need to focus on medicationeffects and outcomes, specifically in the elderly. We need togenerate an evidence base in the elderly for the administrationof medications that are effective in younger people. We alsoneed better information about the management of HF withpreserved LV systolic function. In 5 years we should be on theway to developing these data.

It is critical that quality of life and impact on family caregiversare included as outcomes when treatment efficacy is evaluated.The best possible evolution in 5 years would result in HF carebeing focused on enhancing quality of life rather than life pro-longation. Owing to the financial healthcare burden implied bya rapidly expanding population of elderly patients with HF, thereimbursement structures for HF care will shift. Care manage-ment programs will be the mainstay of HF management forolder people with significant risk factors for readmission; hearttransplant specialists will care for young patients who are likelyto benefit from transplantation; cardiologists will have a con-sultative role in HF care and most care will be rendered bynurses and midlevel providers. Frailty management will be inte-grated into HF management. Medications will represent a por-tion of the interventions for HF care; interdisciplinary care willmake up a significant part of HF care.

Information resources• Heart Failure Society of America

www.hfsa.org(Accessed December 2004)

• Society of Geriatric Cardiologywww.sgcard.org(Accessed December 2004)

• Palliative Care-Heart Failure Education And Research Trialswww.pc-heart.org(Accessed December 2004)

Key issues

• Clinical decision making and management of elderly heart failure (HF) patients needs to incorporate an approach to common conditions and patient preferences. Decision making should incorporate an acknowledgement of HF as a life-limiting disease.

• Conditions such as cognitive impairment or frailty cause increased mortality and, therefore, their recognition should direct HF management away from devices and interventions and towards medical care for HF.

• Management of conditions such as degenerative arthritis and depression can adversely affect HF status by effects on renal retention of sodium and water with nonsteroidal anti-inflammatories and by hyponatremia and increased antidiuretic hormone release with selective serotonin reuptake inhibitors.

• Recognition of arthritis pain should direct clinicians to other interventions, including opioid analgesics and nonpharmacologic approaches.

• Recognition of depression should direct interdisciplinary care and if medications are initiated, careful evaluation of their side effects is warranted in elderly people.

ReferencesPapers of special note have been highlighted as:• of interest•• of considerable interest

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Website

101 American Heart Association. Heart Disease and Stroke Statistics. 2004 Update.www.americanheart.org(Accessed December 2004)

Affiliation• Sarah J Goodlin, MD

Fellow, Intermountain Healthcare, Institute for Healthcare Delivery Research, Salt Lake City, UT, USADirector, Palliative Care-Heart Failure Education And Research Trials (PC-HEART), 681 East 17th Avenue, Salt Lake City, UT 84103, USATel.: +1 801 442 3081Fax: +1 801 442 [email protected]

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Heart failure in the elderly