An 86-year-old woman with a history of heart failure with preserved ejection fraction (HFpEF) is admitted to the hospital for worsening shortness of breath and fatigue. She has multiple coexisting conditions including hypertension (HTN), chronic kidney disease, chronic obstructive pulmonary disease (COPD), anemia, mild cognitive impairment, gait instability, and urinary incontinence. She lives in an assisted living facility and requires help with her medications, grocery shopping, and housework. She uses a walker and had a mechanical fall 4 months prior to admission. She has been hospitalized 3 times in the past year and will require subacute rehabilitation after hospital discharge to regain the ability to perform self-care activities including toileting, bathing, and dressing. She wants to discuss her long-term prognosis.

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  The prevalence of heart failure (HF) increases with age and exceeds 1 in 10 persons over the age of 80 years in the United States (Figure 14-1).¹

  
  
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  The risk of hospitalization for HF increases markedly with age for men and women (Figure 14-2).

  
  
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  Persons 85 years of age and older make up an increasing proportion of all hospitalizations for HF in the United States (Figure 14-3).

  
  
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  Although the majority of older persons hospitalized with HF in the United States have HFpEF,² most persons with heart failure with reduced ejection fraction (HFrEF) are also over 65 years of age.

  
  
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  More than 80% of deaths attributable to HF in the United States occur in persons over 65 years of age, and approximately 60% occur in persons over 75 years of age.

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  Cardiovascular changes with aging contribute to the development of HF, in particular HFpEF. These changes include the following:³

  
  
  
  
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    Increased arterial stiffness as manifested by rising arterial pulse wave velocity (Figure 14-4), systolic blood pressure, and pulse pressure.

    
    
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    Impaired endothelium-mediated vasodilatation with reduced peak coronary blood flow.

    
    
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    Impaired active relaxation of the myocardium in diastole coupled with increased passive myocardial stiffness.

    
    
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    Reduced myocardial response to beta-adrenergic stimulation.

    
    
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    Impaired sinus node function.

  
  
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  Older persons are therefore less able to augment cardiac output in response to stress due to the following:

  
  
  
  
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    Insufficient preload or sufficient preload at the expense of elevated left ventricular (LV) diastolic pressure.

    
    
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    Reduced stroke volume from impaired contractile reserve and increased vascular stiffness.

    
    
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    Reduced peak heart rate (ie, 220 – age).

  
  
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  Concomitant age-related changes to other organ systems include the following:

  
  
  
  
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    Lungs: Reduced elastic recoil, reduced vital capacity, increased ventilation/perfusion mismatching.

    
    
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    Kidneys: Declining glomerular filtration rate, impaired water and electrolyte homeostasis.

    
    
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    Musculoskeletal system: Sarcopenia, osteopenia.

    
    
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    Central nervous system: Impaired baroreceptor responsiveness, impaired thirst mechanism.

    
    
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    Hemostatic system: Shift in balance between thrombosis and fibrinolysis toward thrombosis, increased risk for both thrombosis and hemorrhage.

  
  
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  Physiologic changes with aging contribute to the decline in peak oxygen consumption (peak VO₂) (Figure 14-5) and to the increase in treatment-related side effects with age.³

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  Multimorbidity

  
  
  
  
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    The majority of older persons with HF have 5 or more chronic conditions.

    
    
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    The average number of chronic conditions increases with age.

    
    
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    The average number of chronic conditions is increasing over time (Figure 14-6).

    
    
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    The most common chronic conditions among Medicare beneficiaries 65 years of age or older with HF are HTN (86%), ischemic heart disease (72%), hyperlipidemia (63%), anemia (51%), diabetes (47%), arthritis (46%), chronic kidney disease (45%), COPD (31%), atrial fibrillation (29%), and cognitive impairment (29%).⁴

  
  
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  Polypharmacy

  
  
  
  
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    The median number of unique medications taken each day by persons with HF is 11 (Figure 14-7).

    
    
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    The number of medications taken daily is increasing over time.⁵

    
    
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    Medication adherence declines as complexity of the medical regimen increases.

    
    
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    Risk of drug-drug interactions exceeds 90% with 10 or more concomitant medications.

  
  
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  Cognitive impairment

  
  
  
  
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    More than 1 in 4 older persons with HF have cognitive impairment.⁴

    
    
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    Among older persons hospitalized with HF, almost 1 in 2 have cognitive impairment. More than 1 in 5 has moderate to severe cognitive impairment.⁶

  
  
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  Functional impairment

  
  
  
  
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    Almost 3 in 5 persons newly diagnosed with HF have difficulty in performing at least 1 of the following tasks: Feeding themselves, dressing, using the toilet, housekeeping, climbing stairs, bathing, walking, using transportation, and managing medications.⁷

    
    
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    Almost 2 in 5 older persons hospitalized with HF require assistance with walking.⁸

  
  
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  Frailty

  
  
  
  
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    The phenotype of frailty may result from varied pathways, including the age-associated activation of inflammatory cells and decline in androgen hormones that result in loss of muscle quality and quantity, as well as increasing impairments across multiple organ systems (Figure 14-8).

    
    
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    One in four older persons with HF has at least 3 of the following hallmarks of frailty: Weak grip strength, physical exhaustion, slow gait speed, low activity level, and unintentional weight loss of 10 or more pounds in the past year.⁹

  
  
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  Impact on outcomes

  
  
  
  
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    Increased comorbidities are associated with a higher risk of hospitalization.

    
    
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    Geriatric syndromes, especially frailty, mobility disability, and cognitive impairment, are associated with a higher risk of short- and long-term mortality after hospitalization for HF.⁸

    
    
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    Comorbid conditions contribute to the majority of hospitalizations¹⁰ and rehospitalizations¹¹ among older persons with HF.