Opportunities for Care Optimization and Hospitalization Reduction for Older Persons With Heart Failure

There is an exponential growth in incidence and prevalence of heart failure (HF) with aging resulting in significant health care resource utilization.1 HF impacts function, quality of life (QoL), and increased early mortality.2,3 HF is a global issue; worldwide, in 2015, there were about 40 million people suffering from HF.4 Furthermore, the projected prevalence is expected to rise, driving up health care costs, largely related to emergency department (ED) visits and hospital admissions.5 In clinical trials of HF, enrollees tend to be younger, frequently more men with a lower left ventricular (LV) ejection fraction.6 However, the data from patients with HF registries are mostly related to the age range of 70 to 75 (SD 15 years). There is a higher prevalence of a non-cardiac comorbidity burden in HFpEF patients compared with those with HFrEF.15 Patients with HFpEF have a higher burden of hypertension (55%-86%), diabetes mellitus (26%-45%), stroke (15%-17%), chronic obstructive pulmonary disease (COPD; 7%-31%), obesity (41%-62%), and anemia (21%-53%). [...]management of these patients is more complex and requires optimal therapies for both cardiac and non-cardiac conditions to reduce rehospitalization, number of ED visits, and total mortality. [...]shared care models including both nurse practitioners and PCPs for more complicated patients with HF likely need better clinical resources and increased frequency of encounters with clinicians and other health care multidisciplinary members, including dieticians, physical therapists, and pharmacists.17 Improved care of complex older patients with cardiac disease is dependent on a new model of collaboration and teamwork between PCP, geriatrician, and cardiologist, with timely access to palliative care to accommodate the fundamental heterogeneity of aging and the patient’s choices.18 Recognition and management of frailty in older HF patients are of crucial importance.19 Frailty is a significant predictor of all-cause admission after adjusting for ejection fraction and symptom severity.20 In fact, frailty was associated with a 92% increase in ED visits and a 65% increase risk for hospitalization.21 Therefore, we need to manage frailty, define the goals of treatment, incorporate risk-benefit intervention assessment, and focus on QoL issues and end-of-life values/preferences of patients in decision making.22 Optimization of non-cardiac comorbidities including screening for geriatric syndromes, appropriate pharmacologic