Background
In Western countries, heart failure (HF) is common in older people. The prevalence of HF increases up to 17.4 % at the age of 85 years and more [
1]. It is a growing problem as the population ages and survival rates after cardiovascular events increase [
2]. In addition, there is a longer exposure to risk factors for HF and age-related changes [
3]. Various factors such as older age, hypertension, diabetes mellitus (DM), obesity and coronary artery disease (CAD) have been described as risk factors for developing HF [
4,
5].
Early diagnosis and treatment of HF may prevent progression and lead to improvement of symptoms and quality of life [
6,
7], which are especially important in the care of nursing home residents. These residents can be described as old and considerably disabled persons, with either chronic somatic diseases or progressive dementia beyond the range of home care services [
8]. The diagnosis of HF in nursing home residents is however challenging, due to atypical signs and symptoms, cognitive impairment, immobility, polypharmacy and misinterpretation of symptoms due to co-morbidities [
9,
10]. Importantly, these residents often do not undergo proper diagnostics as recommended by the guidelines [
11]. As a consequence, the prevalence of HF in such residents may be significantly underestimated, but also overestimated due to misinterpretation of symptoms corresponding to comorbidities. A systematic review by Daamen et al. showed that the prevalence of HF in nursing home residents is estimated to be 15–25 % [
12]. The diagnosis of HF was, however, based on information derived from medical records only in all but one study included. In this study by Butler et al., the diagnosis of HF was made after a clinical examination, resulting in an HF prevalence as high as 45 % [
13]. However, the prevalence in UK long-term care facilities was recently reported to be much lower when also using echocardiography (i.e. 23 %) [
14]. Thus, there is significant uncertainty regarding the proper diagnosis of HF in nursing home residents. The aim of this study was, therefore, to determine the prevalence and clinical characteristics of HF in Dutch nursing home residents, based on an onsite comprehensive HF assessment, including not only medical history, medication and clinical assessment, but also ECG, echocardiography and biomarkers, and final diagnosis was made by an expert panel.
Discussion
In this study, the prevalence of HF was 33 % for all participating nursing home residents, of which more than half were previously undiagnosed and a previous diagnosis of HF was rejected in almost one third. HFpEF and HFrEF were equally prevalent. Therefore, the hypothesis that HF is highly prevalent in nursing home residents is confirmed, and the prevalence was clearly higher than among older persons in the general population [
1].
The prevalence of 45 % found in a study by Butler et al.[
13] in which HF was diagnosed in nursing home residents after physical examination by a geriatrician, is higher than in our study. However, the limitations of that study were the lack of a clear description of HF and the lack of further diagnostics such as an echocardiogram as recommended by the guidelines [
20]. Therefore, the presence of HF may be overestimated, which is in line with other studies of a similar population by Hancock et al.[
14] and Barents et al. [
23] where the prevalence of HF was much lower (i.e. 23 %). The HF assessment and definition of HF in these studies were similar to our study. The demographic and clinical characteristics of the residents were also comparable to our study. There is no obvious explanation as to why the prevalence rate in our study was somewhat higher. The difference between the studies of Hancock et al. [
14] and Barents et al. [
23] and our study is the confirmation of the diagnosis of HF by an expert team of two cardiologists and a geriatrician. In their studies, there were individual decisions by two cardiologists and no panel discussions.
Residents with HF had less cognitive disorders; a result which is not in line with studies in the literature where patients with HF suffer more often from cognitive disorders [
24,
25]. This might be explained by the fact that there is a difference in study sample. Our nursing home residents are a specific group of older persons, where a high number suffers from cognitive disorders as the primary diagnosis. However analysis of the MMSE score in the subgroup of somatic residents still shows a higher MMSE score in residents with HF.
In the study by Hanock et al. [
14], more patients (i.e. app. two-third) with HFpEF were observed as compared to our study. HFpEF was equally common as HFrEF in our study, and as expected, more prevalent in women [
4]. In large cohorts of the general population, the frequency of HFrEF versus HFpEF was also the same with approximately half having reduced and half having preserved LVEF [
26,
27], although average age was lower than in our cohort of nursing home residents (i.e. app 75 years). Asymptomatic left ventricular systolic dysfunction was additionally found in 10 % of the residents in our study. Taken together, there was a substantial number of residents with reduced LVEF, i.e. approximately one fourth of all residents investigated in this study. Compared with the study by Hancock et al.[
14], this is a higher percentage of residents with reduced LVEF and could explain the difference in the prevalence of HF. HFrEF is better defined than HFpEF and particularly asymptomatic diastolic dysfunction in such an elderly population is difficult to determine. Therefore, direct comparison of patients with reduced LVEF between different cohorts may be more reliable despite some inaccuracy in measurement of LVEF by echocardiography [
28]. Nevertheless, it obviously remains to be determined how many of the patients with asymptomatic reduced LVEF will develop signs and symptoms of HF over time.
Multivariable analysis showed that factors such as arrhythmia, CAD, age, a history of pre-existing HF were associated with the presence of HF. Interestingly, there was no association found with gender, which may be a risk factor for the development of HF in the general population [
29]. There were no other studies in nursing home residents that investigated risk factors for prevalent HF in multivariable analysis. Thus, the specific pattern of risk factors in residents of nursing homes needs to be confirmed in future trial, in particular because they differ somewhat to what is described in other cohorts.
Furthermore, the diagnosis HF was not known in more than half of those having HF and a previous diagnosis of HF was not confirmed by the expert team in one third of all cases. These findings indicate an important problem as a significant number of residents obviously might not be treated correctly. This could be of significant impact to residents of nursing homes as it can be expected that symptoms are not adequately recognised and treated in a substantial number of patients. Although not prospectively investigated by randomised treatment trials in this population, this may have important impact on well-being and quality of life. Moreover, it implies a challenge to improve the diagnostic process of HF in nursing homes residents. The implementation of the structured procedure used by the expert team may improve the diagnostic process significantly. This includes echocardiography using mobile devices in residents suspected to suffer from HF. The clinical features identified in this study to be accompanied with increased risk of prevalent HF may help to detect such patients that should undergo such structured work-up.
The strength of the present study is the thorough method of data collection using an on-site integral examination of each resident. On the other hand, the participation rate was not as high as anticipated (27 %). A consideration here is that legal representatives often do not want to decide for participation on behalf of the residents, which explains the lower participation rate of psychogeriatric patients. Our findings are in line with a study conducted by Barnes [
30] on HF in the elderly, where only 30 % of patients agreed to participate. Still, residents included did not differ in a clinical meaningful way from those that did not agree to participate. Therefore, it is likely that the results of this study are representative for our nursing home population in the South of the Netherlands. A 10 % missing echo values can be seen as a limitation in this study. This may result in misdiagnosis in some patients and importantly, lack of information on potential underlying causes of heart failure and left-ventricular ejection fraction. This may negatively effect quality of treatment in these patients. However, in routine clinical care, echocardiography cannot be performed in all subjects due to exactly the same reasons also found in our cohort.
Moreover, we did not investigate to what extent treatment would have changed based on more accurate diagnosis and the impact on the patients’ well-being is unknown. This is particularly true since the large treatment trials that are the basis for the treatment recommendations did not include the population of our study. Still, guideline recommendations are independent of patient’s age. Therefore, the diagnostic approach we used would at least result in treatment which is better following current guidelines. Finally, we included residents in one region only and results might be different in other countries and may depend on the structure of health care in each country. Therefore, it is important to conduct such studies in different countries as results in this regard are still very limited.
Competing interests
HPBLR receives unrestricted research grants from and acts as consultant for Roche Diagnostics, Switzerland. None of the other authors have any competing interests arising from this research.
Authors’ contributions
MD: nursing home physician – researcher, designed and performed the study and wrote this manuscript. JS and JH: supervised the study design and provided comments on earlier drafts of this paper. HPB: provided comments on the cardiologic content and revised the manuscript. FT: focused on the statistical part of the manuscript. AG and MvD: helped writing and revising the manuscript. All authors read and approved the final manuscript.