Effect of A Follow‐Up Program in Elderly Adults with Heart Failure with Cognitive Impairment After Hospital Discharge

To the Editor: Heart failure (HF) is an important healthcare concern because of its high prevalence, mortality, morbidity, and cost of care.1 Increasingly, elderly adults with HF have concurrent geriatric syndromes such as cognitive impairment, which results in poor health outcomes.2, 3 Cognitive impairment is common in older adults with HF, with prevalence levels greater than 25%.3 Studies on the outcome of follow-up programs (known as disease management programs (DMPs)) have demonstrated that these programs reduce readmissions and improve quality of life and health without increasing health expenditures,4 but few interventions have been conducted in individuals with HF with cognitive impairment,5, 6 despite the influence of cognitive status on the clinical management of HF, especially with regard to HF knowledge, self-care, and treatment adherence.5 This secondary analysis of a previously published randomized controlled trial7 comparing the effectiveness of a DMP with usual care in elderly adults with HF examined whether the intervention was effective in increasing event-free survivals (defined as the time elapsed until the first readmission or until death of the individual from any cause during the study period) in individuals with cognitive impairment. Individuals consecutively diagnosed with acute HF (according to the criteria of the European Society of Cardiology)8 and discharged from the Geriatric Service of the Caceres Hospital Complex (Spain) were included. Degree of cognitive impairment was measured using the Global Deterioration Scale, with a score of 3 or greater considered cognitive impairment.9 Participants were randomized into intervention or usual care, which was used as the control group. Follow-up ended 12 months after discharge or in case of the participant's death. The intervention group received the DMP, consisting of comprehensive hospital discharge planning and close follow-up at a geriatric day-hospital (GDH), from a multidisciplinary team consisted of a geriatrician (case manager), nurse, and social worker after hospital discharge. Participants were monitored using telephone contacts and face-to-face visits at the GDH. During the telephone contacts, the team provided educational reinforcements and evaluated for possible cardiac decompensation. During visits at the GDH, the team assessed participants for treatment adherence, reinforced the health education, and assessed the ability of participants to meet recommendations; prescriptions and doses were also adjusted according to clinical guidelines. The global therapeutic regime and comorbidities were reevaluated by considering possible changes in the functional, cognitive, affective, and social capacities of the individual. The team provided the contact number of the case manager for consultation regarding the study. This secondary analysis included 116 participants (59 allocated to DMP, 57 to usual care; one usual care participant with mental retardation since childhood was excluded). The mean age was 85 (interquartile range 82–89), and 73% were female. Participants had a high dependency level (78% with a Barthel Index <100) and comorbidity (58% with a Charlson Index ≥3), and 20% had cognitive impairment (Global Deterioration Scale score ≥3, range 3–5); 14.5% lived in a retirement home. Hypertensive cardiopathy (45.3%) was the most common cause of HF. Most participants entered the program in New York Heart Association Class II (47%) or III (38.5%). Average ejection fraction was 58%, with preserved systolic function in two-thirds of participants. There were no significant differences between the groups in any of the baseline demographic or clinical characteristics. Table 1 shows the events, readmissions, and mortality data during the study. When analyzing event-free survival of participants without cognitive impairment, the probability of having an event during follow-up was significantly lower in the DMP (log-rank 6.23, P = .01). There were no significant differences between the groups in participants with cognitive impairment. Cognitive impairment is common in elderly adults with HF and is associated with poor health outcomes,2, 3 so it is important to determine which interventions are beneficial in individuals with both conditions. The present study found that a DMP implemented in a GDH increased event-free survival in elderly adults with HF without cognitive impairment but not in those with cognitive impairment. Because elderly adults with HF with cognitive impairment have rarely been assessed in previous studies of HF,5, 6, 10 further research is required to determine what can be done to improve the self-care of these individuals at home (and to evaluate the contribution that family and caregivers can provide to support self-care) and encourage treatment adherence without forgetting the importance of monitoring neuropsychological, functional, and socioeconomic status. Results presented at the 56th Congress of the Spanish Geriatric and Gerontology Society as an oral presentation, Barcelona, Spain, 2014. This work was funded in part by Research Group Grant GR10127, co-financed by the Regional Government of Extremadura (Spain) and the European Union (Fonds Européen de Développement Régional). Conflict of Interest Checklist: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors: study concept and design; analysis and interpretation of data; preparation, review, and approval of manuscript. González-Guerrero, Alonso-Fernández, and García-Mayolín: acquisition of data. González-Guerrero: statistical analysis. Sponsor's Role: The funder did not influence the design, methods, subject recruitment, data collections, analysis, or preparation of paper.