Evolution of a Geriatric Syndrome: Pathophysiology and Treatment of Heart Failure With Preserved Ejection Fraction

Bharathi Upadhya, MD; Barbara Pisani, MD; Dalane W. Kitzman, MD


J Am Geriatr Soc. 2017;65(11):2431-2440. 

In This Article

Physical Frailty and Cognitive Dysfunction

In older adults hospitalized primarily for HF, many factors outside the heart, such as advanced age, globally low organ system reserve capacity, physical frailty, impaired cognition, and comorbidities (often numerous and severe), strongly influence outcomes.[70] Frailty is associated with poor outcomes in older adults with HF. It is a strong independent predictor of all-cause mortality and is associated with a 92% greater risk of emergency visits and a 22% greater risk of hospitalization.[71] Similarly, older adults with incident HF more likely to significant functional and cognitive impairments.[72] A recent study showed that there is also a high prevalence of subclinical cerebral infarction in individuals with HFpEF, even in the absence of AF.[73] In addition, the hospital environment—with immobilization, fasting, sleep deprivation, and disorientation—can dramatically worsen physical frailty with rapid, severe loss of muscle mass and function.[70] Treatment of HFpEF is much more challenging in individuals with cognitive limitations. Thus, when older adults with HF are thought to be ready for discharge, their multiple comorbidities, globally low organ reserve, severe physical deconditioning, and cognitive dysfunction often remain unaddressed.[70] The result is the "posthospitalization syndrome," with high rates of rehospitalization, mortality, and nursing home admission; prolonged physical disability; poor quality of life; and high healthcare costs.[74] These multiple noncardiac comorbidities not only contribute to the pathophysiology of HFpEF, but are also strong contributors to exercise intolerance in individuals with chronic HFpEF and to the high rate of clinical events, including hospitalizations and death. In contrast to HFrEF, in individuals with HFpEF noncardiac comorbidities account for the majority of all-cause hospitalizations and mortality.[47]