Helping Elderly Heart Failure Patients Not Outlive Their Muscles

I have always been amazed at how quickly elderly patients lose muscle mass and exercise performance when hospitalized. This may be especially true for elderly heart failure (HF) patients because their underlying cardiac condition often limits activity and thereby starts their physical deconditioning prior to admission. The poor physical performance of the previously hospitalized elderly is an important cardiac issue because acute decompensated HF is the leading reason for hospital admission among the elderly in the US.

Kitzman and colleagues examined how a specially designed post-discharge rehabilitation program affected outcomes in elderly patients after HF hospitalization (NEJM May 16, 2021). The program was designed to address strength, balance, mobility, and endurance, issues not generally addressed in standard cardiac rehabilitation (CR). They randomized 349 patients to the rehabilitation program or to usual care. Participants had to be older than age 60, able to walk at least 4 meters, independent prior to admission, and planned for home discharge. An equal number of patients with ejection fractions below and above 45% were randomized to each group. Patients received exercise at home initially if needed, but attended 60-minute exercise sessions thrice weekly for 12 weeks and then transitioned to an independent exercise program. At baseline 97% of the patients were considered frail or pre-frail.

At 3 months, the primary outcome, a battery of physical performance measures, had improved more in the rehabilitation group, but the 6-month secondary endpoints of rehospitalization as well as total and cardiovascular deaths were not different between groups.

Such a specific intervention is not available for most clinicians working with HF patients, but there are multiple clinical lessons from this important study. Clinicians should remember how quickly elderly HF patients lose function during hospitalizations so that the stay should be as short as possible and adjunct services such as physical therapy used to maintain physical function. HF patients should be referred to cardiac rehab whenever possible. Cardiac rehab programs need to evaluate how standard rehab can be adjusted to address the strength, balance, mobility, and endurance deficits of elderly HF patients. Granted, there were no effects on hospitalizations or total and cardiovascular deaths at 6 months, but exercise performance was improved at 3 months, and, for the elderly, there is more to life than just living. Staying independent and away from a chronic care facility is the goal for many elderly patients. To help them do that, clinicians have to help make sure they do not outlive their muscles.

This was also published as:

Thompson PD. Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. PracticeUpdate website. Available at: https://www.practiceupdate.com/content/physical-rehabilitation-for-older-patients-hospitalized-for-heart-failure/118537/65/2/1.