Clinical Picture and Social Characteristics of Super-Elderly Patients With Heart Failure in Japan

Abstract

©2012 Wiley Periodicals Inc.

The number of super-elderly patients older than 80 years with chronic heart failure (HF) is dramatically increased in Japan; however, therapeutic strategies for patients 80 years or older remains to be established. The present investigation was undertaken to clarify the clinical picture and socioeconomic characteristics of super-elderly HF patients. A total of 380 consecutive patients with acute HF or acutely worsening chronic HF were divided into three groups according to age: patients younger than 60 years, those 60 to 80 years, and those 80 years or older (super-elderly group). HF patients in the super-elderly group initially presented with more atypical symptoms at admission compared with those in the younger age group. The prevalence of HF with preserved ejection fraction was more pronounced compared with the patients in the younger age group. Furthermore, the social background was quite different for the 3 groups in several respects: recurrent hospitalization, the prevalence of dementia, and the number of patients living alone all increased with age. The lack of social support in patients with HF is a problem that needs to be resolved in the “super-graying” societies such as Japan.

Statistics published by Japan’s Ministry of Labor and Welfare indicates that the average life expectancy in Japan is 86.39 years for women and 79.64 years for men. In addition, the number of people aged 100 years or older surpassed 40,000 in 2008. Thus, Japan is aging at an unprecedented rate. The advent of the so-called super-aging society raises various health care problems such as the escalation of medical costs and increased numbers of bedridden elderly people unable to look after themselves. In fact, many developed countries are now facing the same problems.

Cardiovascular disease is one of the leading causes of death in Japan, and the prevalence of heart failure (HF) is increasing. Concurrently, advances in treatments for coronary artery disease and acute HF have led to an increase in the number of super-elderly patients (patients older than 80 years) with chronic HF. Various clinical investigations have revealed the effectiveness of a wide variety of pharmacologic agents or mechanical support such as cardiac resynchronization therapy on systolic HF of various types of underlying heart diseases. Based on these clinical investigations, the treatment guidelines for patients with chronic HF have been well established; however, no such clinical research has been conducted on super-elderly patients. It is difficult—or may be even impossible—to perform the randomized controlled clinical trials of HF in the super-elderly, because activities of daily living are limited for many people in this age group. In addition, many of them already have other diseases including respiratory diseases, chronic kidney diseases, or malignancy. Furthermore, it can be difficult to explain the purpose and significance of a clinical trial to super-elderly patients; obtaining informed consent from super-elderly patients and enrolling these patients in the clinical investigation both present their own challenges. These factors have led to limited understanding of the treatment of super-elderly HF patients. Thus, how to treat and manage HF patients aged 80 years or older is one of the key challenging issues in this “super-graying” society.

Given the difficulties inherent in conducting randomized controlled clinical trials with super-elderly patients, it is important to clarify their clinical and social characteristics by the observation for the establishment of the therapeutic strategies. The present investigation is undertaken to clarify the clinical picture and socioeconomic characteristics of super-elderly patients with acute HF or worsening of chronic HF.

Methods

Study Population

The study included a total of 380 consecutive patients with acute HF or acutely worsening chronic HF, who were admitted to our hospital from January 1, 2006, to December 31, 2011. Diagnosis of HF was clinically made from assessment of clinical symptoms, physical examination of fluid retention, and the findings of chest radiography. Patients with acute myocardial infarction or acute coronary syndrome were excluded. The patients were divided into three groups according to age: patients 60 years or younger (middle-aged group), those aged 60 to 80 years old (elderly group), and those aged 80 years or older (super-elderly group). From extensive interviews with the patients or their families, detailed information regarding the composition of the family, their daily life, and the mental state were all collected.

Echocardiography was performed at the point of admission. Left ventricular (LV) dimensions, wall thickness, chamber volumes, and stroke volume were determined by 2-dimensional, M-mode echocardiography, and Doppler spectra using standard methods. Patients with an LV ejection fraction (EF) of >50% by transthoracic echocardiography who met the criteria of Vasan and Levy were regarded as having HF with preserved EF (HFpEF) and those with <50% LVEF were regarded as having HF with reduced EF (HFrEF).¹

Statistical Analysis

Continuous data are expressed as mean±standard deviation. Patient characteristics were compared among the groups by chi-square test and Fisher exact test. P values <.05 were considered statistically significant.

Results

Clinical Features of Super-Elderly HF Patients

The characteristics of the three groups are shown in the Table. Ischemic heart disease was the predominant cause of HF in the middle-aged and elderly groups. The prevalence of hypertensive HF increased with age, whereas that of cardiomyopathy decreased with age. The numbers of patients with atrial fibrillation tended to increase with age. In regard to the prevalence of these underlying causes of HF, there was no significant difference between men and women.

Table TABLE.   Patient Characteristics

	Middle-Aged (Younger than 60 y) (n=116)	Elderly (60–80 y) (n=152)	Super-Elderly (Older than 80 y) (n=112)
Abbreviations: LAD, left anterior descending artery; LV, left ventricular; LVDd, left ventricular diastolic dysfunction; HF, heart failure.
Age, y	54.1±4.8	69.4±2.8	86.1±3.2
Male, % (No.)	75.0 (87)	61.8 (94)	43.8 (49)
Underlying cause of HF, % (No.)
Ischemic	29.3 (34)	35.5 (54)	27.7 (31)
Hypertensive	18.1 (21)	18.4 (18)	37.5 (42)
Valvular	21.6 (25)	17.1 (26)	16.1 (18)
Cardiomyopathic	24.1 (28)	19.7 (30)	13.4 (15)
Others	6.9 (8)	15.8 (24)	5.4 (6)
Atrial fibrillation	4.3 (5)	5.9 (9)	8.0 (9)
Echocardiography
LVDd, mm	50.1±3.8	53.2±13.8	54.1±3.9
LV wall thickness, mm	10.2±1.1	10.6±1.0	10.4±0.9
LAD, mm	42.1±2.8	43.5±2.8	44.1±1.9
Ejection fraction, %	42.1±6.8	46.4±8.8	47.8±7.2

The clinical picture of HF in the super-elderly group was significantly different from that of the other groups in several respects. Regarding the initial symptoms of HF at admission, 21.4% of the super-elderly group presented atypical symptoms for HF such as appetite loss and general fatigue, whereas only 5.2% and 10.5% of the middle-aged and elderly groups, respectively, did so (Figure 1).

Figure 1.  The proportion of heart failure patients presented initially with atypical symptoms. At the admission, 21.4% of the super-elderly group presented atypical symptoms for heart failure such as appetite loss and general fatigue, whereas only 5.2% and 10.5% of the middle-aged and elderly groups. Chi-square test for trend: P<.05.

LV dimension, LV wall thickness, and left atrium dimension were not different among the groups (Table); however, the prevalence of HFpEF increased with age. HFpEF was especially prevalent in women. In 34.9% of female patients in the super-elderly group, EF assessed by echocardiography at admission was preserved to more than 50% (Figure 2). In contrast, 20.7% and 27.6% of female patients in the middle-aged and elderly groups, respectively, showed the clinical features of HFpEF. In male patients, 13.8%, 19.1%, and 24.5% of middle-aged, elderly, and super-elderly groups did, respectively.

Figure 2.  The prevalence of heart failure with preserved ejection fraction (HFpEF) in men (the upper panels) and women (the lower panels) in the 3 groups. The prevalence of HFpEF was more pronounced compared with the patients in the younger age group and in women. Chi-square test for trend: P<.05.

The prevalence of hypertension also increased with age and in women (Figure 3). This was particularly true for HFpEF in the super-elderly group. As shown in Figure 4, most patients with HFpEF had hypertension regardless of age and sex.

Figure 3.  The prevalence of hypertension in men (the upper panels) and women (the lower panels) in the 3 groups. The prevalence of hypertension was also more pronounced compared with the patients in the younger age group regardless of sex. Chi-square test for trend: P<.05.

Figure 4.  Close association of hypertension and heart failure with preserved ejection fraction (HFpEF) in men (the upper panels) and women (the lower panels). The presence of hypertension was closely associated with HFpEF regardless of age and sex.

Social Characteristics of Super-Elderly HF Patients

The social characteristics of patients with HF in the super-elderly group were significantly different from that of the other groups. The prevalence of dementia in the middle-aged, elderly, and super-elderly groups was 0%, 6.5%, and 17.0%, respectively (Figure 5A). The rates of recurrent hospitalization in the middle-aged, elderly, and super elderly groups were 32.8%, 39.4%, and 64.3%, respectively (Figure 5B).

Figure 5.  Social characteristics of super-elderly heart failure patients. (A) The prevalence of dementia in 3 groups. There were no patients with dementia in the middle-aged group, whereas the prevalence of dementia in the super-elderly and elderly was 17.0% and 6.5%, respectively. Chi-square test for trend: P<.05. (B) The proportion of readmission of heart failure patients. The rates of recurrent hospitalization in the middle-aged, elderly, and super-elderly groups were 32.8%, 39.4%, and 64.3%, respectively. Chi-square test for trend: P<.05. (C) The proportion of heart failure patients who lived alone. A total of 44.6% of patients in the super-elderly group lived alone, whereas these figures were 29.6% and 13.8% in the elderly and middle-aged groups. Chi-square test for trend: P<.05.

Interestingly, the number of patients who lived alone were significantly different for the 3 groups. A total of 44.6% of patients in the super-elderly group lived alone, whereas these figures were 29.6% and 13.8% in the elderly and middle-aged groups, respectively (Figure 5C). These trends were not different between men and women. According to a public survey, the percentage of elderly persons living alone in the general population was 14.0% in Japan. Thus, a lack of family support might be one of the contributing factors in HF.

Discussion

The present investigation has clarified the clinical picture and social characteristics of super-elderly HF patients in Japan. HF patients in the super-elderly group initially presented with more atypical symptoms of HF at admission. The prevalence of HFpEF in the super-elderly group was more pronounced compared with the patients in the younger age group. HFpEF was closely associated with hypertension regardless of patient age. Furthermore, the social background was quite different for the 3 groups in several respects: recurrent hospitalization, the prevalence of dementia, and the number of patients living alone all increased with age.

Increasing life expectancy in developed countries has led to a huge population of elderly patients with cardiovascular diseases. This aging society raises many issues regarding medical care for elderly patients. Both the governmental health service and care from family members are essential to prevent deterioration from HF. However, the present investigation revealed that a much greater percentage of super-elderly patients are actually living alone than is the case for patients younger than 80 years. The number of elderly people living far from their children is on the rise as Japan’s population ages. Surveys of the Japanese population reveal that families are becoming more nuclear, with the average number of people per household now down to 2.57. Our finding in the present study suggests that a lack of familial support may be one of the factors in the development of HF.

Since the decline of cognitive capacity is inevitable with age, nursing care and assistance are important for elderly patients. In the present study, 17.0% of super-elderly HF patients presented with symptoms of dementia. In response to this aging society, laws are gradually changing and the Japanese government started a public nursing care insurance system in April 2000. Under this system, elderly people can receive care services such as nursing at home and day care or short stays at care houses; however, the present situation is not adequate for elderly HF patients. There is a compelling need for fundamental enforcement of suitable policies, chronic care management, and the establishment of measures for elderly HF patients in the face of the super-aging of society.

Epidemiological studies have established that approximately one half of all patients with HF have a preserved EF. Although the precise pathophysiology of HFpEF remains to be determined, several features of the pathophysiology have been reported, including structural and functional alterations in the heart, such as hypertrophy of the myocytes, changes in the composition of the extracellular matrix, and abnormalities in intracellular calcium handling.² HFpEF has been reported to afflict predominantly elderly hypertensive women.³ HFpEF was associated with hypertension regardless of age. Our findings are consistent with the previous observations. Target values for blood pressure control in super-elderly patients are debatable; however, our finding indicates that control of blood pressure is crucial for the prevention of HF.

In the older-than-80 super-elderly group, 21.4% of patients presented with atypical symptoms of HF such as appetite loss and general fatigue as the initial symptoms and 17.0% had senile dementia. These factors make the diagnosis of HF and assessment of the severity more difficult in elderly patients. Minor changes in health are likely to be ignored, such as decreased appetite or general fatigue could be a symptom of HF in elderly people. Recently, Hamaguchi and colleagues⁴ reported the clinical features of elderly patients hospitalized with HF in The Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD). They demonstrated that elderly patients had a worse prognosis than younger patients. Therefore, meticulous attention and detailed history-taking are necessary in geriatric medicine.

Conclusions

The clinical features of super-elderly patients with HF were distinctly different from those of both elderly and middle-aged patients in terms of the initial symptoms as well as the prevalence of hypertension and HFpEF. Furthermore, the lack of social support in patients with HF is a problem that needs to be resolved, with Japan rapidly becoming a super-aging society.

Acknowledgments and disclosures:  All authors have contributed intellectually and significantly in the preparation of the manuscript or interpretation of the data. There are no financial conflicts of interest and this investigation did not receive funding support.