key: cord-0921486-sowwla0y
authors: Warraich, Haider J.; Kitzman, Dalane W.; Nelson, M. Benjamin; Mentz, Robert J.; Rosenberg, Paul B.; Lev, Yair; Whellan, David J.
title: Older Patients With Acute Decompensated Heart Failure Who Live Alone: An Analysis From the REHAB-HF Trial
date: 2021-06-18
journal: J Card Fail
DOI: 10.1016/j.cardfail.2021.06.005
sha: 107c995e2c159c003b0a3f082dbd284acaefb854
doc_id: 921486
cord_uid: sowwla0y

BACKGROUND We assessed the prevalence and clinical characteristics of patients with acute decompensated heart failure (ADHF) who live alone and how they were different from patients who lived with someone else. METHODS We analyzed patients in the REHAB-HF Trial. Patients were ≥60 years with preserved or reduced ejection fraction who were hospitalized with ADHF. RESULTS Of 202 patients, 67 (33.2%) lived alone. Patients who lived alone had a mean age of 72.4±7.8 years, 64% (n=43) of whom were female, 52% (n=35) were non-white and had a mean 6.1±5.5 comorbidities. Patients living alone were largely similar in baseline characteristics, comorbid burden and prescribed medications to patients living with someone else. However, patients living alone were more likely to be female than patients living with someone else (63% [n=43] vs. 49% [n=66], p=0.04). Patients living alone had severe impairments in physical function and QoL. Cognitive dysfunction was present in 81% of those living alone. However, after adjusting for sex, no differences in physical function, depression, cognitive dysfunction or QoL were noted between patients who lived alone or those who lived with someone else. CONCLUSIONS In this diverse population of older ADHF patients, 33% lived alone (versus 26% in the general population). Those living alone were more often female, non-white, and had >6 comorbidities. Treatment strategies for older ADHF patients should consider the potential impact of social determinants.

Older Patients With Acute Decompensated Heart Failure Who Live Alone: An Analysis From the REHAB-HF Trial Social isolation has greatly worsened owing to the COVID-19 pandemic and patients with heart failure (HF) who live alone experience poorer outcomes such as hospital readmission. 1 However, drivers of poor outcomes in these patients and estimates about their physical and quality of life (QOL) impairments remain unknown. We sought to assess the prevalence of patients with acute decompensated HF (ADHF) enrolled in the REHAB-HF trial living alone, and hypothesized that these patients would have worse physical function, QOL, cognition, and depression, than patients living with someone else.

We assessed patients enrolled in the REHAB-HF Trial. Patients were 60 years or older with preserved or reduced ejection fraction hospitalized with ADHF. 2 Additional inclusion criteria included independence with activities of daily living, attainment of clinical stability, ability to walk 4 or more meters with or without a device, planned home discharge, and sufficient support to comply with postdischarge exercise intervention. Patients provided written informed consent and the institutional review boards of the participating sites approved the study.

Physical function measures included the short physical performance battery, normal gait speed, 6minute walk distance, handgrip strength, and frailty (Fried criteria). QOL was assessed using the Kansas City Cardiomyopathy Questionnaire, the Short Form-12, and EuroQol-5D-5L. Depression was assessed using the Geriatric Depression Scale. Cognitive function was assessed using the Montreal Cognitive Assessment. Patients were categorized by patient self-reported data into those living alone vs those living with someone. Categorical variables were analyzed as frequencies (percentages) using the x 2 test. Continuous variables were compared by t test and presented as mean § standard deviation. Outcomes were analyzed using analysis of covariance, adjusting for sex.

Of 202 patients, 67 (33.2%) lived alone. Of those who lived with someone, 56.3% lived with their spouse. Patients who lived alone had a mean age of 72.4 § 7.8 years, 64% of whom were female, 52% were non-White and had a mean of 6.1 § 5.5 comorbidities (Table 1) . Patients living alone were more likely to be female, have higher N-terminal pro Btype natriuretic peptides, and more prevalent chronic kidney disease.

Patients living alone had severe impairments in physical function and QOL and more than one-half met the criteria for frailty (56%). Depression was very common in both groups. Cognitive dysfunction was present in 81% of those living alone. However, no differences in physical function, depression, cognitive dysfunction, or QOL were noted between patients who lived alone or those who lived with someone else after adjusting for sex.

Patients who lived with a spouse, compared with those who lived with someone else, were more likely to be male (68% vs 29%), White (63% vs 29%), and have a high school education or greater (91% vs 39%) (all P< .05). No differences in physical function or other clinical parameters were noted between patients who lived with their spouse compared with those who lived with someone other than their spouse.

Our results show that, among a diverse population of older hospitalized patients with ADHF, onethird live by themselves. These patients, mostly women, had significant impairments in physical function, QOL, mood, and cognition, similar to patients living with others with more additional social support. These patients, therefore, represent a large proportion of patients with ADHF at high risk for adverse outcomes.

The prevalence of those living alone was higher in our population (33%) than the general older population (26%). 3 Consistent with the age of this population, women were much more likely to live alone than men. 3, 4 Social isolation, recognized as a major risk factor for readmission, may contribute to women with HF being at greater risk than men for hospital readmission. 5 The high prevalence of women living alone may need to be taken into account when designing postdischarge programs and strategies for patients with ADHF, particularly accounting for variable support that patients might have.

These findings are novel because, to our knowledge, living situation has not been reported for any HF population, let alone for older patients with ADHF. ADHF is the most common Medicare hospital discharge diagnosis, highlighting the potential impact of our findings. These data were collected before the COVID-19 pandemic, which likely magnified the adverse consequences of living alone. Limitations included our small sample size and that this was not a prespecified analysis. Furthermore, our results could be an underestimate of patients with ADHF living alone, because we excluded patients discharged to facilities.

The high prevalence of patients with ADHF living alone suggests that treatment strategies that leverage social supports, such as caregivers, may have to be tailored based on patients' living situation. Mechanisms to better support patients with ADHF living alone should be developed, tested, and implemented.

Dr Kitzman has been a consultant for Relypsa,

Living alone and clinical outcomes in patients with heart failure with preserved ejection fraction

Physical rehabilitation for older patients hospitalized for heart failure

Smaller share of women ages 65 and older are living alone

Living alone among older adults in Canada and the

Sex differences in trajectories of risk after rehospitalization for heart failure, acute myocardial infarction, or pneumonia

Patients with Acute Decompensated Heart Failure Living Alone 163