ROCHESTER, MN—Patients with heart failure who were seen at a
major medical center commonly struggled with nine activities of daily living
(ADL), which often worsened over time and were a powerful predictor of
all-cause death and hospitalization during a mean follow-up of 3.2 years,
according to a new study [1].
Patients who had trouble feeding themselves, using the toilet
and dressing (severe difficulties with ADL) and those who had trouble taking
medication, bathing, taking public transportation, and housekeeping (moderate
difficulties with ADL) had a respective 2.3-fold and 1.5-fold higher risk of
dying during follow-up compared with patients who had trouble walking and
climbing stairs (minimal difficulties with ADL) or had no difficulties with
ADL.
Even patients with no/minimal difficulties with ADL only
survived a mean of 5.6 years. However, those with moderate or severe
difficulties survived a mean of only 3.0 and 1.5 years, respectively. Asking HF patients about ADL “is a relatively
easy thing to assess during a routine clinical visit…[and it] certainly
provides a framework to identify patients…who are at higher risk for adverse
outcomes,” lead author Dr. Shannon M. Dunlay (May Clinic. Rochester, MN) told
heartwire.
The study is unique in that the researchers assessed ADL, a
measure used in oncology and gerontology for many years, but rarely used in
cardiology,” Dr. Kathleen Dracup
(University of California, San Francisco School of Nursing), who was not
involved in the study, told heartwire.
It shows that ADL “provides an important window into the
daily life of the patient…and may provide a powerful tool to identify patients
who might consider palliative care in the future,” she said. Thus, at minimum, clinicians need to ask
about ADLs as part of the routine clinical visit…[which] has never been part of
the standard cardiac assessment.”
Do ADL Difficulties
Predict Early Death?
Little is known about how functional disability affects
survival and hospitalization in patients with HF, Dunlay and colleagues write.
They studied 1128 patients with HF who were seen in the Mayo
Clinic from September 2003 through January 2012 and followed until January 2013
and had completed a questionnaire asking them to reply “yes” or “no” to
indicate if they had difficulties with nine ADLs.
Most patients (69%) were enrolled as outpatients, while the
rest were enrolled when they were hospitalized for HF. The patients had a mean age of 75 years, and
49% were women. About 6 in 10 patients
reported having difficulty with at least one of the nine ADL’s.
The researches ranked the ADL, from easiest to hardest, as
follows: Feeding oneself, using the toilet,
dressing, taking medications, bathing, taking transportation, housekeeping,
walking, and climbing stairs. After a
mean follow-up of 3.2 years, 54% of the patients had died.
Risk of Outcome With Moderate
and Severe vs. No/Minimal Difficulty with ADL, HR (95%CI)*
|
ALL-CAUSE OUTCOME
|
DIFFICULTY WITH ADL AT
ENROLLMENT
|
|
MODERATE
|
SEVERE
|
|
MORTALITY
|
1.49 (1.22—1.82)
|
2.26 (1.79—2.86)
|
|
HOSPITALIZATION
|
1.37 (1.17—1.59)
|
1.22 (1.00—1.49)
|
*During a
mean follow-up of 3.2 years; adjusted for age, sex, Charlson comorbidity index,
and hospitalized vs. outpatient at enrollment ADL= activities of daily living
The 17.7% of survivors who reported more difficulty with ADL
and patients with persistently severe or worsening difficulty were at increased
risk for death (HR 2.10, 95% CI 1.71-2.58; P less than 0.001) and hospitalization (HR
1.51, 95% CI 1.31-17.74; P less than 0.001), Asking about ADLs can help identify which
patients may need physical therapy to improve or retain their mobility, Dunlay
noted. More research is needed to
identify “whether there are specific interventions, physical therapy, of types
of care that can help patients who are having difficulties with ADL and
potentially impact their outcomes and quality of life,” she said.
Useful Prognostic Tool
The study has three key
implications, Dr. Eldrin F. Lewis (Brigham and Women’s Hospital, Boston, MA),
writes in an accompanying editorial. [2]
First, ADL in HF patients could be
assessed by an online questionnaire during or prior to a clinic visit. Second, more research is needed to better
understand why certain ADL limitations are associated with earlier death and to
design targeted therapies for high-risk patients. Last, “this adds another prognostic tool that
can be used by clinicians as we provide guidance into complex shared
decision-making.” He said.
“Unfortunately, 50% of patients
with HF will die within 5 years, [which] has not changed over the past decade
despite advances in treatment,” Drakup noted.
This study—like other studies that used the 6-minute walk—shows that
functional status is an important predictor of mortality, she said.
Moreover, “if high-risk and
low-risk [HF patients] could be identified with any confidence, then clinicians
could begin that all-important discussion about goals of treatment with
high-risk patients,” she said. “Clinicians
may refer patients to hospice care earlier—currently in cardiology such
referrals are infamously late (often in the last 3 days of life)—and shift the
goals of treatment to comfort card vs. ‘cure’ for patients with a high risk of
dying”
This work was supported by grants from the National Institutes of
Health. The authors, Lewis and Drakup
have no relevant financial relationships.
POSTED by: Steven Ajluni, MD
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