Management of heart failure among very old persons living in long-term care: Has the voice of trials spread?

Background increasing prevalence, use of health services, and number of dea ths have made congestive heart failure (CHF) a new epidemic in the United S tates. Yet there are no adequate data to guide treatment of the more typica l and complex cases of patients who are very old and frail. Methods Using the SAGE database, we studied the cases of 86,094 patients wi th CHF admitted to any of the 1492 long-term care facilities of 5 states fr om 1992 through 1996. We described their clinical and functional characteri stics and their pharmacologic treatment to verify agreement with widely app roved guidelines. We evaluated age- and sex-related differences, and we det ermined predictors of receiving an angiotensin-converting enzyme (ACE) inhi bitor by developing a multiple logistic regression model. Results The mean age of the population was 84.9 +/- 8 years. Eighty percent of the patients 85 years of age or older were women. More than two thirds of patients underwent frequent hospitalizations related to CHF in the year preceding admission to a long-term care facility. Coronary heart disease an d hypertension were the most common causes. Half of the patients received d igoxin and 45% a diuretic, regardless of background cardiovascular comorbid ities. Only 25% of patients had a prescription for ACE inhibitors. The pres ence of cardiovascular comorbidity, already being a recipient of a large nu mber of medications, a previous hospitalization for CHF, and admission to t he facility in recent years were associated with an increased likelihood of receiving an ACE inhibitor. The presence of severe physical limitation was inversely related to use of ACE inhibitors, as were a series of organizati onal factors related to the Facilities. Conclusions Patients in long-term care who have CHF little resemble to thos e enrolled in randomized trials. This circumstance may explain, at least in part, the divergence from pharmacologic management consensus guidelines. Y et the prescription of ACE inhibitors varies significantly across facilitie s and depends on organizational characteristics.