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.
Methods
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, 6-minute 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 χ2 test. Continuous variables were compared by t test and presented as mean ± standard deviation. Outcomes were analyzed using analysis of covariance, adjusting for sex.
Results
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 B-type natriuretic peptides, and more prevalent chronic kidney disease.
Table 1.
Characteristics of Older, Hospitalized Patients With Aucte Decompensated Heart Failure Who Live Alone vs Those Not Living Alone
| Characteristics | Living Alone (n = 67) | Not Living Alone (n = 135) | P Value |
|---|---|---|---|
| Age (years) | 72.4 ± 7.8 | 71.9 ± 7.4 | .63 |
| Women | 43 (64%) | 66 (49%) | .040 |
| Non-White | 35 (52%) | 65 (48%) | .96 |
| Less than high school education | 12 (18%) | 25 (19%) | .92 |
| Body mass index (kg/m2) | 34.0 ± 9.0 | 32.8 ± 8.8 | .36 |
| Ejection fraction of ≥45% | 30 (45%) | 66 (49%) | .58 |
| Duration of index hospitalization | 5 (3–6) | 5 (3–7) | .23 |
| Patients w/hospitalizations within 6 months | 26 (39%) | 63 (47%) | .29 |
| Patients w/HF hospitalizations within 6 months | 17 (25%) | 38 (28%) | .68 |
| B-type natriuretic peptide (pg/mL) (n = 117) | 1084 ± 1066 | 850 ± 901 | .37 |
| N-terminal brain natriuretic peptide (n = 77) | 3595 ± 3474 | 7324 ± 12,186 | .041 |
| Comorbidities | |||
| Diabetes mellitus | 36 (54%) | 75 (56%) | .81 |
| Hypertension | 59 (88%) | 128 (95%) | .09 |
| Hyperlipidemia | 45 (67%) | 95 (70%) | .64 |
| Atrial Fibrillation | 31 (46%) | 62 (46%) | .96 |
| Previous myocardial infarction | 14 (21%) | 26 (19%) | .78 |
| Chronic obstructive pulmonary disease | 19 (28%) | 46 (34%) | .41 |
| Chronic kidney disease | 13 (19%) | 54 (40%) | .003 |
| Stroke | 13 (19%) | 19 (14%) | .33 |
| Arthritis/connective tissue disease | 37 (55%) | 57 (42%) | .08 |
| Cancer | 17 (25%) | 25 (19%) | .26 |
| Depression | 11 (16%) | 22 (16%) | .98 |
| Anemia (Hgb <13 for men, <12 for women) | 46 (69%) | 98 (73%) | .56 |
| Peripheral vascular disease | 12 (18%) | 14 (10%) | .13 |
| Peptic ulcer disease | 2 (3%) | 7 (5%) | .48 |
| Dementia | 2 (3%) | 2 (1%) | .47 |
| Obstructive sleep apnea | 19 (28%) | 42 (31%) | .69 |
| AIDS/HIV | 1 (2%) | 1 (1%) | .61 |
| Total No. of comorbidities | 6.1 ± 5.5 | 6.2 ± 2.0 | .62 |
| Medication use | |||
| Loop diuretics | 64 (96%) | 124 (93%) | .42 |
| Beta blockers | 60 (90%) | 108 (81%) | .11 |
| Angiotensin-converting enzymes inhibitors | 35 (52%) | 49 (37%) | .034 |
| Angiotensin receptor blockers | 13 (19%) | 31 (23%) | .55 |
| Calcium channel blockers | 14 (21%) | 46 (34%) | .050 |
| Aldosterone agonist | 15 (22%) | 21 (16%) | .24 |
| Physical function and QOL parameters | |||
| Frailty | 37 (56%) | 64 (49%) | .32 |
| KCCQ overall score | 42 ± 3 | 40 ± 2 | .45 |
| Short Form-12 Physical Composite score | 28 ± 1 | 28 ± 1 | .85 |
| Short Form-12 Mental Composite score | 45 ± 2 | 43 ± 1 | .37 |
| Geriatric depression scale score | 4.9 ± 0.4 | 4.9 ± 0.3 | .99 |
| Geriatric depression scale score ≥5 | 32 (48%) | 61 (45%) | .73 |
| Montreal Cognitive Assessment score | 21.7 ± 0.6 | 21.7 0.4 | .99 |
| Montreal Cognitive Assessment score <26 | 54 (81%) | 135 (77%) | .56 |
| EQ-5D-5L components | |||
| Walking | 2.6 ± 0.1 | 2.4 ± 0.1 | .27 |
| Self-care | 1.8 ± 0.1 | 1.7 ± 0.1 | .32 |
| Usual activities | 2.6 ± 0.1 | 2.7 ± 0.1 | .94 |
| Pain/discomfort | 2.5 ± 0.1 | 2.4 ± 0.1 | .54 |
| Depression/anxiety | 1.8 ± 0.1 | 1.8 ± 0.1 | .91 |
| Health thermometer | 59 ± 3 | 57 ± 2 | .51 |
Abbreviations: HF, heart failure; Hgb, hemoglobin; KCCQ, Kansas City Cardiomyopathy Questionnaire; EQ-5D-5L, EuroQol questionnaire; QOL, quality of life.
Values shown as number (%),median (interquartile range), or mean ± standard error. Outcomes adjusted for sex. Depression is defined as geriatric depression scale score of ≥5. Cognitive impairment is defined as Montreal Cognitive Assessment Score <26.
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.
Discussion
Our results show that, among a diverse population of older hospitalized patients with ADHF, one-third 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.
Disclosures
Dr Kitzman has been a consultant for Relypsa, Abbvie, GlaxoSmithKline, Merck, Corvia Medical, Bayer, CinRx, Boehringer-Ingleheim, and St. Luke's Medical Center in Kansas City, Kansas; received grant support from Novartis, Bayer, and St. Luke's Medical Center in Kansas City, Kansas; and owns stock in Gilead Sciences. Dr Mentz receives research support from the National Institutes of Health (U01HL125511-01A1 and R01AG045551-01A1), Akros, Amgen, AstraZeneca, Bayer, GlaxoSmithKline, Gilead, InnoLife, Luitpold/American Regent, Medtronic, Merck, Novartis and Sanofi; honoraria from Abbott, Amgen, AstraZeneca, Bayer, Boston Scientific, Janssen, Luitpold Pharmaceuticals, Medtronic, Merck, Novartis, and Sanofi; and has served on an advisory board for Amgen, AstraZeneca, Luitpold, Merck, Novartis, and Boehringer Ingelheim. Dr Whellan has research support from Amgen, CVR Global, Merck, NIH, Novartis, and ResMed; and has been a consultant for Akros Pharmaceuticals, BDC Advisors, Cytokinetics, and Fibrogen.
Footnotes
Supported in part by the following research grant awards from the National Institutes of Health: R01AG045551 and R01AG18915. Also supported in part by the Kermit Glenn Phillips II Chair in Cardiovascular Medicine at Wake Forest School of Medicine (DWK); the Claude D. Pepper Older Americans Independence Center NIH Grant P30AG021332 (DWK); and the Wake Forest Clinical and Translational Science Award, NIH Grant UL1TR001420.
References
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