Geriatric MedicineTier 1Disease (DEADMAN)

Cardiac conditions - heart failure

Description

HF in older patients: usually HFpEF, not HFrEF
- Diastolic dysfunction from HTN, LVH, ischaemia, AF
Frequently multimorbid presentation - overlaps with COPD, CKD, obesity, deconditioning
Frailty and HF share a final common pathway - sarcopenia, inflammation, reduced reserve

HTN + LVH -> impaired relaxation -> dec compliance
IHD - silent ischaemia common, atypical angina
AF - loss of atrial kick unmasks diastolic dysfunction
Valvular - degenerative AS/MR common contributors
Amyloid (ATTR) - underrecognised cause of HFpEF in >75s, consider if disproportionate LVH, low voltage on ECG, carpal tunnel history
Iatrogenic - NSAIDs, corticosteroids, fluid load, negatively inotropic drugs

Presentation often atypical - confusion, falls, fatigue, anorexia rather than classic dyspnoea
- May be mislabelled as "generalised decline"
NT-proBNP - higher rule-in/rule-out thresholds needed with age; also raised by CKD, AF
TTE - EF, diastolic function (E/e', LA volume), valve disease
Consider ATTR amyloid workup if HFpEF + red flags above
Deprescribing review at diagnosis - NSAIDs, CCBs (non-dihydropyridine), corticosteroids, high Na-containing formulations

By functional/frailty status

Robust - standard GDMT as per HFrEF pathways if reduced EF; HFpEF: SGLT2i (dapagliflozin/empagliflozin) has trial evidence across EF spectrum
Frail/multimorbid - simplify regimen, avoid polypharmacy cascade, prioritise symptom control and hospitalisation avoidance over strict target-dose titration
Cognitively impaired - regimen must suit carer/self-administration; consider dosette packs, home nursing

Congestion

Loop diuretic - lowest effective dose, risk of postural hypotension + falls, AKI, electrolyte derangement
Daily weights + fluid/salt restriction only if tolerated - strict restriction can worsen nutrition in frail

Falls and polypharmacy

Advance care planning

CKD - cardiorenal syndrome, limits diuretic/RAAS titration
COPD - symptom overlap, complicates beta blocker use (cardioselective preferred, not contraindicated)
Delirium - precipitated by decompensation, hypoxia, uraemia
Falls - from postural hypotension, diuretic-induced dehydration
Frailty and sarcopenia
Depression and cognitive impairment - worsen adherence

HFpEF prognosis similar to HFrEF once symptomatic - ~50% mortality within 5 years
Repeated admissions -> stepwise functional decline, not full recovery between
Death often from non-cardiac cause (infection, frailty) rather than pump failure
Triggers for decompensation - infection, arrhythmia (new AF), non-adherence, NSAID/steroid use, dietary indiscretion

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