Clinical characteristics of heart failure associated with functional dependence at admission in hospitalized elderly

Objective to identify which clinical features of heart failure are associated with a greater chance of functional dependence for the basic activities of daily living in hospitalized elderly. Method cross-sectional study conducted with elderly hospitalized patients. The clinical characteristics of heart failure were assessed by self-report, medical records and scales. Dependency was assessed by the Katz Index. The Fisher’s Exact Test was used to analyze associations between the nominal variables, and logistic regression to identify factors associated with dependence. Results the sample consisted of 191 cases. The prevalence of functional dependence was 70.2%. Most of the elderly were partially dependent (66.6%). Clinical characteristics associated with dependence at admission were dyspnea (Odds Ratio 8.5, Confidence Interval 95% 2.668-27.664, p <0.001), lower limb edema (Odds Ratio 5.7, 95% Confidence Interval 2.148-15.571, p <0.001); cough (Odds Ratio 9.0, 95% confidence interval 1.053-76.938, p <0.045); precordial pain (Odds Ratio 4.5, 95% confidence interval 1.125-18.023, p <0.033), and pulmonary crackling (Odds Ratio 4.9, 95% Confidence Interval 1.704-14.094, p <0.003). Conclusion functional dependence in admitted elderly patients with heart failure is more associated with congestive signs and symptoms.


Introduction
With the aging of the world population, there has been a progressive increase of Cardiovascular Diseases (CVD), including Heart Failure (HF). This is a common condition in the elderly and an increase in its incidence and prevalence is estimated to occur in the coming years, becoming a serious public health problem (1)(2) .
Projections show that the prevalence of HF will increase 46% by the year 2030, resulting in more than 8 million  (4) .
HF is a clinical syndrome in which a structural or functional change in the heart leads to the inability to eject or accommodate blood within physiological pressure values, causing functional limitation and the need for therapeutic intervention (5) .
In hospitalized elderly, the clinical picture is complex and influenced by the presence of an arsenal of signs and symptoms (6) , which are described as clinical characteristics of HF and represent a high risk for dependence, hospital readmissions, morbidity and mortality (7) .
The clinical characteristics of HF are represented by the symptoms of fatigue, dyspnea, lower limb edema, cough, precordial pain, dizziness, palpitation, orthopnea and paroxysmal nocturnal dyspnea; and by signs of crackling at lung auscultation, jugular stasis, signs of hepatomegaly, ascites, and left ventricular ejection fraction (LVEF). In the elderly, dyspnea and fatigue are prominent, which may contribute to exercise intolerance and culminate in dependence on the Basic Activities of Daily Living (BADL) (8)(9) . The situation becomes more evident during hospitalization in which even the independent elderly may need help in BADL, which makes the individual more susceptible to dependence and loss of autonomy (10)(11)(12) .
Hospitalization due to HF, therefore, is considered a marker of clinical instability (13) and is associated with an increase in patient dependence. It is estimated that 25 to 35% of the hospitalized elderly will present some functional impairment after discharge (14) and there is a high risk of potentiating an already existing functional decline (15) . The time of hospitalization for clinical compensation is an important aspect, since it implies costs. The more clinically severe patients, with more comorbidities and, consequently, those with the highest number of associated clinical characteristics, need more time for compensation and will cost more for the health system (16) .
Thus, the identification of individuals at greater risk of functional decline should be a routine action in nursing care practice, since it may contribute to minimize the adverse consequences of hospitalization. Therefore, individualized nursing actions will meet the care demands according to the functional performance of the elderly (17) .
Although age progression may naturally influence functionality, there are not many studies in the literature exploring the association between Functional Dependence (FD) and HF. A previous study showed that HF is associated with higher FD at hospital admission (17)

Methods
This is an epidemiological, observational and cross-  The functional evaluation for BADL was performed through the application of the Katz Index (19) . The instrument was applied twice during the interview: the first application was done retrospectively, with reference to the week prior to hospitalization (prior FD) and the second was done with reference to the time of hospital admission (the first 24 hours -FD at admission).
Data were analyzed using SPSS software, v.22.
Descriptive analyzes were performed presenting absolute and relative frequencies; means, standard deviation, medians, and variation (minimum and maximum).
The Fisher's Exact Test was performed to analyze the associations between the nominal variables. value was presented with its 95% confidence interval and significant p-value (≤0.05).

Results
The sample consisted of 191 elderly, mostly males (n = 106, 55.5%). Mean age was 75.6 years (SD = 9.1) and women were on average about two years older than men, but this difference was not statistically significant (p <0.082). The majority of the sample consisted of white individuals (77.5%), retired (61.8%) and married (53.9%).
Among women, the mean number of years of study was 4.2 (SD = 2.4) and among men, 5.4 (SD = 2.6). Men had 1.2 year of schooling more than women (p <0.001). In relation to LVEF, the highest frequencies were observed between reduced LVEF (n = 78, 40.8%) and preserved LVEF (n = 77, 40.3%), respectively, while 18.9% had borderline LVEF (n = 36). Table 1 shows the clinical characteristics of HF as a function associated with the functional profile, showing a higher frequency of FD among individuals with congestive signs and symptoms. Table 2 presents the factors associated with the greater chance of FD at admission in elderly with HF.
Thus, the hemodynamic profile with congestive pattern is associated with a greater chance of FD.

Discussion
The results of the present study showed a high prevalence of FD at admission. The symptoms of dyspnea, PND, palpitation and fatigue were the most frequent, but the clinical characteristics associated to the greater chance of FD at admission were dyspnea, edema of LL, cough, precordial pain and pulmonary crackling.
In a comprehensive way, congestive and respiratory signs and symptoms are directly associated with FD and unfavorable outcomes (20)(21) . Studies indicate that patients with HF and those with volume overload represent the largest contingent in their decompensated form (22) .
Respiratory symptoms are understood to be threatening (23) and dyspnea, in particular, is the predominant symptom in this population.
The dyspnea symptom is worth noting in the sample, as it not only presented high prevalence upper limbs (24) and in the respiratory muscles, triggering limiting symptoms and functional loss (25)(26) .
Potentially, in this research, limb edema was considered an associated factor, increasing the chance of FD by up to 5.7 times; however, previous studies have not clearly described this association, making it difficult to compare the results. Therefore, edema in the lower limbs may cause mobility restriction, hindering gait due to increased interstitial fluid volume deriving from hemodynamic failure.
Another clinical characteristic associated with a greater chance of FD was precordial pain, which may increase the risk of functional losses by 4.5 times. In this regard, the elderly may choose to spend less energy in order to prevent episodes of stress-related precordial pain, culminating in less active individuals. This prediction should be understood as an impact factor and demands more evidence based on prospective studies.
Cough was considered a factor associated with FD (OR = 9.0) in this study. In addition, it had an association with being a male and between 70 and 79 years of age. Also, no studies were found that analyzed this association, despite the strong evidence between congestive symptoms and functional loss, which may be a consequence of pulmonary overload due to left ventricular failure (27) . Fatigue, in this study, was not considered a predictor of FD, contrary to other studies. It has been demonstrated that fatigue has a high incidence in elderly with HF, being associated with DF and deserving to be studied in other investigations (29) . In spite of the wide incidence of fatigue, its evaluation is carried out in a diversified way due to the range of measurement instruments, which requires attention to integrate information about this clinical characteristic. Authors suggest the establishment of cutoff points for the evaluation instruments of fatigue in the elderly (30) . considerable progress in the therapeutic management of elderly patients with HF, mortality and morbidity remain a major concern, and hospital admissions compromise performance in BADL (32) . Thus, recognizing which factors are associated with a greater chance of FD in the elderly with HF may be the differential for improving the morbidity and mortality profile of these individuals.
Nurses need the skill and expertise to recognize clinical characteristics, response to treatment and its management so that they can provide appropriate care in this population (33)(34) . While measures of quality of care towards HF are reported only in patients hospitalized for HF, some measures seem to be beneficial for all patients, regardless of the cause of hospitalization (35) .
HF is a chronic condition, with high cost and complex treatment because it has multiple factors involved (11)  From the identification of patients with difficulty with one or more BADL or having a progression in the dysfunction, it is possible to conduct a more complete evaluation and an individualized assistance (39) , not only by the nurse but by the entire health team. Thus, the results of this study serve as an indication that the elderly with HF should be carefully evaluated, since the repercussions of the clinical characteristics have a strong impact on the patient's functionality since hospital admission and that can last after discharge.

Conclusion
The prevalence of FD at hospital admission in the elderly with HF was 70.2%. In the admission period, 3.7% of the elderly with HF were totally dependent, 66.6% were partially dependent and 29.7% were independent for the BADL. The most frequent clinical characteristics of HF at hospital admission were dyspnea, fatigue, PND and palpitation; however, only dyspnea, edema of LL, cough, precordial pain and pulmonary crackling were associated with increased chance of FD at admission among elderly with HF.