Assessment and management of cognitive dysfunction and frailty at end of life

Abstract

One out of two patients with advanced cardiovascular disease exhibits signs of frailty or cognitive impairment. Identification of frailty or cognitive impairment, when objectified with a validated instrument, confers a negative effect on prognosis and may be an important clue that the patient with advanced cardiovascular disease is entering the end-of-life phase. These patients have special needs that are best addressed in conjunction with a multidisciplinary palliative care team. Challenges include recognizing and managing pain and other symptoms, assessing competence to make medical decisions, maintaining informed communication with the patients and their families, and differentiating potentially treatable etiologies such as: low cardiac output with hypoperfusion, sleep-disordered breathing, metabolic disturbances, delirium, and depression. Advanced care planning should be encouraged, with the foreseeable outcomes framed around the patient’s cardiovascular disease status but also around their resiliency and homeostatic reserve. Ultimately, an approach of shared decision-making is central to the care of frail and cognitively impaired patients at the end-of-life.