Frail elderly with dyspnoea or reduced exercise tolerance. Screening and beyond

Reduced exercise tolerance and exercise-induced dyspnoea are common complaints affecting many older persons, with prevalence rates varying between 20% and 60%. Both symptoms often coexist and are associated with an increased risk of adverse health outcomes and reduced quality of life. In approximately two third of patients these complaints have a pulmonary or cardiac cause, with heart failure and chronic obstructive pulmonary disease (COPD) as most common underlying disorders. For both diseases effective interventions are available. We performed a diagnostic cluster randomized trial in frail elderly with dyspnoea or reduced exercise tolerance to quantify the yield of such a screening strategy compared to usual care. Primary care practices were randomized to the diagnostic-treatment strategy (screening) or care as usual. Frail community-dwelling persons aged 65 years and older were selected from the electronic medical files of the participating general practitioner. Frailty was defined as having three or more chronic or vitality-threatening diseases and/or receiving five or more drugs chronically during the last year. Those with reduced exercise tolerance or moderate to severe dyspnoea (≥2 score on the Medical Research Council dyspnoea scale) were included in the study. The near-home targeted screening strategy included history taking, physical examination, electrocardiography, spirometry, blood test, and echocardiography. Final diagnoses were set by an expert panel. Participants in the control arm received care as usual. All participants filled out questionnaires about health status and quality of life at baseline and after six months of follow-up. Eighteen general practices were included in the study. Of the 11,839 persons aged 65 years or older, 35% met the criteria of frailty. Of the patients willing to participate, 68% had complaints of reduced exercise tolerance or dyspnoea. In total, 389 persons underwent the screening program and 440 received care as usual. In the screening strategy, 343 new diseases were detected in 226 participants (58%). In usual care there were 74 participants (17%) with one or more newly diagnosed disease. In the screening strategy, 127 participants (34%) received a new diagnosis of heart failure, mainly heart failure with preserved ejection fraction, and 65 participants (17%) were newly diagnosed with COPD. Other new diagnoses included atrial fibrillation (2%), valvular disease (21%), persisting asthma (3%), anaemia (13%) and thyroid disease (0.6%). According to the panel, the screening investigations revealed an explanation for the complaints in 77% of the participants. The treatment advice provided by the expert panel was followed by the general practitioner in less than half of the cases (45%). The scores for health-related quality of life, functional health, and health care use were comparable between the two arms after six months of follow-up. We concluded that screening for heart failure and COPD results in a substantial number of new diagnoses, but this did not result in an improved short-term improvement in functional health or quality of life as compared to care as usual. Based on the principles of screening, using the ten criteria of Wilson and Jungner, we conclude that implementing our screening program is not suitable at this stage