Abstract
Background: Sarcopenia is a complex syndrome associated with ageing, influenced by nutritional factors and physical activity, leading to decline in cognition and quality of life, with socioeconomic impact. It affects 10% of the elderly population, increasing to 20% among those with heart failure (HF). In one year, we evaluated 427 elderly HF patients, with 60% diagnosed with probable sarcopenia (SP). Considering the importance of an intervention program that involves different levels of care, we create the project: SarcoRecuperar. This is the responsibility of the department of Internal Medicine/HF outpatient clinic and the Palmela Community Care Unit (CCU) of ULS Arrábida.
Approach: From March to July 2024, the multidisciplinary team met weekly to set objectives, indicators, and targets. This practice continues through regular huddles meetings, where members efficiently identify and implement improvements while maintaining clear communication.
Purpose: To reduce SP in people over 65 with HF, enhancing their autonomy in daily and social activities, tailored to their needs and context. Those with high dependency or significant cognitive/behavioral impairments are excluded.
The people diagnosed with SP are treated as a key partner and focus of the intervention. Launched in July 2024, the project involves the full multidisciplinary team across hospital, CCU, and home settings.
The initial intervention involves a hospital-based multidisciplinary consultation (internist, specialist/generalist nurse, rehabilitation nurse) for a global assessment, covering socioeconomic, anthropometric, and nutritional factors, NYHA class, and assessment of SP severity and screening analytical. A personalized dietary plan is provided and updated as needed.
The rehabilitation nurse creates a home exercise plan for the individual, enabling the person to perform them, including resistance exercises.
At 3 and 6 months the following endpoints are evaluated: increase muscle strength, reduce the severity of the disease, number of decompensations, hospitalizations, the risk of falling and improving the quality of life.
The end of the program is stipulated 6 months after the start of the intervention, however the person will be re-evaluated 3 and 6 months after the end.
The care plan continues at home with weekly reassessments by the UCC rehabilitation nurse for 4 weeks. After this, the person follows the exercise plan independently, with visits becoming less frequent based on needs identified during teleconsultations or hospital reassessments.
In this project, coordination with the social worker enables social and economic assessments and referrals.
Results: So far, 6 people have joined the SarcoRecuperar program, with one discontinuation due to other health issues. This included 10 multidisciplinary consultations, 38 nursing consultations, and 30 home visits.
Regarding indicators, over 90% of eligible individuals were included. Though still in the initial phase, there has been only 1 emergency visit due to a fall and no hospitalizations. Participants and families reported high satisfaction, better daily functional capacity, increased commitment, and 75% adherence to plans.
Implications: The data highlights a significant impact, emphasizing the need to invest in expanding the project. The person's input improved the process, with strategies implemented automatically. To strengthen the intervention, partnerships were established with pharmaceutical companies and local governments.