Management considerations in the care of elderly

Review

Management considerations in the care of elderly heart failure patients in long-term care facilities George A Heckman1, Veronique M Boscart2 & Robert S McKelvie*,3

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Abstract: Heart failure, a condition that affects up to 20% of older persons residing in long-term care facilities, is an important cause of morbidity, health service utilization and death. Effective and interprofessional heart failure care processes could potentially improve care, outcomes and quality of life and delay decline or hospital admission. This article reviews the clinical aspects of heart failure, and the challenges to the diagnosis and management of this condition in long-term care residents who are frail and are affected by multiple comorbidities. Heart failure (HF) affects millions of people worldwide [1] . The prevalence is rising with population aging, and the lifetime risk for octogenarians approaches 20% [2,3] . HF disproportionately affects older persons, in whom it is a leading cause of morbidity, health service utilization and death [4] . The prevalence of HF in long-term care (LTC) or nursing homes is approximately 20%, and the 1-year mortality exceeds 50% [5–7] . A recent population-based study in Canadian LTC homes showed that HF accounted for 16% of emergency department visits over a 6-month period [8] . It has been suggested that many such visits could be prevented if effective HF care processes were in place in LTC [8–10] . This article will provide a review of HF, its epidemiology and the challenges of managing HF in older residents in LTC facilities. For the purpose of this review, the term LTC designates a facility that provides 24-h nursing care and personal support to persons for whom continued residence in the community is no longer feasible due to multiple concurrent age-associated conditions and disabilities, such as dementia or HF [11] .

Keywords

• diagnosis • disease management • elderly • epidemiology • frailty • heart failure • long-term care • nursing homes

The epidemiology of HF HF is a complex and progressive chronic syndrome in which the heart cannot sufficiently pump blood to meet the needs of the body, or can only do so in a state of increased blood volume, resulting in poor exercise tolerance, fatigue, fluid retention and reductions in quality of life and survival [12] . Common causes of HF include ischemic heart disease (IHD), hypertension, valvular heart disease and nonischemic dilated cardiomyopathy [12] . HF is a common, costly, disabling and ultimately fatal condition [12] . Estimates of the prevalence of symptomatic HF in the general population range from 0.4 to 2% [12] . The prevalence of HF increases rapidly with age [2] , with octogenarians having a 20% lifetime risk and the average age of the HF population being over 75 years [3] . Rapid population growth among seniors is primarily responsible for the rising prevalence of HF, though, unlike other common cardiovascular diseases, ure UK

Research Institute on Aging, University of Waterloo, BMH 3734, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada Conestoga College, School for Health & Life Sciences & Community Services, 299 Doon Valley Drive, Kitchener, ON, N2G 4M4, Canada 3 McMaster University & Hamilton Health Sciences, David Braley Cardiac, Vascular & Stroke Research Institute, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada *Author for correspondence: Tel.: +1 905 572 7155; Fax: +1 905 577 1480; [email protected] 1 2

10.2217/FCA.14.35 © 2014 Future Medicine Ltd

Future Cardiol. (2014) 10(4), 563–577

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Review Heckman, Boscart & McKelvie the age-adjusted mortality attributed to HF also appears to be increasing [13] . Precise estimates of the prevalence of HF in LTC settings can be difficult to obtain, reflecting diagnostic difficulties related to the variability of HF symptoms in this complex and frail population, and the inadequate transfer of health information from the sending care setting to the LTC home [14] . The GOLD-HF prospective cohort study [15] followed 546 newly admitted residents from 42 LTC homes for a year and, based on an exhaustive search of previous health records, found an HF prevalence of 21.4%. Overall annual mortality and hospitalization rates for all residents were 24 and 27%, respectively. Among residents with HF, 42% died and 31% were hospitalized within a year. Other prevalence studies of HF in LTC settings reported similar rates, varying from 15 to 20% based on retrospective reviews of medical records [5,16] . In particular, one study found a very high prevalence rate of HF of 45%, based on a thorough clinical assessment by a geriatrician, while another found significant rates of both undetected and overdiagnosed HF in LTC [17,18] . Despite methodological differences between studies, HF is clearly more common in LTC settings than it is in the general population. The course of HF is characterized by periods of relative stability that are punctuated by acute exacerbations, leading to progressive decline in health, increased health service utilization and ultimately death [19] . The prognosis of HF is poor, with half of the patients dying within 4 years; among patients with HF that is severe or complicated by multiple comorbidities such as dementia, more than 50% will die within 1 year [7,15] . A recent analysis of US Medicare and Medicaid data shows that between 1998 and 2008, 1-year mortality rates associated with HF have not declined [20] . HF remains a leading cause of health service utilization among older persons. While the incidence of HF hospitalizations has recently modestly declined, the absolute number of hospitalizations continues to rise with population aging [20] . Furthermore, a substantial proportion of seniors who are hospitalized with HF require home care support after discharge, or are discharged to an LTC home [21] . The burden of HF is particularly notable among LTC residents. A population-based study of frequency and pattern of emergency department (ED) visits by LTC residents revealed that nearly one quarter of all LTC residents visited

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the ED at least once a month [8] . Almost a third of acute HF hospitalizations from LTC are readmissions [7,22] . Of all visits, approximately 25% are considered potentially avoidable, particularly those associated with pneumonia (30%), urinary tract infection (20%) and HF (16%). Half of the residents returned to the LTC facility immediately after the ED visit; findings consistent with those reported elsewhere [7,23] . An observational analysis of a large cohort of US HF patients found that of those discharged to a skilled nursing facility (SNF), a variant of LTC in which residents are expected to be rehabilitated and discharged back to the community, 14.4% died and 27% were rehospitalized within 30 days and the 1-year mortality rate was over 50% [7] . Clearly, residents with HF in LTC face a substantial risk for adverse events and death: this supports an urgent need to determine optimal diagnosis and management options. Clinical aspects of HF in LTC residents An important aspect of HF among LTC residents is its association with geriatric syndromes, including frailty, functional decline, cognitive impairment and psychiatric comorbidities [4,24] . These associations must be considered when considering optimal care options for these patients. Numerous observational studies confirm that frailty, a state of reduced fitness resulting in vulnerability to adverse health outcomes, and HF are strongly associated [4] . Compared to nonfrail HF patients, frail HF patients are more vulnerable to worse health-related quality of life, hospitalization, mortality and complications from concurrent illness [25–28] . Frailty in seniors with HF can lead to functional decline (progressive loss in ability to perform activities of daily living), resulting in greater need for supportive services [4,29–30] . For example, in the US observational study of 15,459 patients aged 65 years and older and who had been hospitalized for HF, 24% were discharged to an SNF and 22% were discharged home with home health services [7] . Outcomes over the subsequent year were worse among patients discharged to the SNF compared with those discharged home with selfcare: adjusted rates for mortality and all-cause rehospitalization were 1.76 (95% CI: 1.66–1.87) and 1.08 (95% CI: 1.03–01.14), respectively [7] . HF patients are more likely than age- and gender-matched peers to have cognitive impairment [31] . The prevalence of cognitive impairment in hospitalized older HF patients exceeds

future science group

Management considerations in the care of elderly heart failure patients in long-term care facilities 50%, often from delirium, in whom it is associated with a higher risk of readmission, institutionalization and death [32,33] . Delirium can result in psychosis, agitation and aggression, symptoms that can be mistakenly attributed to dementia, thus delaying HF diagnosis and treatment and exposing residents to the inappropriate use of psychotropic drugs or restraints [34] . In addition, HF is a risk factor for dementia [31] . HF patients with cognitive impairment are at increased risk of rehospitalization, functional decline and mortality [31] . Anxiety, depression, sleep disturbances and psychotropic drug use are common in HF patients and can be associated with functional decline, rehospitalization and mortality [15,35,36] . A key consequence of frailty in seniors with HF is the occurrence of nonspecific signs and symptoms that can confound the diagnosis of an HF exacerbation, and which have been associated with a delay in diagnosis and worse clinical outcomes [37] . The clinical features of HF are summarized in (Box 1) . Older patients with an HF exacerbation can present with its classical clinical features. However, some of these features are less specific in frail seniors than they are in younger patients. For example, lower limb edema can also reflect venous insufficiency, malnutrition, immobility or use of calcium channel blockers, and exertional dyspnea may be less common in sedentary persons [24] . Moreover, HF in frail seniors can also present with nonspecific geriatric syndromes such as delirium, falls, incontinence and other syndromes [24,37] . Clinicians must maintain a high index of suspicion for acute illnesses such as HF in frail seniors presenting with nonspecific signs and symptoms. In summary, HF in LTC residents is complicated by geriatric syndromes, leading to misdiagnosis, suboptimal prescribing, functional decline, acute care utilization and mortality. The diagnosis of HF The diagnosis of HF rests primarily on clinical assessment and is based on a history and physical examination. If available, plasma natriuretic peptides such as N-terminal probrain natriuretic peptide (NT-proBNP) and BNP can be useful, when the clinical diagnosis is in doubt, to rule out HF if they are normal, or to rule in HF when they are abnormal [24] . Data from the PRIDE study suggest that NT-proBNP may be associated with a lower false-positive rate (9%) than BNP (20%) in patients with HF with preserved


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Box 1. Clinical features of heart failure. Classical features of HF ●● Dyspnea ●● Orthopnea ●● Paroxysmal nocturnal dyspnea ●● Fatigue, weakness ●● Exercise intolerance ●● Lower extremity edema ●● Cough ●● Weight gain ●● Abdominal distension ●● Pulmonary rales/crackles Nonspecific features of HF in frail seniors

●● Delirium ●● New or worsening cognitive impairment ●● Falls ●● Sudden functional decline ●● Sleep disturbances ●● Incontinence, nocturia ●● Sacral edema ●● Cool extremities HF: Heart failure.

ejection fraction (HFPEF), and may therefore be the preferable assay to utilize [38] . A chest x-ray should be obtained looking for evidence of pleural effusions, vascular redistribution or interstitial or alveolar edema [24] . A normal ECG makes a diagnosis of HF unlikely, and while it is not specific for HF, it can identify the presence of underlying conditions such as IHD or arrhythmias that can exacerbate or precipitate HF [24] . Transthoracic echocardiography is the modality of choice to identify underlying functional and structural cardiac abnormalities that might predispose to HF, including assessing LVEF in order to guide appropriate pharmacotherapy (see ‘The management of chronic HF’ section); it should be performed in all patients with suspected HF. Routine hematological, renal, electrolyte and thyroid indices should be assessed to rule out factors contributing to the HF syndrome, or that could complicate its management. The diagnosis of HF in the LTC population can be challenging for a variety of reasons, including inadequate health information transfer upon LTC admission [39] , in addition to nonspecific clinical presentations [37] . A key barrier to the early diagnosis and/or treatment of HF is limited or absent health information about residents upon admission to LTC. A review of the evidence on care transitions between acute

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Review Heckman, Boscart & McKelvie care and LTC facilities identified four important obstacles to effective transitions, including poor communication between facilities, preventable declines in health status, inadequate discharge planning and gaps in care during the transfers to and from the acute care hospital [40] . These obstacles have been linked to serious adverse events, unmet patient needs and premature death. The GOLD-HF study assessed the value of clinical data upon admission to LTC when assessing a new resident for a possible prior HF diagnosis (Table 1) [39] . Of these, a history of HF provided by the patient or their family was most predictive. While seemingly self-evident, this finding reinforces the importance of obtaining a thorough history on new LTC residents, particularly in the context of poor communication of health information among care providers and settings. The second key barrier in diagnosing HF in LTC residents is related to nonspecific signs and symptoms (Box 1) . Clinicians must maintain a high index of suspicion for an acute medical condition when an LTC resident presents with a change in status. A complete history and physical examination should be conducted to assess any senior presenting with classical clinical features of HF, or the recent development of nonspecific signs and symptoms or geriatric syndromes. For most seniors, collateral information from an informal caregiver is essential [3] . The GOLD-HF study not only confirmed the specificity of individual classic HF symptoms but also emphasized their low sensitivity (Table 2) [39] . Ongoing analysis (unpublished) of these data also suggests that a key precursor of clinical events in LTC residents with HF is accelerated functional decline. These findings

are generally consistent with those of a systematic review [41] conducted to assess the accuracy of diagnosing HF with clinical features. This review pointed out that dyspnea was the only symptom with high sensitivity (89%), yet it had a poor specificity (51%). Clinical features with relatively high specificity included history of myocardial infarction (89%), orthopnea (89%), edema (72%), elevated jugular venous pressure (70%) and presence of a third or fourth heart sound (99%) [41] . The limitations of individual signs and symptoms in aiding a diagnosis of HF also reflect the presence of common comorbidities in frail seniors. Obesity, pulmonary disease, kyphoscoliosis from osteoporosis and deconditioning can contribute to dyspnea. Edema can result from cor pulmonale, malnutrition, chronic venous insufficiency, immobility, or medication side effects [24] . These data underline the importance of conducting a complete clinical assessment of persons suspected of having HF: no one sign or symptom is adequate. Once HF is diagnosed, it is important to determine the extent to which a resident’s functional capacity is impaired. This information can help follow patient progress and guide therapeutic choices. The New York Heart Association (NYHA) Functional Classification [42] is commonly used for this purpose, and comprises four classes based on the presentation of symptoms in relation to activity. While identifying patients with NYHA class I (no functional limitations) and NYHA class IV (symptoms at rest) can be relatively straightforward, the NYHA is less reliable among frail patients with HF, in whom differentiating between class II and class III patients is highly subjective and

Table 1. Elements of a long-term care admission history that are most predictive of an underlying diagnosis of heart failure. Clinical characteristic

AOR (95% CI)

p-value

13.66 (6.61–28.24) 2.01 (1.04–3.89) 1.76 (0.93–3.33)

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