Heart failure in the elderly

Heart failure is the most common reason for hospitalization among older adults in the USA, and impacts five million people. Most people with heart failure are elderly, but in older people the management of the disease is complicated by comorbid conditions. Common problems in the elderly, such as dementia, frailty and depression, are more common in the elderly heart failure population. This review discusses an approach to identifying and managing these problems while managing heart failure. A suggested approach to older people with heart failure addresses the screening and integration of common geriatric problems into heart failure care.     

Guidelines for the diagnosis and management of heart failure

Heart failure has reached epidemic proportions. Five million Americans have been diagnosed with heart failure, and this number is expected to double within the next 30 years. One million patients are hospitalized annually with decompensated heart failure, and half will be readmitted for recurrent symptoms within 6 months. Heart failure primarily affects the elderly and is the most common reason for hospitalization in this age group. The prognosis for heart failure is poor, worse than most malignancies. Heart failure accounts for 280,000 deaths annually, and the 5-year survival rate is less than 50% despite multiple therapeutic advances. Poor survival may be attributed in part to poor application of evidence-based heart failure therapies and patient noncompliance. This review describes current guidelines for diagnosing and managing patients with heart failure.     

Management of heart failure in elderly people

AIMS: To review currently available knowledge on presentation, clinical features and management of heart failure (HF) in elderly people. METHODS: To review currently available evidence, we performed a thorough search of several evidence-based sources of information, including Cochrane Database of Systematic Reviews, Clinical Evidence, Evidence-based guidelines from National Guidelines Clearinghouse and a comprehensive MEDLINE search with the MeSH terms: 'heart failure', 'elderly' and 'management'. RESULTS: A number of features of ageing may predispose elderly people to HF, and may impair the ability to respond to injuries. Another hallmark of elderly patients is the increasing prevalence of multiple coexisting chronic conditions and geriatric syndromes that may complicate the clinical presentation and evolution of HF. Although diagnosis may be challenging, because atypical symptoms and presentations are common, and comorbid conditions may mimic or complicate the clinical picture, diagnostic criteria do not change in elderly people. Drug treatment is not significantly different from that recommended in younger patients, and largely remains empiric, because clinical trials have generally excluded elderly people and patients with comorbid conditions. Disease management programmes may have the potential to reduce morbidity and mortality for patients with HF. CONCLUSIONS: Heart failure is the commonest reason for hospitalisation and readmission among older adults. HF shows peculiar features in elderly people, and is usually complicated by comorbidities, presenting a significant financial burden worldwide, nevertheless elderly people have been generally excluded from clinical trials, and thus management largely remains empiric and based on evidence from younger age groups.     

Development of an end-of-life care pathway for patients with advanced heart failure in a community setting

Chronic heart failure affects around 750000 people per year in the UK. Despite the development of evidence-based treatments the 1-year survival rate is poorer than for many common cancers. Quality of life is poor, with breathlessness, peripheral oedema and fatigue being common symptoms. Through clinical audit a community heart failure nurse identified that the palliative care needs of patients with advanced heart failure were not being adequately addressed in his locality. A more cohesive way of managing these patients was required. Joint working between heart failure and palliative care clinicians as well as the development of an advanced heart failure shared care pathway and supporting tools resulted in patients with heart failure having improved access to palliative care, more of these patients dying in their preferred place of care, and the provision of a holistic heart failure service spanning referral to end of life. The impact of chronic heart failure on both individual patients and the NHS is considerable. With interdisciplinary and interorganisational collaboration, a new approach to managing patients with heart failure has been developed that has resulted in improved patient care.     

Characteristics of the chronic heart failure in the elderly

Chronic heart failure (CHF) in the elderly is a significant healthcare problem. Nearly half of CHF in this age group is diastolic heart failure with preserved left ventricular ejection fraction. However there is the limitation of the evidence-based therapy for this important group of patients. In this article, the treatments for the diastolic heart failure recommended in the ACC/AHA guidelines for the CHF (1998, 2001, 2005 versions) are described and common problems regarding the diagnosis and management of CHF in the elderly is also discussed. Furthermore, the recent topics about the treatment of diastolic heart failure are presented.     

Ongoing work of older adults at home after hospitalization

This paper describes the hospital-to-home transition process as experienced by elderly people with a medical diagnosis of congestive heart failure Qualitative data were collected in semi-structured interviews with a sample of 25 older adults within 2 weeks following discharge Constant comparative data analysis procedures were used The findings suggest that at 2 weeks post-hospitalization, the situation could be described as tentative The core variable for this study was conceptualized as 'a tentative situation', characterized by three key processes ups and downs associated with managing the illness, caregiver issues, and quality of life challenges These elders were in need of a post-hospital plan which provided them with ongoing information, additional resources and supportive assistance To emphasize the changing, uncertain nature of this chronic illness, and the necessity of the health care team developing an ongoing plan of care with the client and family, the trajectory was graphed using the trajectory phasing scheme as described by Corbin & Strauss The changing nature of congestive heart failure in these participants is noted as well as the need for a continuum of care     

Functional Limitation and Disability Associated with Congestive Heart Failure

Congestive heart failure (CHF) is a common and increasing problem among older persons. Symptoms associated with CHF include edema, fatigue, dyspnea, limited exercise tolerance, and significant activity limitation. Using a comprehensive review of literature, this article describes the public health burden arising out of CHF in the United States. It describes CHF in terms of functional limitation and disability in the elderly following the National Center for Medical Rehabilitation and Research (NCMRR) disability model. The use of home based interventions (HBI) to assist people with CHF is discussed.     

Advanced heart failure: impact on older patients and informal carers

AIM: This paper reports a study exploring the impact of advanced heart failure on the lives of older patients and their informal carers. BACKGROUND: Prognosis is poor in heart failure, with more than a third of patients dying within 12 months of diagnosis, and end-of-life symptoms are distressing and poorly controlled. Although end-of-life care for people with heart failure has received increased attention in recent years, there are still few data on the impact of advanced heart failure on the lives of patients and their informal carers. METHODS: Focused interviews were conducted with 10 older people with advanced heart failure and their nominated informal carer identified from one district general hospital in the United Kingdom (UK). Joint interviews were conducted with patients and carers in their own home. Thematic analysis was used to identify themes and subthemes. FINDINGS: Heart failure affected all aspects of the lives of patients and carers and, in particular, curtailed everyday activities. Patients were very concerned about the 'burden' their illness placed on their carer, who in all cases was their partner, although carers did not conceptualize the situation in this way. The socially isolating influence of the condition on both patients and carers was compounded by lack of professional input, and confusion about diagnosis was evident. Concerns about the future were common and, although few participants reported having been explicitly told about their prognosis, many made realistic statements about their limited life expectancy. CONCLUSIONS: This older cohort of people suffering from heart failure appears to have needs not unlike those of patients with 'terminal diseases'. When people are diagnosed with more familiar terminal illnesses, in particular cancer, they are given ongoing explanations, reassurance and support. Similar professional input is needed for patients with advanced heart failure and their carers.     

Elderly patients in the emergency department.

Emergency department nursing care of the older individual requires a specific knowledge base to ensure optimal outcomes. Health-care resource utilization specific to elderly patients in the emergency department and selected common health problems that bring older people to the emergency department are described. Distinctions between normal age-related changes and disease signs and symptoms are explained to provide emergency department nurses with the requisite information to care for the elderly appropriately.     

Evaluation and management of geriatric depression in primary care

Geriatric depression is a common but frequently unrecognized or inadequately treated condition in the elderly population. Manifestations of major depression in elderly persons may hinder early detection; anxiety, somatic complaints, cognitive impairment, and concurrent medical and neurologic disorders are more frequent. Like major depression, minor depression, which is often ignored, produces morbidity for elderly persons. Both major and minor depression are associated with high mortality rates if left untreated. This article reviews the important aspects of geriatric depression for the nonpsychiatric clinician: the etiology of depressive conditions in the elderly population, the unique clinical features of depression in older people, important evaluation considerations in a population with many medical and neurologic comorbidities, and the nonpharmacological and pharmacological treatment options for managing depression in the geriatric population.     

Atrial fibrillation among older adults: pathophysiology, symptoms, and treatment

Atrial fibrillation is the most common arrhythmia among older adults. Valvular heart disease, dilated cardiomyopathy, aortic stenosis, hypertension, coronary artery disease, pericarditis, thyrotoxicosis, pulmonary disease, cardiac surgery, alcohol excess, and alcohol withdrawal are associated with atrial fibrillation. Nurses caring for older adults need to understand the condition's pathophysiology, signs and symptoms, diagnostic data and treatment protocols, and adherence issues to prevent the formation of emboli in chronic atrial fibrillation and to understand treatment of this common arrhythmia. This article presents an individual example of an elderly man exhibiting a new onset of atrial fibrillation and the interventions required to manage the associated complications. Atrial fibrillation places patients at risk for stroke from a thromboembolism; thus, pharmacological and nonpharmocological care strategies for managing patients with atrial fibrillation are discussed.     

HEART FAILURE IN THE ELDERLY PATIENT

SUMMARY Both prevalence and incidence of heart failure rise with age. Diagnosis of heart failure in the older patient may be difficult because of atypical symptoms or the acceptance of symptoms as manifestations of old age. Heart failure is not a diagnosis but a syndrome. Echocardiograms should be obtained in most elderly patients to aid diagnosis and assessment. Loop diuretics, taking into account the altered homoeostasis of old age and presence of co-morbidity, are the mainstay of symptomatic treatment. ACE inhibitors are likely to benefit survival, although formal trials have failed to include many older patients. Digoxin and direct vasodilators are less well tolerated in elderly patients.     

Dialysis in Older Patients

Older persons with chronic uremia tolerate hemodialysis or a renal transplant as well as younger patients. However, this is not true in acute renal failure. One of the most distressing problems during hemodialysis in elderly patients with acute uremia is aspiration pneumonitis with respiratory arrest. Most problems with dialysis for patients past age 50 are related to illnesses more common in older persons.     

Living with chronic heart failure: a review of qualitative studies of older people

Title. Living with chronic heart failure: a review of qualitative studies of older people Aim. This paper is a report of a systematic review of qualitative studies of how older people live with chronic heart failure. Background. Chronic heart failure is a global epidemic mainly affecting an ageing population. Understanding how older people live with this disease is important to help promote their adjustment to the distressing illness experience. Data sources. Eligible studies published in 1997–2007 were identified from several databases (Medline, CINAHL, PsycINFO and Sociological Abstracts). A manual search was conducted of bibliographies of the identified studies and relevant journals. Review methods. Two researchers independently reviewed the studies and extracted the data. Key concepts from the papers were compared for similarities and differences. The transactional model of stress was used to guide data synthesis. Findings. Fourteen qualitative studies were identified. Most described the illness experiences of older people with chronic heart failure and associated coping strategies. There was some emerging work exploring the adjustment process. The findings indicated that living with chronic heart failure was characterized by distressing symptoms, compromised physical functioning, feelings of powerlessness and hopelessness, and social and role dysfunction. There were gender differences in the way the disease was conceived. Adjustment required patients to make sense of the illness experience, accept the prognosis, and get on with living with the condition. Conclusion. Empowering older people to manage chronic heart failure, instilling hope and bolstering support system are means of promoting successful adjustment to the disease. Further research needs to explore the cultural differences in the adjustment process.     

Caregiver self‐efficacy for managing behavioural problems of older people with dementia in Taiwan correlates with care receivers’ behavioural problems

Aims and objective. To investigate the relationship between family caregivers’ self‐efficacy for managing behavioural problems of older people with dementia and their behavioural problems in Taiwan. Background. Older people with dementia commonly have at least one behavioural problem, which caregivers complain is difficult to handle. To provide interventions that can help caregivers more effectively manage the behavioural problems of care receivers with dementia, caregivers’ self‐efficacy on managing behavioural problems must be assessed. However, it is not clear yet how these behavioural problems of older people with dementia may influence caregivers’ self‐efficacy for managing behavioural problems. Design. A prospective, correlational study. Method. Eighty dyads of older people with dementia and their family caregivers were recruited from neurological clinics of a medical centre in Taiwan. Care receivers were assessed for behavioural problems using the Chinese version of Cohen‐Mansfield Agitation Inventory, community form. Caregivers’ self‐efficacy for managing care receivers’ agitation was measured by the research team‐developed Agitation Management Self‐Efficacy Scale. Results. Caregiver self‐efficacy for managing behavioural problems was significantly and positively associated with more caregiver education, greater duration of caregiving and with care receivers’ less physically non‐aggressive behaviours. When caregiver characteristics were controlled for in hierarchical regression analysis, physically non‐aggressive behaviours explained 6% of the variance in caregiver self‐efficacy. Conclusions. Results of this study contradict the general belief that physically aggressive behaviours of elders with dementia are more difficult for family caregivers to handle than other behavioural problems. Clinicians need to address physically non‐aggressive problem behaviours. Relevance to clinical practice. Nurses could assess older patients with dementia for physically non‐aggressive behaviours and train less educated caregivers to improve their self‐efficacy for managing problem behaviours, thus enhancing the quality of life for both caregivers and care receivers.     

Challenges in nursing adults with congenital heart disease

Heart failure is a growing problem and is commonly associated with an older population. A proportion of young people also have heart failure. These patients are quite rarely seen but are increasing in number, and heart failure nurses need to ensure that when these patients present in clinic they have an understanding of their differing needs in comparison with older cardiac patients.     

A new look at heart failure

Heart failure is the number one hospital admission for the elderly and a leading client population for home care with numbers expected to rise steadily during the next decade. This article discusses systolic and diastolic heart failure, compensatory mechanisms, pathophysiology, and the signs and symptoms of right and left-sided heart failure. The most current treatment regimen for managing the heart failure patient in the home including medication, diet, activity, and patient education is presented.     

Cultural diversity in heart failure management: findings from the DISCOVER study (Part 2)

Self-management is a critical dimension in managing chronic conditions, particularly in heart failure (HF). Knowledge, attitudes and beliefs, relating to both illness and wellness, are strongly influenced by culture and ethnicity, impacting upon an individual's capacity to engage in self-care behaviours. Effective management of HF is largely dependent on facilitation of culturally informed, self-care behaviours to increase adherence to both pharmacological and non-pharmacological strategies. The Understanding the cultural experiences of individuals with chronic heart failure (CHF) in South East Health (DISCOVER) study is an exploratory, observational study investigating health patterns, information needs and the adjustment process for overseas-born people with HF living in Australia. An integrative literature review was augmented by qualitative data derived from key informant interviews, focus groups and individual interviews. A key finding of this study is that culture provides an important context to aid interpretations of attitudes, values, beliefs and behaviours, not only in illness but in health. While individual differences in attitudes and beliefs were observed among participants, common themes and issues were identified across cultural groups. Data from the DISCOVER study revealed the primacy of family and kinship ties. These relationships were important in making decisions about treatment choices and care plans. Participants also revealed the critical role of the 'family doctor' in assisting people and their families in brokering the health care system. In this study, heart disease was considered to be a significant condition but cancer was the condition that people both feared and dreaded the most, despite the high mortality rates of HF. This sample reported that religious and traditional beliefs became more important as people aged and considered their mortality. As HF is predominately a condition of ageing, the information derived from this study will assist clinicians to tailor health care service delivery for older people with HF, across multiple ethnic backgrounds.     

Heart failure and weight gain monitoring

Heart failure is one of the most common diagnoses of the elderly in the United States. The nursing literature has demonstrated that nursing interventions aimed at effective discharge planning and appropriate self-care activities can improve outcomes for patients hospitalized with heart failure. The purpose of this research was to identify, through retrospective medical record review, the discharge instruction related to self-weight monitoring provided to a sample of heart failure patients. The patients in the sample were 65 years and older with an ICD-9 diagnostic code of heart failure upon discharge from an acute care hospital in the Midwest. Results demonstrated the lack of nursing attentiveness to teaching self-monitoring weight gain to heart failure patients while hospitalized and the need for more comprehensive planning for appropriate discharge referrals. Suggestions are made for expanding documentation tools to improve nursing discharge planning and case management to ensure that the patient or caregiver is able to carry out self-care activities at home.