Management of Heart Failure in the Oldest Residents in a Continuing Care Retirement Community
Heart failure (HF) is an increasingly common condition in older adults and can be challenging to manage, especially in the oldest geriatric patients who have poor functional reserve and multiple comorbidities. Constant medical supervision and an interdisciplinary approach to medical management is often required. We present a case series highlighting an approach to clinical management of the oldest residents with HF, utilizing resources in a continuing care retirement community.
Key words: heart failure, elderly, long-term care, continuing care retirement community
Chronic medical conditions like heart failure (HF) are very common in older adults. With the population aging, the prevalence of HF is increasing exponentially with rates ranging from 4.9% to 14.7% in adults 60 years old and older compared with prevalence rates of 0.2% to 1.9% in younger age groups.1,2 HF is often regarded as the end stage of other cardiac diseases such as hypertension, coronary artery disease, valvular dysfunction, or various cardiomyopathies and is also one of the major causes of morbidity and death in older adults.2,3 In the elderly population, patients with both preserved (diastolic) and reduced systolic function are seen in equal frequency and have a similar prognosis.4 In spite of this, life expectancy in the United States has increased two-fold in the last century,5,6 and people are living better, healthier lives. Nonagenarians and centurions with very productive and fulfilling lives are now commonplace in society, mostly due to the significant medical advances over the years.
Several models of long-term care (LTC), such the continuing care retirement community (CCRC) model, can help promote lifelong care7,8 and provide a means to achieve consistent medical management as residents get older and their chronic conditions progress. Geriatricians, however, are often faced with the challenge of managing HF in elderly patients in conjunction with other chronic medical problems as well, such as osteoarthritis, chronic pulmonary diseases, chronic kidney disease (CKD), and diabetes mellitus. These comorbidities further complicate LTC delivery and can potentially lower patients’ quality of life.
We report a case series representing the oldest geriatric patients with systolic HF in conjunction with complex medical issues and outline an approach to clinical management of this condition, utilizing resources in a CCRC to promote symptom control and elevate quality of life.
Management Strategies
The CCRC model of geriatric care greatly facilitates a multidisciplinary approach to medical management. This is invaluable in the management of HF, which often involves disciplines such as nursing, dietary, physical and occupational therapists, social work, and medicine.
Three main strategies were utilized in optimally managing these medically complex patients with HF: medication management, close clinical supervision, and cardiology co-management.
Medication Management
Medications such as angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and diuretics are key components of medical treatment for all patients with HF due to reduced left ventricular systolic function. Often, these agents have to be used with caution and close monitoring in the elderly, because adverse effects such as hypotension, hypovolemia, and electrolyte imbalance are common.
In the three cases presented (see Case Vignettes 1-3), all three patients had systolic HF and were treated with the above medications. For optimal diuresis, the dosage of furosemide, a loop diuretic, was titrated with careful monitoring of electrolytes and kidney function. Also, the addition of metolazone, a thiazide diuretic, was necessary after optimal dose titration of furosemide in all three patients to achieve optimal diuresis. This is a widely accepted treatment strategy to overcome diuretic resistance in patients with acute decompensated HF,9 but this had to be done very cautiously. Such caution was warranted in our patients, who incidentally also had CKD and developed acute kidney injury with electrolyte imbalance such as hypokalemia. Dosage increments of metolazone were added at the rate of a low dose (2.5 mg) per week to the diuretic regimen, with concomitant daily monitoring of weight, blood pressure (BP), and blood electrolytes. We favor using metolazone and furosemide mainly because of cost, but other loop or thiazide diuretics could be combined with similar effect. This is also preferable to other diuretic regimens such as intravenous loop diuretics, which are invasive and often cumbersome in LTC patients by limiting daily activities.10
Close Clinical Supervision
For our patients, the clinical structure of the CCRC made it possible to provide close clinical supervision, so we could monitor daily weight and BP, and conduct frequent laboratory testing (electrolytes and kidney function) depending on diuretic dosage titration. The clinical supervision was especially necessary because of the patients’ advanced age and the presence of several comorbidities such as CKD in these patients. This was done across the spectrum of care in the different sections of the CCRC, including the nursing home (NH) and independent sections. In addition, we maintained the continuity of patient care by monitoring these patients while in the different care sections, enabling our patients to maintain their normal daily routine and quality of life. Our patients were seen frequently in the onsite geriatrician/nurse practitioner (NP) clinic with weekly appointments initially, upon discharge from the NH section of the CCRC, then extended to every 2 weeks, and then monthly as the patient’s condition stabilized.
Cardiology Co-management
In addition to the geriatrician/NP health team, each patient also had an off-site cardiologist whom we consulted as necessary and maintained appropriate communication by providing updates of the patients’ condition. Each patient also was assessed in-person by the cardiologist every 4 to 6 months. This multidisciplinary approach with effective interaction between different health disciplines is of critical importance for improving clinical outcomes, such as quality of life, and reducing hospitalization rates in elderly patients with HF.11
Challenges
While the clinical structure of the CCRC enabled us to provide effective medical management, there were some limitations in ensuring consistent monitoring of these patients. For instance, in obtaining consistent daily weights, we had to make sure that patients were weighed with the same weight scale and at a consistent time each day so as to avoid variations in weight that can occur over the course of the day and by using different scales. This was addressed through staff education and assigning specific nursing aides to obtain weights. Also, one of our patients, Mr Y, declined weights and BP monitoring on the weekends as it interfered with his weekend routine, so we made accommodations to monitor him only during the week and adjusted his medications accordingly (Case Vignette 2). Overall, we were able to provide consistent and comprehensive medical care for these patients, making it possible for them to have adequate symptom control and good quality of life.
Conclusion
The very elderly with severe HF represent a special challenge to care providers. Our clinical experience specifically focuses on those patients with reduced systolic function. Specific challenges can include any one or all of the fundamental aspects of care. Because many of these patients live in a setting that prevents the salt content of their diet from being controlled, salt and fluid restrictions are not realistic.
Regarding medications, many of the studies that we use to guide therapy have a paucity of data in patients over the age 75, though we still utilize this data to guide treatment in the very elderly. The best course of therapy, as outlined above, is always to start treatment at a low dose and escalate slowly if possible. The patients presented above highlight the particular value and role of carefully dosed and monitored diuretics to improve symptoms. The burden for frequent monitoring fell on the geriatrics team (consisting of a geriatrician and NP), which was critical for safety and success.
Finally, because many of these patients have chronic comorbid conditions, they will eventually die, and many due to noncardiac illnesses. Because many of these patients have implantable cardiac defibrillators implanted, it is important to be able to guide patients and their families through the final process of living through the partnership between geriatrics and cardiology. It is critical to be able to frankly discuss when it is appropriate to disable the shock functions of these devices and make comfort the first priority.
1. van Riet EE, Hoes AW, Wagenaar KP, Limburg A, Landman MA, Rutten FH. Epidemiology of heart failure: the prevalence of heart failure and ventricular dysfunction in older adults over time. A systematic review. Eur J Heart Fail. 2016;18(3):242-252.
2. Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics – 2010 update: a report from the American Heart Association. Circulation. 2010;121(7):e46–e215.
3. Kochanek KD, Murphy SL, Xu JQ, Arias E. Mortality in the United States, 2013. NCHS data brief, no 178. Hyattsville, MD: National Center for Health Statistics. 2014.
4. Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med. 2006;355(3):251-259.
5. Arias E. United States Life Tables, 2011. National Vital Statistics Reports. 2015;64(11):1-63. http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_11.pdf. Accessed September 4, 2016.
6. Besdine R, Boult C, Brangman S, et al. Caring for older Americans: the future of geriatric medicine. J Am Geriatr Soc. 2005;53(suppl 6):S245-S256.
7. Gaines JM, Poey JL, Marx KA, Parrish JM, Resnick B. Health and medical services use: a matched case comparison between CCRC residents and national health and retirement study samples. J Gerontol Soc Work. 2011;54(8):788-802.
8. Bynum JP, Andrews A, Sharp S, McCollough D, Wennberg JE. Fewer hospitalizations result when primary care is highly integrated into a continuing care retirement community. Health Aff (Millwood). 2011;30(5):975-984.
9. Moranville MP, Choi S, Hogg J, Anderson AS, Rich JD. Comparison of metolazone versus chlorothiazide in acute decompensated heart failure with diuretic resistance. Cardiovasc Ther. 2015;33(2):42-49.
10. Ng TM, Konopka E, Hyderi AF, et al. Comparison of bumetanide- and metolazone-based diuretic regimens to furosemide in acute heart failure. J Cardiovasc Pharmacol Ther. 2013;18(4):345-353.
11. Del Sindaco D, Pulignano G, Minardi G, et al. Two-year outcome of a prospective, controlled study of a disease management programme for elderly patients with heart failure. J Cardiovasc Med (Hagerstown). 2007;8(5):324-329.
