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Congestive Heart Failure in the Elderly (CE)
CE Article Instructions to CE enrollees: The closed-book, multiple-choice examination that follows this article is designed to test your understanding of the educational objectives listed below. The answer form is on page 187. On completion of this article, the reader should be able to: 1. Describe the physiology of congestive heart failure in the elderly 2. Identify assessment parameters for elderly clients with congestive heart failure 3. Discuss nursing management of clients with congestive heart failure
Congestive Heart Failure in the Elderly Mickey Stanley, RN, PhD, C
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Abstract: Congestive heart failure is a complex disease that is complicated by the normal changes that accompany aging. The medical profession has learned a great deal about managing this disease in the past decade. However, the challenge remains for the nursing profession to help individuals and their families live with this chronic, debilitating disease. We must be prepared to coordinate the complex array of services needed, educate the elder to an acceptable level of understanding, counsel regarding end-of-life issues, and encourage all elders to remain active in an effort to help these fragile individuals retain the quality in their life until the end of life. (Geriatr Nurs 1999;20:180-6)
A
s we approach the new millennium, advances in the diagnosis and treatment of heart disease are evident. Thrombolytic agents have revolutionized the treatment of acute myocardial infarction, resulting in the preservation of myocardial muscle for many patients and a reduction in the number of deaths each year from heart disease. With this reduced death toll, however, has come an increase in the number of individuals living with chronic cardiac conditions, primarily congestive heart failure (CHF). Recent statistics reveal that CHF is the most common reason for hospital admissions among the elderly, accounting for 1 million admissions annually at a cost of approximately $10 billion.1 CHF increasingly is noted as the admitting or secondary diagnosis for transitional care units, home health care, and long-term care (LTC) as well. Although CHF has been described in the medical literature for more than 200 years, the results of many current research studies are allowing for improved symptom management, survival, and quality of life for older adults. We now can appreciate that CHF is a complex medical condition complicated by normal aging. Management of the older adult with CHF must take into consideration the normal aging changes and the developmental changes associated with aging, psychosocial responses to illness, family dynamics, and numerous other factors that affect the older adult’s ability to engage in self-care. Nurses in every phase of health care must remain up to date on the latest information to provide the comprehensive management required for older adults with CHF.
lar wall, which leaves the aging heart less capable of distention with a less-effective contractile force. The aortic and mitral valves also thicken and form ridges along the valve closure lines.2 Stiffness at the base of the aortic cusps prevents complete opening, resulting in a partial obstruction to blood flow during systole. This obstructed blood flow provides the basis for the systolic ejection murmur commonly found in the elderly. Incomplete ventricular emptying may occur during times of increased heart rate (eg, fever, stress, and exercise) and compromise coronary artery and systemic circulation. With advanced age, the aorta and peripheral arterial system become stiff and twisted. These changes result from an increase in collagen fibers and a loss of elastic fibers in the middle layer of the artery. The intimal (innermost) layer of the artery thickens with increased calcium deposits.3 This age-related process of increasing stiffness and thickness is known as arteriosclerosis. As a compensatory mechanism, the aorta and other major arteries progressively dilate to receive a greater volume of blood.4 The veins stretch and dilate in a similar fashion. The venous valves may become incompetent or fail to close completely owing to their dilated state.
Table 1. Normal Age-Related Changes in the Cardiovascular System Age-related Changes
Clinical Implications
Left ventricle thickens
Decreased contractile force
Valves thicken and form ridges
Impaired flow across valves, systolic ejection murmur
Pacemaker cells decrease
Dysrhythmia, bradycardia, sick sinus syndrome
Arteries dilate, become stiff
Decreased baroreceptor response, poor tolerance of extremes of heat and cold
Veins dilate, valves deteriorate
Edema in lower extremities
NORMAL AGING The aging process can best be represented as a gradual process of decline. The rate of decline varies with the individual, being more rapid in sedentary people and slower in active individuals. Both structural and functional changes of aging account for this process of decline. Structural changes. The most noticeable structural change in the heart is the thickening of the left ventricu-
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Adapted from Stanley M. The cardiovascular system and its problems in the elderly. In: Stanley M, Beare PG, editors. Gerontological nursing. 2nd ed. Philadelphia: FA Davis Publishers; 1999.
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Functional changes. From a functional or performance point of view, the primary age-related change in the cardiovascular system is a reduced ability to increase output in response to an increased demand. The heart In recent years, functions closer to its physiological limit clinical research under usual circumstances, leaving little has shown physiological reserve. The young heart meets increased demand that a major an for oxygenated blood primarily by increasing pathophysiologic the heart rate, but the older heart cannot inprocess in heart crease the rate when the need arises. failure involves the The principal mechanism used by the aged renin-angiotensin heart to increase cardiac output is an insystem (RAS). This creased end-diastolic volume, which in turn stroke vollatest information increases ume (known as Starling’s law). 3,4 If the provides the basis filling time is inadequate (as in tachycarfor the use of dia) or the ventricles become overdistended angiotensin- (as in heart failure), this mechanism may converting enzyme fail. The symptoms of dyspnea and fatigue (ACE) inhibitors occur when the heart cannot provide the with an adequate to treat CHF. body supply of oxygenated blood to meet the demand or when metabolic waste products cannot be effectively removed. Table 1 lists the common age-related changes in the cardiovascular system and their clinical implications.
HEART FAILURE: ETIOLOGY AND CLINICAL DIAGNOSIS Heart failure is a set of clinical signs and symptoms that follow injury to or dysfunction of the myocardium. Heart failure is characterized by symptoms of volume overload, such as shortness of breath, rales and edema, or manifestations of inadequate tissue perfusion, such as fatigue or poor exercise tolerance.1 Numerous disease processes can produce heart failure in the elderly, includ-
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ing hyperthyroidism, anemia, alcohol abuse, hypertension, valvular abnormalities, rapid fluid administration, and infectious and inflammatory processes.5,6 The most common cause of heart failure in the elderly, however, is coronary artery disease.7 Determining the cause of failure and correcting any treatable underlying processes (such as hyperthyroidism) is essential for long-term management. Heart failure may occur in the form of diastolic or systolic dysfunction. Distinguishing between these two forms is important because of differences in pharmacologic management. The diastolic form of failure is characterized by a stiff left ventricle that cannot fill adequately with normal filling pressures, which results in a decreased left ventricular end-diastolic volume and a normal to elevated ejection fraction. Although the percentage of blood ejected with each contraction is normal, the total volume of blood being propelled around the body is decreased as a result of the ventricles’ decreased ability to fill during diastole.8 Systolic dysfunction is the most common form of heart failure in the elderly. This form of failure is the picture of chronic volume overload with a distended left ventricle, which results in an elevated left ventricular end-diastolic volume and a decreased ejection fraction.8 Once again, the total volume of blood sent to the body is inadequate to meet its metabolic needs. Early descriptions of the pathophysiology of heart failure focused on the heart’s inability to adequately pump blood to the major organs, resulting in volume expansion and edema. Based on this understanding, treatment included digitalis glycosides and loop diuretics. Later work revealed that the primary symptoms of dyspnea and fatigue were not merely related to the failing heart but also resulted from increased tone in the pulmonary and peripheral blood vessels. As a result, vasodilators were added.9 In recent years, clinical research has shown that a major pathophysiologic process in heart failure involves the renin-angiotensin system (RAS).10 This latest information provides the basis for the use of angiotensin-converting enzyme (ACE) inhibitors to treat CHF.
MANAGEMENT OF HEART FAILURE CHF is a chronic, debilitating disease that often goes undiagnosed in the elderly until it has progressed to advanced stages. The early warning signs of fatigue and dyspnea on exertion often are attributed to the aging process, and the elder adapts his or her activity levels to accommodate the increasing dysfunction. Assessment. Given the frequency of the problem in the elderly population, all caregivers must be alert to its signs and symptoms. Careful assessment techniques can provide important clues. For example, weight gain unrelated to dietary intake often is the first noticeable sign
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of CHF. A weekly weight chart is a helpful strategy for nurses in all types of settings. The presence of edema can be a confusing symptom in the elderly because of this symptom’s multiple causes. The type of edema associated with CHF is bilateral in nature and typically worse in the evening in the dependent areas of the body. The edema associated with malnutrition is found in all soft tissues and can be easily detected in the periorbital areas. The edema associated with venous stasis often is unilateral, seen as greater in one leg than the other. A simple technique that will reveal increasing volume overload is jugular venous pressure assessment when performed in a consistent manner at regular intervals. Ask the elderly patient to lie on his or her back with legs extended. Note the level at which the jugular veins are visible. Apply pressure to the abdomen or ask the elder to raise both legs together. Observe for a rise in the level of the jugular veins. This finding is called a positive hepatojugular reflex. If possible, measure the amount of change in centimeters. Advanced assessment techniques, such as distinguishing between third and fourth heart sounds, and observing for changes in the precordial pulse are helpful in monitoring disease progression.11 Clinicians should remember that the presence of crackles in the lungs or the chest radiograph are not sensitive measures of ventricle size or function in the elderly because of changes in the pulmonary skeleton and the difficulty of achieving a full expansion with inspiration.12 Functional assessment. Clinicians often fail to fully assess functional status in this group, although functional status repeatedly is identified as a significant predictor of outcomes for the elderly.13 Using functional assessment tools, such as the Index of Independence in Activities of Daily Living and the Instrumental Activities of Daily Living Scale, will provide objective data on which to base discharge planning decisions.14 Changes in functional status over time are also the most reliable indicators of worsening of the CHF1 and provide a realistic ongoing assessment measure. The tools are simple to use and should become a consistent portion of the assessment process for any older adult with heart failure. Noncompliance. One of the most common reasons for repeated hospitalizations of community-dwelling elders with CHF is noncompliance with the therapeutic plan.11 This failure to comply most often can be attributed to failure on the part of the practitioner to establish acceptable goals and follow through with the elder. It is essential from the beginning of the practitioner/patient relationship to establish trust and open communication by treating the elder with dignity and respect. Assume that the elder is capable of making decisions regarding treatment and is fully capable of learning and managing the therapeutic regimen. Significant others should be encouraged to participate in the patient’s
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Signs and Symptoms of CHF in the Elderly Changes in functional status Presence of a third heart sound Weight gain greater than 3 pounds + hepatojugular reflex Dyspnea on exertion Shift to the left of the precordial pulse Fatigue Rales (crackles in lung bases) Edema (generalized to dependent areas) Systolic dysfunction Increased left ventricular end diastolic volume Decreased ejection fraction Diastolic dysfunction Decreased left ventricular end diastolic volume Normal to elevated ejection fraction
treatment plan but not in an effort to usurp the elder’s rights and responsibilities. This approach should vary only at the request of the elder or in situations in which cognitive difficulties render the elder incapable.
NURSING MANAGEMENT CHF is a chronic, silent process that must be continually managed. The elder must understand that the established management plan is life-long. The goals of therapy include but are not limited to symptom relief. Quality-of-life issues are an equally important focus. Failure to adhere to the necessary components of the plan will result in decreased quality of life, repeated hospitalizations, nursing home placement, and premature death.15 The successful management of this complex condition can be achieved only with the active participation of the elder. Studies frequently point to the issues of inadequate preparation for discharge, support systems, and follow-up as the key predictors of readmission to an acute care facility for an elder with CHF.11 Many social issues impair an elder’s ability to fully comply with recommended therapy. Such issues as inadequate finances to purchase needed medications, lack of transportation to appointments, and lack of a safe place to exercise are barriers to compliance. Elders frequently are unaware of available resources and require assistance to find ways to remove these barriers. A critical role for the nurse is to determine the cause of noncompliance and address each issue to the elder’s satisfaction. Developmental tasks. The developmental tasks associated with old age—ego integrity versus despair— may be complicated by the onset of a chronic disabling condition, such as CHF. Elders frequently find them-
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selves in need of assistance with many activities of daily living. At times they can feel they are a burden to family and friends as the disease process worsens and their dependence on others increases. Instead of being able to give of themselves, they are forced into a situation of being the passive recipient of care. Strategies to enhance the individual’s sense of selfworth and ego integrity include reminiscence and life review.16 Reviewing the accomplishments of a lifetime helps the elder put the current situation into perspective and view his or her position in the family structure as meaningful. Nurses can support the importance of this activity in LTC or home settings by encouraging family members to display photographs from the elder’s youth. Storyboards that depict the elder’s life and accomplishments help those in the enviAlthough many ronment to see him or her as someone who elders are eligible has made meaningful contributions to socifor in-home ety and is worthy of dignity and respect. Psychosocial reservices, their sponses to illness. Deis by far the acceptance of such pression most common psychosocial response to services may the process of decline in health and function represent a loss seen with CHF. Nurses must be alert to the of independence symptoms of this condition and make apand a threat to propriate treatment referrals. In addition, social their privacy. isolation may occur as a result of chronic fatigue and the problems associated with diuretic therapy. Elders need to be encouraged to maintain social activities. Attendance at religious services, family gatherings, and community events can help maintain a positive outlook on life and prevent feelings of hopelessness. Group activities that incorporate themes from earlier eras are enjoyed by most older adults and can be appropriate in a variety of settings, such as senior citizen centers or LTC facilities. Family dynamics. Coordination of services is an ongoing need for older adults with CHF because of the disabling effect that cardiac failure has on their functional abilities. Families frequently come to visit when acute exacerbations place the elder in the hospital. However, on-
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going arrangements frequently do not involve family members, many of whom do not live in the area or are unable to provide the ongoing support needed by the elder. In addition, the issue of acceptability of recommended services needs to be considered. Although many elders are eligible for in-home services, their acceptance of such services may represent a loss of independence and a threat to their privacy. It is important to discuss support services with the elder to determine his or her wishes and willingness to accept them. Helping elders identify and select from possible options allows them to maintain a sense of independence and promotes adherence to the recommended therapy. Education. Because of the chronic nature of CHF, education must form the cornerstone of the total patient management plan. Although the teaching process must be initiated in the hospital setting, the most appropriate environment for learning is in the elder’s own home. Many elders respond well to group programs, such as support groups, in which short presentations are given with ample opportunity for sharing among participants.17 Although frequent repetition is required, older adults have been shown capable of learning complex information, such as that required by the person with CHF. It is important to present small amounts of information at each session. Teaching sessions always should begin with what the elder wants to know or is concerned about at the time. Individuals or groups must be given the opportunity to discuss ways to apply the information to their current routine. The participants should be asked to discuss the obstacles to their ability to carry out the recommendations and then problem-solve around the identified barriers. Each subsequent session should begin with a progress report on success or failure with the earlier recommendations. Diet and alcohol. It is important not to be overly aggressive with diet restrictions in an elderly population. Many elders suffer from protein calorie malnutrition because of finances, loneliness, gastrointestinal disorders, and depression. Low serum albumin levels on admission even have been shown to be predictive of length of stay, readmission, and death for elders with CHF.14 Severe restrictions, such as a 2 g sodium diet or a low cholesterol diet, may further compromise health status rather than improve the heart condition. A moderate restriction of a 3 g sodium diet, which can be achieved by not adding salt at the table and avoiding salty foods, usually is sufficient unless the elder requires large doses of diuretics to control fluid status.12 Given the pervasive nature of malnutrition among the elderly and the importance of good nutrition to healing and health, nurses in all settings must be vigilant in their assessment of nutritional status and habits. Making a referral to the dietitian or Meals on Wheels program is not sufficient. What is placed before elders and what they actually consume may be dramatically
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different. Eating is as much a social event as it is a functional skill. Such strategies as providing the aroma of fresh-baked bread, creating a home-like atmosphere in the dining room of the LTC setting, or asking the inhome caregiver to sit down with the elder for meals may increase his or her appetite and ultimately improve the nutritional status. If the etiology of the CHF is related to alcohol, the recommendations clearly call for abstinence. Otherwise, elders can be advised to limit alcohol consumption to no more than one drink per day (30 mL of liquor or its equivalent in wine or beer).1,12
ACTIVITY Fatigue and exercise intolerance are the most frequent complaints offered by older adults with CHF, and fatigue has been found to increase as the disease process worsens.18 Although fatigue is a vague symptom often associated with aging, exercise intolerance associated with CHF may relate more to abnormalities in working muscles than to the changes in pulmonary capillary pressure. Reduced cardiac output and changes in skeletal muscle blood flow result in an increase in lactate production and the perception of fatigue. Recent studies have demonstrated that exercise training appears to improve vasodilation and muscle oxidative capacity. All older adults should be encouraged to remain as active as symptoms allow.19 A walking program is considered the best choice to help elders maintain muscle tone and flexibility and combat the physiological and psychologic damage of fatigue and inactivity.19 Mall walking programs are popular in urban areas because these settings provide the safety and environmental controls that are important to elders. In addition, public health departments, senior citizen centers, and LTC settings are demonstrating success with exercise classes. These age-appropriate classes frequently use videos or cassettes designed for older adults. A major portion of the class focuses on flexibility and may be completed while sitting in a chair. Follow-up. All elders should be taught to weigh themselves daily and report any gain of 2 pounds or more to the nurse or physician. Reports from around the country are showing that when elders with CHF receive prompt attention to signs of worsening failure (eg, unexpected weight gain) and treatment (typically an increased dose of their diuretic), an acute episode of failure can be avoided. Dracup et al.12 believe as many as half of all cardiac deaths will be sudden, and up to 25% of all deaths will occur without significant worsening of heart failure. It is imperative that elders be given accurate information regarding their disease process and its prognosis so that decisions can be reached as to their wishes for life-sustaining treatment before a crisis occurs. They should be encouraged to complete advance directives and assign a
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durable power of attorney for health care decisions. Family members also must be provided with accurate information about what to do in the event of sudden death. In the anxiety-filled minutes that surround these events, a call to emergency personnel will initiate a chain of events that may be contrary to the elder’s expressed wishes.
SUMMARY CHF is a complex disease that is complicated by the normal changes that accompany the aging process. As nurses we must understand not only the medical management but also the quality-of-life issues that are critical for these patients and their caregivers. REFERENCES 1. Konstam M, Dracup K, Baker D, et al. Heart failure: evaluation and care of patients with left-ventricular systolic dysfunction. Clinical Practice Guideline No. 11. AHCPR Publication No. 94-0612. Rockville (MD): Agency for Health Care Policy and Research, U.S. Department of Health and Human Services; 1994. 2. Tresch DD, Aronow WS. Clinical manifestations and diagnosis of coronary artery disease. Clin Geriatr Med 1996;12:89-99. 3. Gerber RM. Coronary artery disease in the elderly. J Cardiovasc Nurs 1990;4:23-6. 4. Stanley M. The cardiovascular system and its problems in the elderly. In: Stanley M, Beare PG, editors. Gerontological nursing. 2nd ed. Philadelphia: FA Davis Publishers; 1999. 5. Rich MW, Shah AS, Vinson JM, Freedland KE, Kuru T, Sperry JC. Iatrogenic congestive heart failure in older adults: clinical course and prognosis. J Am Geriatr Soc 1996;44:638-43. 6. Opasich C, Febo O, Riccardi G, Traversi E, Forni G, Pinna G, Pozzoli M. Concomitant factors of decompensation in chronic heart failure. Am J Cardiol 1996;78:354-7. 7. Hazzard WR. Cardiovascular disease. In: Hazzard WR, Bierman EL, Blass JP, Ettinger WH, Halter JB, editors. Principles of geriatric medicine and gerontology. 3rd ed. New York: McGraw-Hill; 1994. p. 517. 8. Stanley M. Clinical management of an old enemy: congestive heart failure in the elderly. AACN Clinical Issues: Advanced Practice in Acute and Critical Care 1997;8:616-26. 9. Packer M. How should physicians view heart failure? The philosophical and physiological evolution of three conceptual models of the disease. Am J Cardiol 1993;71:3C-11. 10. Cohn JN. The management of chronic heart failure. N Engl J Med 1996;335:490-7. 11. Vinson JM, Rich MW, Sperry JC, Shah AS, McNamara T. Early readmission of elderly patients with congestive heart failure. J Am Geriatr Soc 1990;38:1290-5. 12. Dracup K, Baker DW, Dunbar SB, Dacey RA, Brooks NH, Johnson JC, et al. Management of heart failure: counseling, education, and lifestyle modifications. JAMA 1994;272:1442-6. 13. Reiley P, Howard E. Predicting hospital length of stay in elderly patients with congestive heart failure. Nurs Economics 1995;13:210-6. 14. Lawton M, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179. 15. Bull MJ. Use of formal community services by elders and their family caregivers 2 weeks following hospital discharge. J Adv Nurs 1994;19:503-8. 16. Heriot C. Developmental tasks and development in later years of life. In: Stanley M, Beare P, editors. Gerontological nursing. 2nd ed. Philadelphia: FA Davis Publishers; 1999. 17. Herrmann FR, Safran C, Levkoff SE, Minaker KL. Serum albumin level of admission as a predictor of death, length of stay, and readmission. Arch Intern Med 1992;152:125-9. 18. Friedman MM, King KB. Correlates of fatigue in older women with heart failure. Heart Lung 1995;24:512-8. 19. Wenger NK. Physical inactivity and coronary heart disease in elderly patients. Clin Geriatr Med 1996;12:79-85.
MICKEY STANLEY, RN, PhD, CS, is an associate professor at Southern Illinois University in Edwardsville. Copyright © 1999 by Mosby, Inc. 0197-4572/99/$8.00 + 0
34/1/1094
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CE
Test I.D. No.: G1094 Contact hours: 1.5 Processing fee: $10 Passing score: 75% (twelve correct answers)
1. The aging process is: A. More rapid in sedentary people B. More rapid in people who socialize a lot C. Slower in sedentary quiet people D. Slower in optimistic, happy people 2. Which structural change was NOT identified as occurring with the aging process? A. Stiffness at the base of the aortic cusps B. Loss of elastic fibers in the artery C. Vasoconstriction to keep the blood pressure up D. Incomplete ventricular emptying 3. Symptoms of volume overload (heart failure) include the following EXCEPT: A. Fatigue B. Rales C. Hypoventilation D. Edema 4. What is the most common cause of heart failure in the elderly? A. Alcohol abuse B. Coronary artery disease C. Hypertension D. Poor diet 5. Heart failure as a result of diastolic dysfunction is exhibited by: A. Decreased left ventricular end diastolic volume, normal to increased ejection fraction B. Decreased left ventricular end diastolic volume, decreased ejection fraction C. Increased left ventricular end diastolic volume, decreased ejection fraction D. Increased left ventricular end diastolic volume, increased ejection fraction
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6. Heart failure as a result of systolic dysfunction is exhibited by: A. Decreased left ventricular end diastolic volume, normal to increased ejection fraction B. Decreased left ventricular end diastolic volume, decreased ejection fraction C. Increased left ventricular end diastolic volume, decreased ejection fraction D. Increased left ventricular end diastolic volume, increased ejection fraction 7. Edema around the periorbital areas most likely is associated with: A. Congestive heart failure B. Malnutrition C. Venous stasis D. ADH malfunction 8. Bilateral edema that becomes worse in the evening in dependent areas most likely is associated with: A. CHF B. Malnutrition C. Venous stasis D. ADH malfunction 9. Which assessment parameter would be LEAST likely to determine heart failure? A. Hepatojugular reflex B. Heart sounds C. Precordial pulse changes D. Crackles in the lungs
12. Key predictors of readmission to an acute care facility for an elder with CHF do NOT include: A. Inadequate discharge preparation B. Home environment that has stairs C. Poor support systems D. Poor follow-up 13. For an elder’s ability to comply with a discharge regimen, what social issues need to be addressed? A. Money to pay for medications B. Transportation to appointments C. Safe place to exercise D. All the above 14. When an elder needs more assistance with activities of daily living and is feeling like a burden, it is best to: A. Downplay or discount any need for assistance B. Withhold assistance to foster independence C. Reminisce about the elder’s life and valued accomplishments D. Ignore those comments and continue to help 15. To offset feelings of hopelessness, which of the following would be LEAST desirable? A. Antidepressive therapy B. Increased family interactions C. Attendance at social functions D. Increased group interactions
10. Which assessment parameter would be MOST likely to determine heart failure? A. Hepatojugular reflex B. Heart sounds C. Precordial pulse changes D. Crackles in the lungs 11. The most reliable indicator of worsening CHF is: A. Hepatojugular reflex B. Pitting edema C. Functional assessment changes D. Pulmonary congestion
16. When presenting educational information to the elder, what should be done first? A. Review the material that was covered in the last meeting B. Talk loudly C. Have written handouts D. Discuss his or her concerns first
Geriatric Nursing Volume 20, Number 4
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Congestive Heart Failure in the Elderly Mickey Stanley, RN, PhD, C
180
Geriatric Nursing Volume 20, Number 4
Abstract: Congestive heart failure is a complex disease that is complicated by the normal changes that accompany aging. The medical profession has learned a great deal about managing this disease in the past decade. However, the challenge remains for the nursing profession to help individuals and their families live with this chronic, debilitating disease. We must be prepared to coordinate the complex array of services needed, educate the elder to an acceptable level of understanding, counsel regarding end-of-life issues, and encourage all elders to remain active in an effort to help these fragile individuals retain the quality in their life until the end of life. (Geriatr Nurs 1999;20:180-6)
A
s we approach the new millennium, advances in the diagnosis and treatment of heart disease are evident. Thrombolytic agents have revolutionized the treatment of acute myocardial infarction, resulting in the preservation of myocardial muscle for many patients and a reduction in the number of deaths each year from heart disease. With this reduced death toll, however, has come an increase in the number of individuals living with chronic cardiac conditions, primarily congestive heart failure (CHF). Recent statistics reveal that CHF is the most common reason for hospital admissions among the elderly, accounting for 1 million admissions annually at a cost of approximately $10 billion.1 CHF increasingly is noted as the admitting or secondary diagnosis for transitional care units, home health care, and long-term care (LTC) as well. Although CHF has been described in the medical literature for more than 200 years, the results of many current research studies are allowing for improved symptom management, survival, and quality of life for older adults. We now can appreciate that CHF is a complex medical condition complicated by normal aging. Management of the older adult with CHF must take into consideration the normal aging changes and the developmental changes associated with aging, psychosocial responses to illness, family dynamics, and numerous other factors that affect the older adult’s ability to engage in self-care. Nurses in every phase of health care must remain up to date on the latest information to provide the comprehensive management required for older adults with CHF.
lar wall, which leaves the aging heart less capable of distention with a less-effective contractile force. The aortic and mitral valves also thicken and form ridges along the valve closure lines.2 Stiffness at the base of the aortic cusps prevents complete opening, resulting in a partial obstruction to blood flow during systole. This obstructed blood flow provides the basis for the systolic ejection murmur commonly found in the elderly. Incomplete ventricular emptying may occur during times of increased heart rate (eg, fever, stress, and exercise) and compromise coronary artery and systemic circulation. With advanced age, the aorta and peripheral arterial system become stiff and twisted. These changes result from an increase in collagen fibers and a loss of elastic fibers in the middle layer of the artery. The intimal (innermost) layer of the artery thickens with increased calcium deposits.3 This age-related process of increasing stiffness and thickness is known as arteriosclerosis. As a compensatory mechanism, the aorta and other major arteries progressively dilate to receive a greater volume of blood.4 The veins stretch and dilate in a similar fashion. The venous valves may become incompetent or fail to close completely owing to their dilated state.
Table 1. Normal Age-Related Changes in the Cardiovascular System Age-related Changes
Clinical Implications
Left ventricle thickens
Decreased contractile force
Valves thicken and form ridges
Impaired flow across valves, systolic ejection murmur
Pacemaker cells decrease
Dysrhythmia, bradycardia, sick sinus syndrome
Arteries dilate, become stiff
Decreased baroreceptor response, poor tolerance of extremes of heat and cold
Veins dilate, valves deteriorate
Edema in lower extremities
NORMAL AGING The aging process can best be represented as a gradual process of decline. The rate of decline varies with the individual, being more rapid in sedentary people and slower in active individuals. Both structural and functional changes of aging account for this process of decline. Structural changes. The most noticeable structural change in the heart is the thickening of the left ventricu-
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Adapted from Stanley M. The cardiovascular system and its problems in the elderly. In: Stanley M, Beare PG, editors. Gerontological nursing. 2nd ed. Philadelphia: FA Davis Publishers; 1999.
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Functional changes. From a functional or performance point of view, the primary age-related change in the cardiovascular system is a reduced ability to increase output in response to an increased demand. The heart In recent years, functions closer to its physiological limit clinical research under usual circumstances, leaving little has shown physiological reserve. The young heart meets increased demand that a major an for oxygenated blood primarily by increasing pathophysiologic the heart rate, but the older heart cannot inprocess in heart crease the rate when the need arises. failure involves the The principal mechanism used by the aged renin-angiotensin heart to increase cardiac output is an insystem (RAS). This creased end-diastolic volume, which in turn stroke vollatest information increases ume (known as Starling’s law). 3,4 If the provides the basis filling time is inadequate (as in tachycarfor the use of dia) or the ventricles become overdistended angiotensin- (as in heart failure), this mechanism may converting enzyme fail. The symptoms of dyspnea and fatigue (ACE) inhibitors occur when the heart cannot provide the with an adequate to treat CHF. body supply of oxygenated blood to meet the demand or when metabolic waste products cannot be effectively removed. Table 1 lists the common age-related changes in the cardiovascular system and their clinical implications.
HEART FAILURE: ETIOLOGY AND CLINICAL DIAGNOSIS Heart failure is a set of clinical signs and symptoms that follow injury to or dysfunction of the myocardium. Heart failure is characterized by symptoms of volume overload, such as shortness of breath, rales and edema, or manifestations of inadequate tissue perfusion, such as fatigue or poor exercise tolerance.1 Numerous disease processes can produce heart failure in the elderly, includ-
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ing hyperthyroidism, anemia, alcohol abuse, hypertension, valvular abnormalities, rapid fluid administration, and infectious and inflammatory processes.5,6 The most common cause of heart failure in the elderly, however, is coronary artery disease.7 Determining the cause of failure and correcting any treatable underlying processes (such as hyperthyroidism) is essential for long-term management. Heart failure may occur in the form of diastolic or systolic dysfunction. Distinguishing between these two forms is important because of differences in pharmacologic management. The diastolic form of failure is characterized by a stiff left ventricle that cannot fill adequately with normal filling pressures, which results in a decreased left ventricular end-diastolic volume and a normal to elevated ejection fraction. Although the percentage of blood ejected with each contraction is normal, the total volume of blood being propelled around the body is decreased as a result of the ventricles’ decreased ability to fill during diastole.8 Systolic dysfunction is the most common form of heart failure in the elderly. This form of failure is the picture of chronic volume overload with a distended left ventricle, which results in an elevated left ventricular end-diastolic volume and a decreased ejection fraction.8 Once again, the total volume of blood sent to the body is inadequate to meet its metabolic needs. Early descriptions of the pathophysiology of heart failure focused on the heart’s inability to adequately pump blood to the major organs, resulting in volume expansion and edema. Based on this understanding, treatment included digitalis glycosides and loop diuretics. Later work revealed that the primary symptoms of dyspnea and fatigue were not merely related to the failing heart but also resulted from increased tone in the pulmonary and peripheral blood vessels. As a result, vasodilators were added.9 In recent years, clinical research has shown that a major pathophysiologic process in heart failure involves the renin-angiotensin system (RAS).10 This latest information provides the basis for the use of angiotensin-converting enzyme (ACE) inhibitors to treat CHF.
MANAGEMENT OF HEART FAILURE CHF is a chronic, debilitating disease that often goes undiagnosed in the elderly until it has progressed to advanced stages. The early warning signs of fatigue and dyspnea on exertion often are attributed to the aging process, and the elder adapts his or her activity levels to accommodate the increasing dysfunction. Assessment. Given the frequency of the problem in the elderly population, all caregivers must be alert to its signs and symptoms. Careful assessment techniques can provide important clues. For example, weight gain unrelated to dietary intake often is the first noticeable sign
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of CHF. A weekly weight chart is a helpful strategy for nurses in all types of settings. The presence of edema can be a confusing symptom in the elderly because of this symptom’s multiple causes. The type of edema associated with CHF is bilateral in nature and typically worse in the evening in the dependent areas of the body. The edema associated with malnutrition is found in all soft tissues and can be easily detected in the periorbital areas. The edema associated with venous stasis often is unilateral, seen as greater in one leg than the other. A simple technique that will reveal increasing volume overload is jugular venous pressure assessment when performed in a consistent manner at regular intervals. Ask the elderly patient to lie on his or her back with legs extended. Note the level at which the jugular veins are visible. Apply pressure to the abdomen or ask the elder to raise both legs together. Observe for a rise in the level of the jugular veins. This finding is called a positive hepatojugular reflex. If possible, measure the amount of change in centimeters. Advanced assessment techniques, such as distinguishing between third and fourth heart sounds, and observing for changes in the precordial pulse are helpful in monitoring disease progression.11 Clinicians should remember that the presence of crackles in the lungs or the chest radiograph are not sensitive measures of ventricle size or function in the elderly because of changes in the pulmonary skeleton and the difficulty of achieving a full expansion with inspiration.12 Functional assessment. Clinicians often fail to fully assess functional status in this group, although functional status repeatedly is identified as a significant predictor of outcomes for the elderly.13 Using functional assessment tools, such as the Index of Independence in Activities of Daily Living and the Instrumental Activities of Daily Living Scale, will provide objective data on which to base discharge planning decisions.14 Changes in functional status over time are also the most reliable indicators of worsening of the CHF1 and provide a realistic ongoing assessment measure. The tools are simple to use and should become a consistent portion of the assessment process for any older adult with heart failure. Noncompliance. One of the most common reasons for repeated hospitalizations of community-dwelling elders with CHF is noncompliance with the therapeutic plan.11 This failure to comply most often can be attributed to failure on the part of the practitioner to establish acceptable goals and follow through with the elder. It is essential from the beginning of the practitioner/patient relationship to establish trust and open communication by treating the elder with dignity and respect. Assume that the elder is capable of making decisions regarding treatment and is fully capable of learning and managing the therapeutic regimen. Significant others should be encouraged to participate in the patient’s
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Signs and Symptoms of CHF in the Elderly Changes in functional status Presence of a third heart sound Weight gain greater than 3 pounds + hepatojugular reflex Dyspnea on exertion Shift to the left of the precordial pulse Fatigue Rales (crackles in lung bases) Edema (generalized to dependent areas) Systolic dysfunction Increased left ventricular end diastolic volume Decreased ejection fraction Diastolic dysfunction Decreased left ventricular end diastolic volume Normal to elevated ejection fraction
treatment plan but not in an effort to usurp the elder’s rights and responsibilities. This approach should vary only at the request of the elder or in situations in which cognitive difficulties render the elder incapable.
NURSING MANAGEMENT CHF is a chronic, silent process that must be continually managed. The elder must understand that the established management plan is life-long. The goals of therapy include but are not limited to symptom relief. Quality-of-life issues are an equally important focus. Failure to adhere to the necessary components of the plan will result in decreased quality of life, repeated hospitalizations, nursing home placement, and premature death.15 The successful management of this complex condition can be achieved only with the active participation of the elder. Studies frequently point to the issues of inadequate preparation for discharge, support systems, and follow-up as the key predictors of readmission to an acute care facility for an elder with CHF.11 Many social issues impair an elder’s ability to fully comply with recommended therapy. Such issues as inadequate finances to purchase needed medications, lack of transportation to appointments, and lack of a safe place to exercise are barriers to compliance. Elders frequently are unaware of available resources and require assistance to find ways to remove these barriers. A critical role for the nurse is to determine the cause of noncompliance and address each issue to the elder’s satisfaction. Developmental tasks. The developmental tasks associated with old age—ego integrity versus despair— may be complicated by the onset of a chronic disabling condition, such as CHF. Elders frequently find them-
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selves in need of assistance with many activities of daily living. At times they can feel they are a burden to family and friends as the disease process worsens and their dependence on others increases. Instead of being able to give of themselves, they are forced into a situation of being the passive recipient of care. Strategies to enhance the individual’s sense of selfworth and ego integrity include reminiscence and life review.16 Reviewing the accomplishments of a lifetime helps the elder put the current situation into perspective and view his or her position in the family structure as meaningful. Nurses can support the importance of this activity in LTC or home settings by encouraging family members to display photographs from the elder’s youth. Storyboards that depict the elder’s life and accomplishments help those in the enviAlthough many ronment to see him or her as someone who elders are eligible has made meaningful contributions to socifor in-home ety and is worthy of dignity and respect. Psychosocial reservices, their sponses to illness. Deis by far the acceptance of such pression most common psychosocial response to services may the process of decline in health and function represent a loss seen with CHF. Nurses must be alert to the of independence symptoms of this condition and make apand a threat to propriate treatment referrals. In addition, social their privacy. isolation may occur as a result of chronic fatigue and the problems associated with diuretic therapy. Elders need to be encouraged to maintain social activities. Attendance at religious services, family gatherings, and community events can help maintain a positive outlook on life and prevent feelings of hopelessness. Group activities that incorporate themes from earlier eras are enjoyed by most older adults and can be appropriate in a variety of settings, such as senior citizen centers or LTC facilities. Family dynamics. Coordination of services is an ongoing need for older adults with CHF because of the disabling effect that cardiac failure has on their functional abilities. Families frequently come to visit when acute exacerbations place the elder in the hospital. However, on-
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going arrangements frequently do not involve family members, many of whom do not live in the area or are unable to provide the ongoing support needed by the elder. In addition, the issue of acceptability of recommended services needs to be considered. Although many elders are eligible for in-home services, their acceptance of such services may represent a loss of independence and a threat to their privacy. It is important to discuss support services with the elder to determine his or her wishes and willingness to accept them. Helping elders identify and select from possible options allows them to maintain a sense of independence and promotes adherence to the recommended therapy. Education. Because of the chronic nature of CHF, education must form the cornerstone of the total patient management plan. Although the teaching process must be initiated in the hospital setting, the most appropriate environment for learning is in the elder’s own home. Many elders respond well to group programs, such as support groups, in which short presentations are given with ample opportunity for sharing among participants.17 Although frequent repetition is required, older adults have been shown capable of learning complex information, such as that required by the person with CHF. It is important to present small amounts of information at each session. Teaching sessions always should begin with what the elder wants to know or is concerned about at the time. Individuals or groups must be given the opportunity to discuss ways to apply the information to their current routine. The participants should be asked to discuss the obstacles to their ability to carry out the recommendations and then problem-solve around the identified barriers. Each subsequent session should begin with a progress report on success or failure with the earlier recommendations. Diet and alcohol. It is important not to be overly aggressive with diet restrictions in an elderly population. Many elders suffer from protein calorie malnutrition because of finances, loneliness, gastrointestinal disorders, and depression. Low serum albumin levels on admission even have been shown to be predictive of length of stay, readmission, and death for elders with CHF.14 Severe restrictions, such as a 2 g sodium diet or a low cholesterol diet, may further compromise health status rather than improve the heart condition. A moderate restriction of a 3 g sodium diet, which can be achieved by not adding salt at the table and avoiding salty foods, usually is sufficient unless the elder requires large doses of diuretics to control fluid status.12 Given the pervasive nature of malnutrition among the elderly and the importance of good nutrition to healing and health, nurses in all settings must be vigilant in their assessment of nutritional status and habits. Making a referral to the dietitian or Meals on Wheels program is not sufficient. What is placed before elders and what they actually consume may be dramatically
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different. Eating is as much a social event as it is a functional skill. Such strategies as providing the aroma of fresh-baked bread, creating a home-like atmosphere in the dining room of the LTC setting, or asking the inhome caregiver to sit down with the elder for meals may increase his or her appetite and ultimately improve the nutritional status. If the etiology of the CHF is related to alcohol, the recommendations clearly call for abstinence. Otherwise, elders can be advised to limit alcohol consumption to no more than one drink per day (30 mL of liquor or its equivalent in wine or beer).1,12
ACTIVITY Fatigue and exercise intolerance are the most frequent complaints offered by older adults with CHF, and fatigue has been found to increase as the disease process worsens.18 Although fatigue is a vague symptom often associated with aging, exercise intolerance associated with CHF may relate more to abnormalities in working muscles than to the changes in pulmonary capillary pressure. Reduced cardiac output and changes in skeletal muscle blood flow result in an increase in lactate production and the perception of fatigue. Recent studies have demonstrated that exercise training appears to improve vasodilation and muscle oxidative capacity. All older adults should be encouraged to remain as active as symptoms allow.19 A walking program is considered the best choice to help elders maintain muscle tone and flexibility and combat the physiological and psychologic damage of fatigue and inactivity.19 Mall walking programs are popular in urban areas because these settings provide the safety and environmental controls that are important to elders. In addition, public health departments, senior citizen centers, and LTC settings are demonstrating success with exercise classes. These age-appropriate classes frequently use videos or cassettes designed for older adults. A major portion of the class focuses on flexibility and may be completed while sitting in a chair. Follow-up. All elders should be taught to weigh themselves daily and report any gain of 2 pounds or more to the nurse or physician. Reports from around the country are showing that when elders with CHF receive prompt attention to signs of worsening failure (eg, unexpected weight gain) and treatment (typically an increased dose of their diuretic), an acute episode of failure can be avoided. Dracup et al.12 believe as many as half of all cardiac deaths will be sudden, and up to 25% of all deaths will occur without significant worsening of heart failure. It is imperative that elders be given accurate information regarding their disease process and its prognosis so that decisions can be reached as to their wishes for life-sustaining treatment before a crisis occurs. They should be encouraged to complete advance directives and assign a
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durable power of attorney for health care decisions. Family members also must be provided with accurate information about what to do in the event of sudden death. In the anxiety-filled minutes that surround these events, a call to emergency personnel will initiate a chain of events that may be contrary to the elder’s expressed wishes.
SUMMARY CHF is a complex disease that is complicated by the normal changes that accompany the aging process. As nurses we must understand not only the medical management but also the quality-of-life issues that are critical for these patients and their caregivers. REFERENCES 1. Konstam M, Dracup K, Baker D, et al. Heart failure: evaluation and care of patients with left-ventricular systolic dysfunction. Clinical Practice Guideline No. 11. AHCPR Publication No. 94-0612. Rockville (MD): Agency for Health Care Policy and Research, U.S. Department of Health and Human Services; 1994. 2. Tresch DD, Aronow WS. Clinical manifestations and diagnosis of coronary artery disease. Clin Geriatr Med 1996;12:89-99. 3. Gerber RM. Coronary artery disease in the elderly. J Cardiovasc Nurs 1990;4:23-6. 4. Stanley M. The cardiovascular system and its problems in the elderly. In: Stanley M, Beare PG, editors. Gerontological nursing. 2nd ed. Philadelphia: FA Davis Publishers; 1999. 5. Rich MW, Shah AS, Vinson JM, Freedland KE, Kuru T, Sperry JC. Iatrogenic congestive heart failure in older adults: clinical course and prognosis. J Am Geriatr Soc 1996;44:638-43. 6. Opasich C, Febo O, Riccardi G, Traversi E, Forni G, Pinna G, Pozzoli M. Concomitant factors of decompensation in chronic heart failure. Am J Cardiol 1996;78:354-7. 7. Hazzard WR. Cardiovascular disease. In: Hazzard WR, Bierman EL, Blass JP, Ettinger WH, Halter JB, editors. Principles of geriatric medicine and gerontology. 3rd ed. New York: McGraw-Hill; 1994. p. 517. 8. Stanley M. Clinical management of an old enemy: congestive heart failure in the elderly. AACN Clinical Issues: Advanced Practice in Acute and Critical Care 1997;8:616-26. 9. Packer M. How should physicians view heart failure? The philosophical and physiological evolution of three conceptual models of the disease. Am J Cardiol 1993;71:3C-11. 10. Cohn JN. The management of chronic heart failure. N Engl J Med 1996;335:490-7. 11. Vinson JM, Rich MW, Sperry JC, Shah AS, McNamara T. Early readmission of elderly patients with congestive heart failure. J Am Geriatr Soc 1990;38:1290-5. 12. Dracup K, Baker DW, Dunbar SB, Dacey RA, Brooks NH, Johnson JC, et al. Management of heart failure: counseling, education, and lifestyle modifications. JAMA 1994;272:1442-6. 13. Reiley P, Howard E. Predicting hospital length of stay in elderly patients with congestive heart failure. Nurs Economics 1995;13:210-6. 14. Lawton M, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179. 15. Bull MJ. Use of formal community services by elders and their family caregivers 2 weeks following hospital discharge. J Adv Nurs 1994;19:503-8. 16. Heriot C. Developmental tasks and development in later years of life. In: Stanley M, Beare P, editors. Gerontological nursing. 2nd ed. Philadelphia: FA Davis Publishers; 1999. 17. Herrmann FR, Safran C, Levkoff SE, Minaker KL. Serum albumin level of admission as a predictor of death, length of stay, and readmission. Arch Intern Med 1992;152:125-9. 18. Friedman MM, King KB. Correlates of fatigue in older women with heart failure. Heart Lung 1995;24:512-8. 19. Wenger NK. Physical inactivity and coronary heart disease in elderly patients. Clin Geriatr Med 1996;12:79-85.
MICKEY STANLEY, RN, PhD, CS, is an associate professor at Southern Illinois University in Edwardsville. Copyright © 1999 by Mosby, Inc. 0197-4572/99/$8.00 + 0
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CE
Test I.D. No.: G1094 Contact hours: 1.5 Processing fee: $10 Passing score: 75% (twelve correct answers)
1. The aging process is: A. More rapid in sedentary people B. More rapid in people who socialize a lot C. Slower in sedentary quiet people D. Slower in optimistic, happy people 2. Which structural change was NOT identified as occurring with the aging process? A. Stiffness at the base of the aortic cusps B. Loss of elastic fibers in the artery C. Vasoconstriction to keep the blood pressure up D. Incomplete ventricular emptying 3. Symptoms of volume overload (heart failure) include the following EXCEPT: A. Fatigue B. Rales C. Hypoventilation D. Edema 4. What is the most common cause of heart failure in the elderly? A. Alcohol abuse B. Coronary artery disease C. Hypertension D. Poor diet 5. Heart failure as a result of diastolic dysfunction is exhibited by: A. Decreased left ventricular end diastolic volume, normal to increased ejection fraction B. Decreased left ventricular end diastolic volume, decreased ejection fraction C. Increased left ventricular end diastolic volume, decreased ejection fraction D. Increased left ventricular end diastolic volume, increased ejection fraction
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6. Heart failure as a result of systolic dysfunction is exhibited by: A. Decreased left ventricular end diastolic volume, normal to increased ejection fraction B. Decreased left ventricular end diastolic volume, decreased ejection fraction C. Increased left ventricular end diastolic volume, decreased ejection fraction D. Increased left ventricular end diastolic volume, increased ejection fraction 7. Edema around the periorbital areas most likely is associated with: A. Congestive heart failure B. Malnutrition C. Venous stasis D. ADH malfunction 8. Bilateral edema that becomes worse in the evening in dependent areas most likely is associated with: A. CHF B. Malnutrition C. Venous stasis D. ADH malfunction 9. Which assessment parameter would be LEAST likely to determine heart failure? A. Hepatojugular reflex B. Heart sounds C. Precordial pulse changes D. Crackles in the lungs
12. Key predictors of readmission to an acute care facility for an elder with CHF do NOT include: A. Inadequate discharge preparation B. Home environment that has stairs C. Poor support systems D. Poor follow-up 13. For an elder’s ability to comply with a discharge regimen, what social issues need to be addressed? A. Money to pay for medications B. Transportation to appointments C. Safe place to exercise D. All the above 14. When an elder needs more assistance with activities of daily living and is feeling like a burden, it is best to: A. Downplay or discount any need for assistance B. Withhold assistance to foster independence C. Reminisce about the elder’s life and valued accomplishments D. Ignore those comments and continue to help 15. To offset feelings of hopelessness, which of the following would be LEAST desirable? A. Antidepressive therapy B. Increased family interactions C. Attendance at social functions D. Increased group interactions
10. Which assessment parameter would be MOST likely to determine heart failure? A. Hepatojugular reflex B. Heart sounds C. Precordial pulse changes D. Crackles in the lungs 11. The most reliable indicator of worsening CHF is: A. Hepatojugular reflex B. Pitting edema C. Functional assessment changes D. Pulmonary congestion
16. When presenting educational information to the elder, what should be done first? A. Review the material that was covered in the last meeting B. Talk loudly C. Have written handouts D. Discuss his or her concerns first
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