Heart Failure in the Critically ill Older Patient

Heart Failure in the Critically ill Older Patient

Heart failure (HF) is a clinical syndrome that usually develops after sufficient myocardial cell damage has occurred to impair ventricular contractility or relaxation. To maintain tissue and organ viability, the neurohumoral axis is activated. Neurohumoral activation is adaptive initially; however, with time, sustained neurohumoral activation produces symptomatic and progressive HF. There is no cure for HF, although with recent advances in treatment, prognosis can be improved, hospitalizations prevented, and quality of life enhanced. These improvements, however, are modest in most patients (Cleland et al., 2006; Koelling, Chen, Lubwama, L’Italien, & Eagle, 2004; Shahar & Lee, 2000).

In the 1980s through the 1990s, HF emerged as a significant public health threat that reached epidemic proportions (Garg, Packer, Pitt, & Yusuf, 1993; Ho, Anderson, Kannel, Grossman, & Levy, 1993; McMurray, Petrie, Murdoch, & Davie, 1998; O’Connell, 2000). Since that time, the prevalence of HF has increased (Ni, Nauman, & Hershberger, 1999), and it now afflicts more than 5 million people in the United States (Rosamond et al., 2008) and 30 million of the 1 billion people in the 47 countries represented by the European Society of Cardiology (McMurray & Stewart, 2002). The negative impact of HF is expected to worsen dramatically in coming years (Gambassi et al., 2000; Zannad et al., 1999), amid concerns that HF remains an unchecked epidemic (Butler & Kalogeropoulos, 2008; Fang, Mensah, Croft, & Keenan, 2008).
The worsening HF epidemic is thought to be the product of two major phenomena-the aging of the population and improved survival from the potentially deadly manifestations of cardiac disease (e.g., acute myocardial infarction, dysrhythmias, sudden cardiac death). Heart failure incidence increases dramatically with age (Ahmed, 2007; Thomas & Rich, 2007). This coupled with the rapidly rising number of elderly people in the United States and worldwide, along with increasing longevity will increase both incidence and prevalence of HF. Better treatment, and improved survival from acute cardiac events means that there are more individuals alive with damaged hearts who could later go on to develop HF, which is the final common pathologic endpoint for a number of cardiac conditions and cardiovascular risk factors (e.g., acute myocardial infarction, hypertension, diabetes). Against this backdrop, the purpose of this chapter is to provide an overview of the unique care needs of critically ill older adults hospitalized with HF. Many, if not most, hospitalizations for exacerbations of HF occur because of issues (e.g., failed self-care or inadequate use of evidence based therapies) related to management of the chronic heart failure patient in the outpatient setting. Critical care nurses are an important link in the chain of education and advocacy that results in better educated patients, and the provision of appropriate care by health care providers. Thus, a portion of this chapter concentrates on chronic outpatient management so as to provide the critical care nurse with the information needed to better educate patients and their families and to advocate for evidence based therapy.
Changes with Aging That Predispose Older Adults to Heart Failure
A number of factors associated with aging contribute to the higher incidence and prevalence of HF seen in elderly individuals. These include physiologic changes with aging, the higher incidence of hypertension and coronary artery disease with aging, and the higher rate of multiple comorbidities in elderly individuals (Table.1).

Table.1 Physiologic and Pathophysiologic Changes With Aging That Increase Susceptibility to Heart Failure

Physiologic or Pathophysiologic Change
Predisposition to Heart Failure
§  Normal aging
· Collagen deposition and degeneration of elastin in arterial walls leads to increased arterial stiffness
· Increased myocardial interstitial collagen deposition leads to myocardial stiffness
· Increased myocardial hypertrophy in response to increased afterload and increased myocardial apoptosis
· Reduced responsiveness to beta-adrenergic stimulation
· Impaired adenosine triphosphate production by mitochondria in response to increased demands
· Decreased nitric oxide production
§  Development of systolic hypertension, a major risk factor for heart failure
§  Increased left ventricular afterload that can increase cardiac work and reduce cardiac output
§  Alterations in left ventricular diastolic filling characterized by decreased early filling and augmented atrial contraction
§  Predisposition to diastolic heart failure and atrial fibrillation
§  Diminished ability to increase heart rate and contractility
§  Impaired beta2-mediated peripheral arterial vasodilation leads to increased afterload
§  Decreased ability to increase cardiac output with increased myocardial demand
§  Reduced peak coronary blood flow; endothelial dysfunction with increased development of atherosclerosis and myocardial ischemia
§  Increased incidence and prevalence of coronary artery disease
§  Increase in myocardial ischemia and infarction
§  Increased incidence and prevalence of age-associated cardiac disorders
§  Increase in valvular heart disease, dysrhythmias, hypertension
§  Coronary artery disease is one of the 2 major cause of heart failure, along with hypertension
§  Increased propensity for heart failure development, which is often multifactorial

§  Increased incidence and prevalence of comorbidities
§  Predisposition to coronary artery disease
§  Pulmonary, renal, hepatic, and gastrointestinal system changes reduce compensatory ability of these organ systems and predispose to fluid overload
§  Declining function of renal, pulmonary, hepatic, gastrointestinal systems
§  Altered pharmacokinetics and pharmaco dynamics predispose to toxicities and side effects

Cardiovascular Aging
Physiology and pathophysiology of aging are covered in depth in chapter 12 of this book. Changes in cardiovascular physiology with aging (Lakatta, 2002, 2003; Lakatta & Levy, 2003a, 2003b) that contribute specifically to development of HF are outlined in Table.1.
Briefly, aging is associated with an increase in collagen deposition and crosslinking in arterial walls, a change that predisposes one to increasing arterial stiffness. Aging also is associated with deterioration of elastin fibers in the arterial walls, a change that coupled with increasing collagen deposition, leads to increasing systolic blood pressure. These arterial changes also increase left ventricular afterload, putting increasing stress on the left ventricle. Elevated afterload along with myocardial collagen deposition produces myocardial stiffness. Myocardial stiffness is compounded by myocyte hypertrophy, which occurs to compensate for increasing afterload, myocardial stiffness, and an increase in myocyte apoptosis that occurs with aging. These changes alter diastolic function and provide one reason for the higher prevalence of HF with normal left ventricular ejection fraction seen in older adults.
Other changes that may contribute to the development of HF include a decrease in cardiac and vascular response to beta-adrenergic stimulation with increasing age. This change is associated with a decrease in peak contractility, maximal heart rate, and peripheral vasodilation. These alterations result in a decrease in attainable cardiac output meaning that elderly individuals have an attenuated ability to increase cardiac output when faced with increased demand.
Changes in endothelial function with aging can contribute to ischemia during periods of increased myocardial oxygen demand through two mechanisms. First, the production of nitric oxide decreases with aging, reducing maximum coronary blood flow, as nitric oxide is important for coronary vasodilation and coronary blood flow regulation. Second, endothelial dysfunction can contribute to atherosclerosis, increasing the risk for ischemia.
The changes in endothelial function, beta-adrenergic responsiveness, and arterial and myocardial stiffness produce a progressive decline in maximal cardiac performance and cardiac reserve. This decline in cardiac reserve can be substantial and makes elderly patients susceptible to the development of ADHF (acute decompensated heart failure). Moreover, ADHF develops more easily in the elderly compared to younger individuals in response to physical stressors (e.g., ischemia, volume overload, or surgery).
Comorbidities and Declining Function of Organ Systems
Given the adverse cardiovascular changes with aging noted previously, it is not surprising that the prevalence of cardiovascular disease increases with age. Ischemic heart disease and hypertension are the two most common causes of HF, and they often coexist in elderly individuals predisposing them to HF and ADHF.
The incidence of diabetes increases with age up to age 80, as does that of chronic obstructive pulmonary disease. Diabetes adversely affects endocrine and renal function, and promotes ischemic heart disease, which contributes to the development of HF and to ADHF. The presence of chronic obstructive pulmonary disease renders pulmonary compensation difficult when fluid overload occurs with ADHF.
In addition to adversely affecting the cardiovascular system, aging affects other systems. Renal function declines with age such that elderly individuals are more prone to fluid overload because the renal system is unable to handle excess fluid and sodium intake. Because of age-related declines in gastrointestinal, hepatic, and renal function, the pharmacokinetics and pharmacodynamics of most drugs are altered in elderly individuals and older adults are more susceptible to side effects and toxicities. Many factors that affect loading condition adversely (e.g., anemia, atrial fibrillation, and hypothyroidism) are more common among elders and predispose them to the expression of symptomatic HF.
In summary, multiple factors conspire to increase the incidence of HF, contribute to the development of ADHF, and render the management of elderly HF patients difficult. Understanding these factors provides perspective to clinicians caring for elderly patients as they work to reduce the increased morbidity and mortality seen in elderly HF patients.
Hospitalization for Heart Failure in Older Adults
Individuals 65 and older account for about 12% of the U.S. population, yet they are responsible for approximately 35% of hospital stays annually (Nagamine, Jiang, & Merrill, 2006). An acute exacerbation of chronic HF is the most common reason Medicare-aged individuals are hospitalized, and has been for at least the past 2 decades (Fang et al., 2008; Nagamine et al.; O’Connell, 2000; Schocken et al., 2008). Thus, most of the estimated $34 billion direct and indirect annual costs for HF (Rosamond et al., 2007) are a result of hospitalizations for acute decompensated HF (ADHF) in elders (Lee, Chavez, Baker, & Luce, 2004; Liao et al., 2006, 2007; Linne, Liedholm, Jendteg, & Israelsson, 2000). Hospitalizations among elderly individuals are thought to be responsible for more than 70% of these annual HF health care costs (Lee et al.). Largely as a result of these hospitalizations, health care costs are higher for elders with HF than for elders without HF (Liao et al.). Moreover, elders hospitalized for ADHF have a substantially higher mortality rate, and higher rehospitalization rates than younger patients hospitalized with ADHF. Since 1980, hospital admissions for HF have doubled (Miller & Missov, 2001). After being discharged from a hospitalization for decompensated HF, 27% of patients are readmitted within 90 days for recurrent HF, whereas 29% of these are readmitted more than once, and 6-month readmission rates across the United States average about 44 to 47% (Kimmelsteil & Konstam, 1995; Krumholz et al., 1997; Miller & Missov; Rosamond et al.). The increasing rates of hospitalization for HF among elders is of particular concern given the need of many elders for additional nursing care after discharge (Croft et al., 1997) and the high risk for rehospitalization and mortality among elderly individuals (Dar & Cowie, 2008).
Data from national registries in the United States (i.e., ADHERE[Acute Decompensated Heart Failure National Registry]) (Adams et al., 2005) and Europe (e.g., Euro Heart Failure Surveys) (Nieminen et al., 2006) demonstrate that the typical patient admitted for ADHF is older than 70 years of age, equally likely to be a man or woman, and has a history of HF, coronary artery disease, and hypertension (Dar & Cowie, 2008). On average in the United States, patients admitted with ADHF spend a total of about 5 days in the hospital and if admitted to an intensive care unit, they spend about 3 days there (Dar & Cowie). Longer length of stay in elderly HF patients is predicted by female gender and worse functional status (Formiga et al., 2008). Mortality in the hospital is about 4%, whereas it is 10% in the 30 days following discharge, and about 36% in the year following discharge (Dar & Cowie). Higher mortality rates are found in the elderly compared to younger patients. Other indicators of worse prognosis are renal insufficiency, lower hemoglobin level, and use of inotropes during the hospitalization (Dar & Cowie).
Acute Heart Failure Syndromes
Acute HF is commonly defined as the development of signs and symptoms of cardiac dysfunction that occur as a new presentation of HF or as an acute exacerbation of existing HF (Niemenen et al., 2005). It is useful for clinicians to remember that acute HF is not a homogeneous condition and for that reason, we usually refer to acute HF syndromes to describe the possible presentations and etiologies for ADHF. Hypertensive crisis, pulmonary edema, new acute HF, large myocardial infarction leading to cardiogenic shock, worsening chronic HF, and advanced/end-stage HF are all capable of presenting as acute HF. Of these, worsening chronic HF is the most common cause of hospitalizations in elderly individuals. Acute decompensated HF can be precipitated by a number of factors, including acute coronary syndrome, dysrhythmias, fluid overload, uncontrolled hypertension, nonadherence to prescribed medications or diet or other self-care activities, anemia, infection, pulmonary disease, ingestion of cardiac toxins, or thyroid abnormalities. Of these, the most common causes are acute coronary syndrome, nonadherence to the recommended medication and diet regimen, dysrhythmias—particularly atrial fibrillation, poorly controlled hypertension, and infection (Dar & Cowie, 2008).

Table 2. Symptoms and Signs That Suggest a Diagnosis of Acute Decompensated Heart Failure in Older Patients

§  Escalating dyspnea on exertion, orthopnea, and/or paroxysmal nocturnal dyspnea
§  Increasing fatigue, weakness, lethargy, anorexia, altered sensorium
§  Increasing edema, weight, or abdominal girth

§  Elevated jugular venous pressure
§  Edema
§  S3 or S4 heart sounds
§  Ascites
§  Tachycardia
§  Diffuse or laterally displaced point of maximal intensity
§  Rales
§  Tachypnea

Management of Acute Decompensated Heart Failure
Diagnosis of Acute Decompensated Heart Failure
Symptoms and Signs
Most patients with ADHFare admitted to the hospital from the emergency department, the most common place for elders to present with symptoms (Fonarow & Corday, 2004). Because HF is not a specific disease, but a clinical syndrome, there are no specific diagnostic criteria by which one can make a definitive diagnosis. A history of HF in a patient presenting with symptoms and signs of ADHF is strongly predictive of the diagnosis (Heart Failure Society of America [HFSA], 2006a), but ultimately, the diagnosis of ADHF is based largely on presenting signs and symptoms (Table 23.2) (Allen & O’Connor, 2007).
Dyspnea is the most common symptom of ADHF in both younger and older HF patients. The prevalence of dyspnea on exertion in ambulatory elders is as high as 95% in some studies and dyspnea at rest is present in up to 65% (Ahmed, 2007). Among hospitalized elders with ADHF, 90% have dyspnea at rest (Ahmed). The occurrence of this symptom also makes the diagnosis difficult as dyspnea is a common symptom of a number of respiratory conditions and, in the elderly, acute shortness of breath may also be a manifestation of myocardial ischemia and infarction, pneumonia, pulmonary embolism, or chronic lung disease. Increasing fatigue is another common symptom, but because of its vague nature and the accommodations that elders make when faced with such symptoms, its significance is often missed. The diagnosis of ADHF in elderly patients also is made more difficult because elderly patients present atypically more commonly than do younger patients. Atypical symptoms include confusion or worsening mental status, irritability, somnolence, and anorexia.
The hallmark signs of ADHF are jugular venous distension (the most specific sign of fluid overload in elders) (Ahmed, 2007), S3 gallop, and peripheral edema. In elderly HF patients, these signs can be present in ADHF, but they are also commonly present in other comorbid conditions seen in elders, making a definitive diagnosis of ADHF more difficult in the older adult. Increasing weight is a common sign, but one that is commonly ignored or not measured by patients and thus missed. Ascites and hepatomegaly may also be present with long-standing, severe fluid overload. Because HF with preserved ejection fraction is more common among elders (Ahmed), they may present with ADHF without elevated jugular venous pressure or an S3 gallop.
When uncertainty exists about the source of symptoms, measurement of plasma B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-pro-BNP) can assist in the determination of the cause of dyspnea (HFSA, 2006a). Although BNP levels rise with increasing age, thus reducing their specificity in elders (Omland, 2008), a normal value in an elderly patient who presents with dyspnea strongly suggests that ADHF is not the cause of the symptom. Although BNP levels are prognostic of outcomes in patients with ADHF, their diagnostic accuracy in the intensive care unit is reduced because many elderly patients in such units have comorbid conditions other than HF that can be associated with elevated BNP levels (i.e., hypoxia, renal failure, shock, and pulmonary hypertension) (Omland). Other diagnostic tools, such as chest radiography and echocardiography, that are useful in HF, have limitations that also must be considered when using them in elderly patients (Table 23.3).
Diagnostic Tests
Several routine diagnostic tests can assist in the evaluation and management of patients with ADHF (HSFA, 2006a). A chest radiograph is indicated to identify pulmonary congestion, the presence of cardiomegaly, and to rule out other causes of symptoms, such as pneumonia. An electrocardiogram and measurement of at least two sets of cardiac troponin are used to identify ongoing ischemia or new infarction as a cause of ADHF. A complete blood count is used to assess for anemia or infection, whereas serum electrolytes and routine blood chemistry are indicated to determine whether electrolyte imbalances or hyperglycemia are present. Liver and renal function tests will illuminate presence of comorbid liver or renal problems. Thyroid hormone and thyroid-stimulating hormone tests identify hyper- or hypothyroidism as factors contributing to ADHF. A urinalysis is helpful to screen for proteinuria or if there is reason to suspect a urinary tract infection. As discussed previously, BNP or NT-pro-BNP levels are helpful in making the diagnosis of ADHF when the cause of dyspnea is uncertain.

Table.3 Problems Reducing the Diagnostic Utility of Chest Radiography and Echocardiography in Elderly Acutely Ill Patients
Chest radiography
Reduced ability to obtain good-quality chest radiograph
§  patient confusion
§  poor inspiratory effort
§  kyphosis of the thoracic spine
Reduced ability to adequately interpret the film
§  presence of chronic lung disease
§  scarring
§  atelectasis
§  Normal heart size with diastolic heart failure
§  Presence of heart failure with preserved ejection fraction
§  Diastolic dysfunction with reversal of amplitude of early and late diastolic filling waves is also a characteristic of normal aging

Treatment Goals
Definition of therapeutic goals is essential in ADHF as the potential for harm or inadequate therapy is high if such goals are not considered during the treatment process. The two paramount goals in the treatment of ADHF are to (a) institute and (b) maintain evidence-based therapies that improve prognosis and enhance quality of life. A major step in achieving these goals in elderly HF patients and one that is often overlooked in the critically ill, is to return patients to their previous state (or to a higher state) of functioning. If this step is not achieved, elderly patients can experience a series of steady declines from each exacerbation that make subsequent exacerbations more likely, increase patients’ long-term dependence on others for care, and markedly reduce patients’ quality of life. The importance of increasing or maintaining quality of life among symptomatic elderly HF patients cannot be underestimated (Stanek, Oates, McGhan, Denofrio, & Loh, 2000).
Other important steps to achieving the major treatment goals in ADHF include improvement of symptoms and optimization of volume status. Factors precipitating decompensation should be identified and addressed. Chronic outpatient oral drug therapy should be reviewed and optimized. Although polypharmacy may be a necessity in elderly HF patients, careful review of elderly patients’ drug regimen by a clinician with expertise in geriatric pharmacology often can reduce the number of extraneous medications, associated adverse reactions, and patient difficulties with adherence (Rich et al., 1995; Rich, Gray, Beckham, Wittenburg, & Luther, 1996). A final vital step in achieving the treatment goals is beginning the vital process of patient and family/caregiver education and counseling and ensuring that it is continued once the patient is transferred out of the intensive care unit and out of the hospital.
In an attempt to operationalize the goals of treatment of ADHF, the European Society of Cardiology published the first set of guidelines devoted exclusively to the treatment of acute HF (Nieminen et al., 2005), although some other organizations have now addressed ADHFwithin their chronic HFguidelines (HFSA, 2006a). The European Society of Cardiology treatment goals were divided into several categories: clinical (reduce symptoms, signs, and body weight while determining underlying causes of ADHF); laboratory (normalize electrolytes, blood glucose, BNP, and decrease blood urea nitrogen or creatinine and total bilirubin); hemodynamic (decrease pulmonary artery occlusion pressure to <18 mmHg while increasing cardiac output); outcome (decrease intensive care unit and hospital length of stay, transition to an outpatient regimen that maintains clinical stability, and increase survival and time to readmission); and tolerability (low rate of withdrawal from therapeutic measures and low incidence of adverse effects).
The goals of therapy often are not met in elderly HF patients because of demands for quick turnaround of beds in hospitals, changes in the physician reimbursement system, lack of continuity of care, and time constraints (Fonarow, 2003; Riegel & Moser, 2008). For all of these reasons, it is not uncommon for clinicians to fail to make the coordinated effort necessary to identify and manage the underlying cause of the exacerbation or to undertake all of the necessary steps to optimize patient outcomes.
This failure can lead to inadequate management and discharge of elderly patients while they are still highly vulnerable to readmission (Moser, Doering, & Chung, 2005).
Because the management of ADHF is driven by an episodic, acute care view, attention to all of the details of care necessary to achieve optimal outcomes in elderly HF patients may seem out of the realm of responsibility for nurses caring for critically ill patients. Yet, as the first clinicians to see and manage these patients, nurses have the responsibility to advocate for comprehensive care. Use of a transitional care model that (see chapter 6) acknowledges the chronicity of HF, the need for continuity of care, and employs a case management approach by advanced practice nurses caring for elderly HF patients has been found to be quite effective in avoiding these failures (Naylor et al., 1999). Other successful models of care through which the goals of therapy are met for elderly HF patients include multidisciplinary HF disease management models (Blue et al., 2001; Stewart & Horowitz, 2002; Stromberg et al., 2003). In a meta-analysis of 29 trials of a variety of multidisciplinary management strategies, specially trained HF nurses were identified as one of three crucial elements that should be included to improve patient outcomes (McAllister, Stewart, Ferrua, & McMurray, 2004).
Monitoring Patients’ Progress During Hospitalization
Fluid overload (from a variety of sources) is a common cause of ADHF, and monitoring fluid status in hospitalized patients is essential to properly determine progress in meeting therapeutic goals. The Heart Failure Society of America guidelines recommend monitoring daily weights, fluid balance, renal function, and electrolyte status to assess the effectiveness and potential negative consequences of diuresis (HFSA, 2006a). Possibly because monitoring of fluid status has become so routine, the importance of these data tend to be overlooked by clinicians, and some clinicians express skepticism about the value of weights in monitoring fluid status. In a recent study, Chaudhry and associates demonstrated the strong predictive value for hospitalization of weight gain in the week prior to a hospitalization for ADHF (Chaudhry, Wang, Concato, Gill, & Krumholz, 2007). Moreover, data from thousands of patients enrolled in an acute heart failure registry, ADHERE (Acute Decompensated Heart Failure National Registry), demonstrate that fewer than 50% of patients experience a substantial weight loss ( = 5 pounds) during their hospitalization (Fonarow & Corday, 2004). Thus, attention to daily monitoring of fluid status is warranted and deserves attention from clinicians.
A daily cardiovascular examination is indicated and it is important to assess for improvement in the signs and symptoms that brought the patient to the hospital. Although the clinical signs show improvement at a faster rate than do patients’ subjective symptoms, patients are still quite capable of detecting changes in their symptom status on a daily basis and such subjective assessments need to be monitored (Allen et al., 2008). Heart failure symptoms are often not extensively evaluated in the hospital because patients remain relatively inactive. As a consequence, clinicians only assess symptoms at rest. Encouraging patients to walk in the hall and assessing their symptoms during or after this activity provides an opportunity for appropriate evaluation of symptoms. Assessing symptoms while patients are walking may lead to more aggressive management of fluid status during acute care and thereby reduce some of the undertreatment of fluid overload and early readmissions seen, particularly among elders.
Recent evidence suggests that using serial measurements of BNP or N-terminal prohormone B-type natriuretic peptide (NT-pro-BNP) to guide therapy, particularly in the hospitalized patient, may result in earlier discharge and better assessment of a patient’s readiness for discharge (Disomma et al., 2008; Gallegos, Maclaughlin, & Haase, 2008; Masson et al., 2008; Miller Hartman, Grill, Burnett, & Jaffe, 2009; Valle et al., 2008). Although a definitive recommendation awaits the results of ongoing large randomized trials of use of serial BNP or NT-pro-BNP to tailor therapy, evidence to date suggests that prognosis is worse in patients whose BNP or NT-pro-BNP fails to decrease with therapy during hospitalization and that outcomes may be improved in patients whose therapy is guided using serial measurements of either of these neurohormones.
Management of ADHF is commonly guided by the results of an assessment of patients’ hemodynamic presentation, that is, are they fluid overloaded or not (i.e., “wet” or “dry”) and are they suffering from poor perfusion or not (i.e., “cold” or “warm”) (Fonarow & Weber, 2004). For patients who are “wet and warm,” the recommended therapy includes intravenous (IV) diuretics and IV nesiritide, nitroglycerine, or nitroprusside to reduce fluid overload and filling pressures to relieve symptoms. For patients who are “wet and cold,” IV diuretics are supplemented with IV nesiritide, nitroglycerine, or nitroprusside if the patient’s systemic vascular resistance (SVR) is thought to be high or with an inotrope or pressor if the SVR is low. Nitroglycerine is the agent of choice in elderly patients with ADHF who need intravenous vasodilators because of the higher likelihood of renal problems with the use of nesiritide or nitroprusside. If the patient presents as “dry and cold” IV inotropes or pressors are indicated as these patients have low blood pressure and cardiac output. As a consequence, they require astute management of fluid status. Patients who are “dry and warm” usually do not require IV therapy or hospitalization and the cause of their symptoms needs to be further investigated.
Elderly patients are managed with these principles, although clinicians need to provide greater attention to precisely determining fluid status in older compared to younger patients to avoid over diuresis. In addition, vasodilators and inotropes are used in elderly individuals, but greater caution is needed as elders do not tolerate swings in blood pressure as well as younger patients and may require lower doses than younger patients because of their altered renal and liver function.
Particularly important in the management of ADHF in the elderly is optimization of blood pressure; heart rate; blood glucose; cardiac rhythm; and attention to ischemia, anemia, and other conditions that can precipitate acute exacerbations of chronic HF. It is substantially more difficult for elderly individuals to compensate for physiologic insults or to regain homeostasis than it is for younger individuals. As a consequence, it is essential to address physiologic abnormalities early to avoid acute exacerbations from developing, and it is important to correct these abnormalities when an exacerbation does occur.
Because diuretics increase urinary excretion of fluid, they are useful in the mobilization of excess fluid that contributes to most HF exacerbations. Intravenous diuretics usually provide symptomatic relief when congestion is part of the clinical presentation of
ADHF. Diuretics are appropriate for elders as they are for younger patients, but elders need closer monitoring for the adverse effects associated with diuretic use and care needs to be taken to avoid over diuresis. Adverse events for which elders need to be monitored include dehydration with associated hypotension and reduced renal function (Domanski et al., 2003). Electrolyte abnormalities, particularly hypokalemia, are also common. In secondary analyses, the use of non-potassium–sparing diuretics has been associated with increased risk of mortality in HF patients, causing some to call for a randomized controlled trial comparing the use of non-potassium–sparing diuretics with that of potassium sparing diuretics (Domanski et al., 2003; Domanski, Tian, Haigney, & Pitt, 2006).
As do younger patients, elderly patients can suffer from so-called diuretic resistance, which is a decreased response or lack of response to administration of diuretic doses that were formerly effective. Many cases of diuretic resistance are thought to be related to lack of adherence to the low-sodium-diet recommendation and continued high-sodium intake. In these cases, working closely with patients to reduce sodium intake may be beneficial. The addition of sequential nephron blocking agents for diuresis can be helpful in some cases. In other cases, the use of IV diuretics is helpful in overcoming diuretic resistance, particularly if gut edema can be reduced. Continuous infusions may also be helpful. An underrecognized cause of diuretic resistance is thiamine deficiency, which can occur in patients who are placed on dose loop diuretics for a prolonged period.
A potential alternative to diuresis in select patients with ADHF is the use of ultrafiltration (Costanzo et al., 2007; Rogers et al., 2008). This option is useful in patients with severe diuretic resistance, renal insufficiency, or need for removal of large amounts of extracellular fluid. This therapeutic option can now be delivered at the bedside without a central line. Findings from the Ultrafiltration versus Intravenous Diuretics for Patients Hospitalized for Acute Decompensated Heart Failure (UNLOAD) trial demonstrated a mean fluid loss at 48 hours with ultrafiltration that was significantly greater than that seen with IV diuresis (Costanzo et al.). On 3-month follow-up, patients who received ultrafiltration had a lower rehospitalization rate and fewer unscheduled clinic visits for ADHF. Ultrafiltration appeared safe and although there were no subgroup comparisons by age, the mean age of participants was 63 years and patients with preserved systolic function were included.
The intravenous vasodilators-nitroprusside, nitroglycerine, and nesiritide (a recombinant peptide identical to human BNP)-are commonly used in ADHF to reduce elevated filling pressures and SVR, improve symptoms, and increase cardiac output and organ perfusion. Unlike inotropes, the use of intravenous vasodilators does not produce ischemia or dysrhythmias. Because cardiac output is afterload dependent in HF, vasodilation and reductions in SVR even in normotensive patients can improve cardiac output and maintain blood pressure.
Of these three drugs, nitroglycerine and nesiritide are more commonly used because of the greater potential for toxicity and adverse effects in nitroprusside. Among elderly patients with declining renal function, nitroglycerine may be the best option given the suggestion for declining renal function and increased mortality with nesiritide (Sackner-Bernstein, Kowalski, Fox, & Aaronson, 2005). There are no studies comparing the efficacy of these three drugs, but the Vasodilation in the Management of
Acute CHF (VMAC) study compared intravenous nitroglycerin, nesiritide and placebo (Publication Committee for the VMAC Investigators, 2002). In this trial, 489 hospitalized patients with dyspnea at rest from ADHF were randomized to IV nesiritide, IV nitroglycerin, or placebo, in addition to standard medications. The mean age of patients was 60 to 62 years, patients with preserved systolic function were included, but there were no comparisons among age subgroups. After 3 hours, the placebo group was further randomized to active treatment with nesiritide or nitroglycerin. Hemodynamics improved to a greater extent in the nesiritide group than the other two groups. Nesiritide improved dyspnea at 3 hours compared with placebo but not compared with nitroglycerin. There were greater reductions in filling pressures with nesiritide over time in the hospital, although there was no difference in symptoms. Therefore, it appears that given the possibility for negative impact on renal function in elders and the similarities with nitroglycerine, IV nitroglycerine is the vasodilator of choice in elderly patients.
Inotropic Agents
Historically, inotropic agents (e.g., dobutamine, dopamine, and milrinone) were used commonly in ADHF, particularly when blood pressure was low. More recently, their use has diminished with data demonstrating their negative effects. Long-term use of inotropes is associated with increased mortality. Even short-term use that improves hemodynamics and blood pressure does not improve number of days hospitalized or in-hospital mortality compared to placebo and is associated with increased risk of atrial fibrillation and hypotension requiring intervention (Cuffe et al., 2002). Moreover, inotropes may be less effective in elderly patients and thus the use of inotropes in ADHF is limited to short-term use in elderly patients who present with cardiogenic shock. Inotropes also are appropriate in the short term in patients with low blood pressure, despite adequate filling pressures, who show no improvement with vasodilators.
Arginine Vasopressin Receptor Antagonists
Given that fluid overload is the most common cause of acute exacerbations of HF, investigators are examining new approaches to the pharmacologic management of HF using medications that can increase fluid excretion without adversely affecting electrolytes or renal function (Farmakis, Filippatos, Kremastinos, & Gheorghiade, 2008; Oghlakian & Klapholz, 2009). Arginine vasopression (AVP, also known as antidiuretic hormone) is a neurohormone that is increased in patients with HF. AVP causes vasoconstriction and water retention in excess of sodium retention. As a consequence, hyponatremia, a predictor of poor outcomes in patients with HF (Gheorghiade et al., 2007), is common in patients with severe HF and excessive fluid retention. The effects of AVP are mediated by receptors found in the kidneys (V1a receptors) and in vascular smooth muscle and myocardium (V2 receptors). Inhibition of either one or both of these receptors by a class of drugs now commonly known as “vaptins” (for example, conivaptin, satavaptin, lixivaptan) produces excretion of free water (aquaresis) and normalization of serum sodium level. Use of this class of drugs in ADHF is associated with reduction in weight and improved hemodynamics without negative effects on blood pressure, electrolytes, or heart rate. The impact of vaptins on morbidity and mortality outcomes await the results of large-scale clinical trials currently underway.
Optimization of Chronic Therapy
Despite publication of multiple chronic heart failure guidelines, many patients still do not receive optimal drug therapy and this problem is more prevalent in elderly patients (Setoguchi, Levin, & Winkelmayer, 2008) in part because of the lack of studies that include very elderly patients or that make subgroup comparisons by age. Nonetheless, although practitioners should be cognizant of potential altered pharmacodynamics in elders and their effect on drug therapy, available evidence suggests that guideline driven therapy that is beneficial in younger HF patients is equally beneficial in older ones (HFSA, 2006a). Thus, in elderly patients with systolic dysfunction, angiotensin converting enzyme (ACE) inhibition and beta-adrenergic blockage is recommended as standard therapy (HFSA). In patients truly intolerant of ACE inhibitors because of cough or angioedema, angiotensin receptor blockers are indicated. Worsening renal function, hypotension, and hyperkalemia occur with equal frequency in ACE inhibitors and angiotensin receptor blockers and are not an appropriate indication for changing from an ACE inhibitor to an angiotensin receptor blocker. Chronic renal insufficiency is common in HF and elders and is not considered a contraindication to ACE inhibitors or angiotensin receptor blockers (Ahmed, Kiefe, & Allman, 2002). Volume status must be considered carefully when starting and up titrating these medications in elders in whom fluid balance may be more precarious. Starting these medications at low doses and increasing the dose gradually at 2- to 4-week intervals may assist clinicians in helping their elderly patients achieve the target dose (Rich, 2005). In African American elders, the addition of combination hydralazine and isosorbide dinitrate has been shown to decrease mortality (Taylor et al., 2004). This combination also is useful in patients who do not tolerate ACE inhibitors or angiotensin receptor blockers. Elderly patients with congestion should be treated with oral diuretics and usually loop diuretics are necessary. Aldosterone antagonists are considered when patients with an LV ejection fraction of < 30 to 40% remain symptomatic despite optimal therapy on ACE inhibitors and beta-blocking agents. Digoxin is sometimes added to the regimen in patients who remain symptomatic despite treatment with diuretics, an ACE inhibitor, or ARB and beta-blockers (Hunt et al., 2005). There is no survival advantage to using digoxin, but there is a modest reduction in rehospitalization and improvement in symptoms with its use. Initiation of digoxin therapy is not indicated for the treatment of ADHF (Hunt et al.). Digoxin can be used regardless of underlying rhythm, and although it is used for rate control in patients in atrial fibrillation, beta-blockers are more effective in this regard. Combination therapy with hydralazine and isosorbide dinitrate may be useful in patients who remain symptomatic on standard therapy, and such therapy effectively reduces morbidity and mortality (Hunt et al.). African American HF patients particularly may benefit from therapy with this combination of medications.
In patients with HF and preserved systolic function, treatment options are less clear owing to the paucity of clinical trials. Based on limited data, consensus guidelines recommend vigilant control of blood pressure in elderly patients with HF and preserved systolic function (HFSA, 2006a). For patients with congestion, loop diuretics are indicated although great care should be taken to avoid over diuresis. Angiotensin receptor blockers or ACE inhibitors are recommended for patients with HF and preserved systolic function (HFSA). Beta-blockade is recommended in patients in this group if they have had a myocardial infarction, have hypertension, or have atrial fibrillation and need rate control (HFSA).
Management of Comorbidities
Much of the high cost of HF hospitalization is related to the presence of comorbidities (Liao et al., 2007), and elderly HF patients commonly have multiple comorbidities that complicate their care. In a study of Medicare beneficiaries, 40% of those with HF had five or more noncardiac comorbid conditions (Braunstein et al., 2003). A comprehensive approach to patient management produces the best outcomes and an important aspect of the comprehensive approach is recognition and treatment of all comorbid conditions. Hospitalization offers an excellent opportunity for optimization of therapy for HF and for any comorbid conditions. All elderly patients should be assessed for the presence of comorbidities and therapy coordinated to avoid adverse effects while optimizing all comorbid conditions. Comorbidities should be actively and vigorously managed as many can contribute to progression or worsening of HF. Diabetes, hypertension, and hyperlipidemia should be controlled using the most recent evidence-based guidelines to manage therapy (HFSA, 2006a; Hunt et al., 2005). Table.5 includes common comorbidities and related comments about management.
Promoting Patient Self-Care

Table.5 Common Comorbidities Among Elders With Heart Failure

Key Points
Renal dysfunction

Independent risk factor for morbidity and mortality
·        Keep fluid status optimized to decrease potential for damage from diuretics and angiotensin converting enzyme inhibitors
·        Data from ADHERE suggest that angiotensin converting enzyme inhibition may preserve renal function over the long term

Independent risk factor for morbidity and mortality
·        Beneficial effects of iron and erythropoietin on cardiac function and exercise capacity have been reported, but additional study is needed
Cognitive impairment

In elders, cognitive impairment is twice as likely to occur in those with than without heart failure
·        Cognitive impairment adversely affects selfcare multiple dimensions
·        Cognitive impairment is associated with increased short-term and long-term mortality
Chronic obstructive pulmonary disease

One of the most common comorbidities in heart failure patients
·        Because dyspnea is a presenting symptom of both, diagnostic uncertainty is common; measurement of b-type natriuretic peptide level is helpful to distinguish cardiac and pulmonary causes of dyspnea
·        Beta-blockers may exacerbate pulmonary disease; beta-agonists may induce tachycardia and arrhythmias; corticosteroids may promote fluid retention
Sleep-disordered breathing

May occur in as many as70% of heart failure patients
·        Associated with increase in adverse events
·        Referral for sleep study and management of sleep disordered breathing may be appropriate
As many as 36% of hospitalized heart failure patients meet DSM-IV criteria for depression; 20%have major depression and 16% have depressive symptoms
·        Depression is strongly and independently associated with morbidity and mortality
·        Depressed patients have more difficulties with self-care
·        Can screen for depression prior to discharge by asking: During the past 2 weeks have you been bothered by (1) little interest or pleasure in doing things or (2) feeling down, depressed, or hopeless
§ Score answers to these 2 questions on a scale from 0 = not at all, 1 = several days; 2 = more than half the days; 3 = every day
§ A total score of 3 or greater suggests depression and patient referral for further assessment and treatment should be made
Diabetes Arthritis

Highly prevalent in older patients and the leading cause of disability
·        NSAIDs interfere with diuretics, ACEIs and ARBs promote fluid retention, and may contribute to worsening renal function
Increasingly common in HF patients
·        Contributes to disability and functional limitations
·        Increases risk of hypertension, diabetes, sleep-disordered breathing, venous thromboembolic disease, and skin breakdown

Health care providers commonly think of HF as an acute, episodic condition that requires intense intervention followed by periods of quiet. It is these periods of “quiet” that are the most challenging to patients who in these times are charged with managing all of their care. In fact, the vast majority of care is performed by patients and the informal caregivers who support them (usually family members or friends) in the home setting (HFSA, 2006a). Considering the huge challenge this engenders for many
patients and their families (Moser et al., 2005), it is not surprising that failure of patient self-care is one of the most common causes of rehospitalization. It is tempting for clinicians to blame patients for their poor self-care, but lack of appropriate and effective patient education and counseling on the part of health care providers is a root cause of poor patient self-care.
Heart failure patient self-care requires expertise in a number of relatively complex activities (Exhibit.1). Riegel and associates recently examined the characteristics of experts in self-care and discovered that fewer than 10% of heart failure patients could be considered expert (Riegel, Vaughan, Dickson, Goldberg, & Deatrick, 2007). Patients who were considered experts were characterized by their ability to describe their symptoms, link them to HF pathophysiology (even in simple terms), and then had a plan for managing symptoms. Experts also demonstrated an understanding of their treatment and impact, and could verbalize a comprehensive understanding of the medication regimen. Experts were vigilant about their self-care, actively sought information about HF, had good family support and engaged family members. The number of self-care tasks patients must perform and the high level of functioning required to be expert at self-care suggest that our education and counseling strategies need to be much more comprehensive, evidence-based, and extensive than those used in usual practice. Such a discussion is beyond the scope of this chapter, but the Heart Failure Society of America heart failure guideline includes recommendations and advice about appropriate teaching strategies (www.hfsa.org). Exhibit.2 also lists some recommended strategies for enhancing adherence.
Patient adherence to the recommended regimen is a major self-care activity that patients often find difficult (Wu, Moser, Chung, et al., 2008; Wu, Moser, Lennie, & Burkhart, 2008; Wu, Moser, Lennie, Peden, et al., 2008). It is never sufficient to simply provide patients with the information that health care providers believe is important for adherence (HFSA, 2006a). Patients must be taught the skills they need to engage in the requested behavior and it is helpful, while teaching, to consider specific critical target behaviors. For example, when teaching patients how to follow a low-sodium diet, one might keep in mind that at the end of teaching the nurse can expect that patient to be able to pick low-sodium foods off a restaurant menu, or to sort foods into low-and high-sodium categories (HFSA). Consideration of what you expect patients to be able to do guides teaching so that it is more than simple advice to “eat less salt.”
Exhibit.1 Heart Failure Self-Care Activities

§ Medication taking
· Take, don’t stop, identify side effects and differentiate them from other effects
· Average of 9–13 pills per day
· Complex instructions for some
§ Following a low-sodium diet
· Following a diabetic diet, low-fat diet, others
· Know levels, know how to calculate, shop, cook, follow when not at home, adapt family customs
§ Avoidance of excess fluid intake (no more than 48–64 ounces/day for most patients)
§ Monitoring symptoms of worsening heart failure
· Daily weighing and what to do; symptom recognition and what to do; which symptoms are important, which are not; when to act with symptom escalation
§ Physical activity
· How much, how, what if never done, rest?
§ Home monitoring of blood pressure
§ Alcohol restriction and smoking cessation
§ Manage comorbidities, emotional problems, cognitive impairment, functional impairment, social isolation, lack of financial resources
§ Flu vaccine, other prevention activities
§ Negotiate the health care system
· Keep appointments, transitions, multiple care providers

Prior to discharge, health care providers should assess patients for the factors known to interfere with self-care and address those factors (Moser & Watkins, 2008). For example, clinicians should address patients’ financial barriers to buying medications before discharge. Patients who lack a source of social support upon discharge will need help to mobilize support from friends, relatives, their church or other group, or home health care. Low health literacy, anxiety and depression, cognitive impairment, poor functional status, sensory impairments, lack of social support, and presence of comorbidities (all factors common to aging heart failure patients) can conspire to limit patients’ abilities to engage in effective self-care (Moser & Watkins).
Exhibit.2 Strategies for Improving Adherence in Patients With Heart Failure

§  Remember that knowledge is necessary but not sufficient to achieve treatment adherence.
§  Assess potential barriers to adherence, such as lack of knowledge, memory problems, and beliefs or values that are inconsistent with self-care behaviors.
§  Identify those patients able to self-dose, and teach these patients to use PRN diuretics to manage elevations in weight.
§  Use once-daily dosing whenever possible, and tailor medications to patients’ daily schedules
§  Consider providing pre-prepared pill dispensers.
§  Make sure that all pill bottles are labeled in large print with the drug name and dosing regimen.
§  Provide patients with an updated medication list at each visit.
§  Provide written instructions for medication changes made at each visit.
§  Do not assume that patients are taking all of their medicines all the time; be open to hearing about problems and working through solutions (“Lots of patients have trouble taking their water pills on a regular basis. Are you having this problem? Other problems?”).
§  Ask about any over-the-counter substances taken, such as herbs or vitamins.
§  Address potential financial difficulties or problems with access to care during the patient’s stay in the hospital.
§  Follow up with patients about self-care through e-mails or by phone. ¦ Consider providing care to patient at worksite.
§  Provide patients with take-home material about diet and medication and the importance of treatment adherence.
§  Provide scale for daily weights, if needed.

Premature discharge from a hospitalization for ADHF is one reason for the high readmission rate seen in elders with HF. To address this problem, the Heart Failure Society of America HF guidelines specifically provide criteria for discharge (HFSA, 2006a). Prior to discharge all patients with HF need to (a) have factors precipitating their exacerbation of HF addressed, (b) have optimal fluid status obtained, (c) have achieved the transition from IV to oral diuretic, (d) have patient and family education completed, (e) chronic outpatient drug therapy optimized or near-optimized, and (f) have a follow-up clinic visit scheduled within 7 to 10 days (HFSA). Patients with more advanced HF who have recurrent hospitalizations need to (a) have oral medication regimen stable for 24 hours, (b) have had IV therapy discontinued at least 24 hours prior to discharge,(c) ambulate so that functional status can be assessed, (d) have plans (for example, scale ready for daily weights, home nurse visit, or telephone follow-up within 3 days of discharge) in place for post discharge management, and (e) be referred to an HF disease management program if available (HFSA).
Additional resources are available from OPTIMIZE-HF to assist in the discharge planning process. These resources include a (a) heart failure discharge summary checklist; (b) “Dear Doctor Letter” for the referring physician; and (c) take-home packet for patients on what to do if symptoms worsen, dietary information, and advice on reading food labels, and other education information. This resource packet is available at https://www.optimize-hf.org/art/OPT-CombinedToolkit.pdf.
The care of patients with ADHF is challenging, particularly so when the patient is elderly. Hospitalization for ADHF is common among elderly adults, but critical care nurses are in a position to assist patients and their families improve aspects of selfcare that can substantially reduce the risk of rehospitalization. In addition, they can advocate for delivery of evidence-based care to improve outcomes in this vulnerable patient population.
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