Monitoring Is Key to Heart Failure in Elders

Abstract

Christine Kilgore is a freelance writer for Elsevier Global Medical News.Michael W. Rich, MD, a cardiologist who studies the geriatric population, calls heart failure the “quintessential disease of cardiovascular aging.”It's a fitting description with growing relevance for long-term care. As cardiovascular reserve declines and hypertension and coronary problems increase with age, heart failure becomes a common disorder in older adults. Much to the interest of government and third-party payers, it is the leading cause of hospitalization in people 65 and older.Innovative therapies such as cardiac contractility modulation have made medical news in past years, and cardiologists continue to call for other novel therapies. Yet the cutting edge of heart failure management isn't relevant to the average patient with heart failure, especially those in long-term care settings, according to Dr. Rich and other experts interviewed for this article.“In older individuals with heart failure, the most important goal is improving the quality of life,” said Dr. Rich, professor of medicine at the Washington University, St. Louis. “We have to look at each patient individually.”He asserted that in long-term care, real value lies in managing symptoms and optimizing functional capacity, in making sure patients are taking the medications that can benefit them and staying as active as possible, and in carefully monitoring them to detect drug side effects and prevent hospitalizations. More than 50% of all heart failure hospital admissions occur in people aged 75 years and older.Tomorrow's best practices will be defined by today's efforts to determine “how best to monitor the condition long term,” said Mary Pat Rapp, RN, PhD, of the nursing program at the University of Texas Health Sciences Center, Houston.“The textbooks and literature get us through diagnosis and treatment [and] medications, but they don't get us through the issues of monitoring on a weekly or monthly basis in long-term care,” said Dr. Rapp, a contributor to AMDA's clinical practice guideline on heart failure. “This is what we're learning to do now.”Medications That WorkFor medical directors, this means making sure that all patients who have systolic heart failure with reduced left ventricular ejection fraction—whether or not they have symptoms—are prescribed angiotensin-converting enzyme inhibitors and beta-blockers, unless they have clear contraindications. Both drugs, said Dr. Rich and others, can improve both quality and length of life but are underused in older patients.Major heart failure trials have enrolled mainly middle-age men with systolic dysfunction and therefore are hard to generalize to women, anyone with diastolic heart failure, and people over 75 years, said Dr. Rich. Several studies have observed the impact of ACE inhibitors in elderly patients with heart failure. One study with a 3-year follow-up found a 23% reduction in mortality in elders receiving an ACE inhibitor, and a 1-year study found a 26% reduction (Arch. Intern. Med. 2002;162:1682–8). But these and other results are “difficult to interpret” because of possible selection bias and other limitations, said Dr. Rich.Still, the cumulative results of these observational studies in elderly people, coupled with extrapolations of findings in younger patients, provide “firm and strong support,” Dr. Rich said, for the routine use of ACE inhibitors. In fact, the American College of Cardiology, the American Heart Association, AMDA, and other groups currently recommend the regimen in elders.Advanced age should not be a rationale for prescribing lower dosages of ACE inhibitors, emphasized Dr. Rich. It's true that older patients are more likely to have significant renal impairment, “so the risk of ACE inhibitors aggravating renal insufficiency or precipitating hyperkalemia is greater,” he said. “But one just has to be careful with how rapidly ACE inhibitors are titrated and be sure patients are appropriately monitored.”Ali Ahmed, MD, a geriatric heart failure expert, similarly asserted that heart failure patients with kidney disease are just as likely to benefit from ACE inhibitors as are patients without kidney disease. The rise in serum creatinine or serum potassium associated with ACE inhibitors generally is small and transient and should not be viewed as a reason to discontinue one of these drugs, he noted. Before discontinuing an ACE inhibitor for hyperkalemia, clinicians should consider stopping potassium supplements or the aldosterone antagonist spironolactone, said Dr. Ahmed of the University of Alabama, Birmingham, and director of the geriatric heart failure clinics at the university and the Veteran Affairs Medical Center in Birmingham.Compared with ACE inhibitors, the angiotensin receptor blockers (ARBs) are no less likely to induce deterioration in renal function or cause hyperkalemia. The ARBs are less likely, however, to cause cough and other sometimes troubling side effects. Generic ARBs aren't available but should be in a few years, Dr. Rich said.Spironolactone also has been shown to improve outcomes, including hospitalization and mortality, in patients with advanced systolic heart failure (an ejection fraction of 30%–35% or less) and persistent symptoms despite the use of ACE inhibitors, beta-blockers, and diuretics. An ongoing National Institutes of Health trial is investigating the role of spironolactone in diastolic heart failure. For now, Dr. Rich said, “the risks outweigh the possible benefits” of the drug in diastolic heart failure.Dr. Ahmed said that in heart failure patients with hypokalemia, spironolactone may be superior to a potassium supplement. The drug may correct several electrolyte imbalances while it suppresses aldosterone, a harmful neurohormone in heart failure, he said. A recent study of patients with chronic heart failure did not find any long-term benefit from the use of potassium supplements, he noted.Dr. Rich said that when spironolactone is prescribed to elderly patients, it should be started at the lowest available dose (12.5 mg/day) and increased to no more than 25 mg/day. It should not be used in patients who have advanced renal insufficiency or a tendency to develop hyperkalemia, he added.Digoxin is “still a useful drug” for improving symptoms and reducing hospital admissions in patients with systolic heart failure “who continue to have significant symptoms” despite the use of ACE inhibitors, beta-blockers, and diuretics, Dr. Rich noted.An important but underappreciated caveat, Dr. Rich said, is that “digoxin needs to be given at a very low dose.” He recommended 0.125 mg/day for patients 70 years or older with normal renal function and half that amount if renal function is impaired.According to AMDA's 2002 guideline, as many as half of all heart failure patients in the nursing home may have diastolic dysfunction. Dr. Rich and Dr. Ahmed said that diastolic dysfunction may be even more prevalent. “It's probably higher than 50%,” Dr. Ahmed said. While the burden of symptoms and the risk of hospitalization are similar for diastolic and systolic heart failure, their prognoses and treatments differ substantially.Patients with diastolic dysfunction have the lower mortality risk, but the best treatment for them is murky. No major trial has shown that an ACE inhibitor or drug in any of other major class improves clinical outcomes for these patients, so practitioners have little evidence to guide their decision making.Diuretic therapy to decrease fluid volume is important for most heart failure residents regardless of left ventricular ejection fraction, but physicians and staff must appreciate that it requires attentiveness and individualization, said Charles Cefalu, MD, MS, chief of geriatric medicine at the Louisiana State University and director of the geriatric medicine program at the Medical Center of Louisiana at New Orleans. “Best practice means maximizing and customizing diuretic therapy” so that individuals achieve optimal fluid reduction while not becoming dehydrated or hypotensive or otherwise adversely affected from overdiuresis, he said.Most older patients—especially those with diastolic heart failure—also have systolic hypertension, which leads many experts to believe that blood pressure control may be the most important treatment for diastolic heart failure.Exactly how much blood pressure should be lowered in elderly individuals —nursing home residents, especially—is an issue of ongoing controversy, however. Dr. Rich explained that he doesn't aim for systolic blood pressures less than 140 mm Hg in a nursing home population because of concern over orthostatic hypotension and other side effects. Dr. Ahmed said he emphasizes the need for individualization of therapy because of the heterogeneous nature of nursing home residents.Individualize and MonitorIn general, experts recommend a no-salt-added diet for residents with heart failure, but this issue also is not always straightforward.Dr. Rapp said that until more is learned about the value of a low-salt diet in nursing home residents with heart failure, she will advise nurses to watch each resident's response to various levels of salt intake and balance quality of life issues with the need to prevent hospitalizations.Similarly, she said that caregivers should be attentive to fluid intake “on an individual basis” since underhydration is more of a problem in nursing homes than overhydration is.There are good, long-standing data showing that a person's weight usually rises prior to his or her heart failure symptoms getting worse, so experts have traditionally recommended weighing heart failure patients and residents as frequently as possible. Daily weights are the standard recommendation in outpatient clinics.Given the staff shortages in nursing homes and the challenges of using wheelchair scales, it may be more cost effective and sensible—especially for fairly stable heart failure patients—to weigh residents less frequently but to devote more time to monitoring symptoms of heart failure.“Clinicians should recall that examination of the neck veins is one of the most sensitive tools for evaluating fluid status,” said Karl Steinberg, MD, CMD, a California medical director and editor-in-chief of Caring for the Ages.“A useful video is available [www.youtube.com/watch?v=tJzBKdKg2k0&feature=related]. Monitoring frequent weights is also a good idea, and protocols for physician notification and increased diuresis in response to weight gain can be helpful in reducing exacerbations and hospitalizations. The combination of heart failure and renal insufficiency carries a poor prognosis, and residents and their families should be counseled to prepare accordingly.”Said Dr. Rapp, “We can work with nurses' aides in asking, ‘What are the chief symptoms of heart failure for each individual? What symptoms are they going to manifest if their heart failure gets worse?’ For Mr. Jones it might be shortness of breath and cough, for Mrs. Smith it might be fatigue or getting fatigued more easily, and for Mrs. Anderson it might be getting confused.”Best practices then lie in effectively communicating the goals and integrating such individualized care into the each facility's care planning process, she and others said. Christine Kilgore is a freelance writer for Elsevier Global Medical News. Michael W. Rich, MD, a cardiologist who studies the geriatric population, calls heart failure the “quintessential disease of cardiovascular aging.” It's a fitting description with growing relevance for long-term care. As cardiovascular reserve declines and hypertension and coronary problems increase with age, heart failure becomes a common disorder in older adults. Much to the interest of government and third-party payers, it is the leading cause of hospitalization in people 65 and older. Innovative therapies such as cardiac contractility modulation have made medical news in past years, and cardiologists continue to call for other novel therapies. Yet the cutting edge of heart failure management isn't relevant to the average patient with heart failure, especially those in long-term care settings, according to Dr. Rich and other experts interviewed for this article. “In older individuals with heart failure, the most important goal is improving the quality of life,” said Dr. Rich, professor of medicine at the Washington University, St. Louis. “We have to look at each patient individually.” He asserted that in long-term care, real value lies in managing symptoms and optimizing functional capacity, in making sure patients are taking the medications that can benefit them and staying as active as possible, and in carefully monitoring them to detect drug side effects and prevent hospitalizations. More than 50% of all heart failure hospital admissions occur in people aged 75 years and older. Tomorrow's best practices will be defined by today's efforts to determine “how best to monitor the condition long term,” said Mary Pat Rapp, RN, PhD, of the nursing program at the University of Texas Health Sciences Center, Houston. “The textbooks and literature get us through diagnosis and treatment [and] medications, but they don't get us through the issues of monitoring on a weekly or monthly basis in long-term care,” said Dr. Rapp, a contributor to AMDA's clinical practice guideline on heart failure. “This is what we're learning to do now.” Medications That WorkFor medical directors, this means making sure that all patients who have systolic heart failure with reduced left ventricular ejection fraction—whether or not they have symptoms—are prescribed angiotensin-converting enzyme inhibitors and beta-blockers, unless they have clear contraindications. Both drugs, said Dr. Rich and others, can improve both quality and length of life but are underused in older patients.Major heart failure trials have enrolled mainly middle-age men with systolic dysfunction and therefore are hard to generalize to women, anyone with diastolic heart failure, and people over 75 years, said Dr. Rich. Several studies have observed the impact of ACE inhibitors in elderly patients with heart failure. One study with a 3-year follow-up found a 23% reduction in mortality in elders receiving an ACE inhibitor, and a 1-year study found a 26% reduction (Arch. Intern. Med. 2002;162:1682–8). But these and other results are “difficult to interpret” because of possible selection bias and other limitations, said Dr. Rich.Still, the cumulative results of these observational studies in elderly people, coupled with extrapolations of findings in younger patients, provide “firm and strong support,” Dr. Rich said, for the routine use of ACE inhibitors. In fact, the American College of Cardiology, the American Heart Association, AMDA, and other groups currently recommend the regimen in elders.Advanced age should not be a rationale for prescribing lower dosages of ACE inhibitors, emphasized Dr. Rich. It's true that older patients are more likely to have significant renal impairment, “so the risk of ACE inhibitors aggravating renal insufficiency or precipitating hyperkalemia is greater,” he said. “But one just has to be careful with how rapidly ACE inhibitors are titrated and be sure patients are appropriately monitored.”Ali Ahmed, MD, a geriatric heart failure expert, similarly asserted that heart failure patients with kidney disease are just as likely to benefit from ACE inhibitors as are patients without kidney disease. The rise in serum creatinine or serum potassium associated with ACE inhibitors generally is small and transient and should not be viewed as a reason to discontinue one of these drugs, he noted. Before discontinuing an ACE inhibitor for hyperkalemia, clinicians should consider stopping potassium supplements or the aldosterone antagonist spironolactone, said Dr. Ahmed of the University of Alabama, Birmingham, and director of the geriatric heart failure clinics at the university and the Veteran Affairs Medical Center in Birmingham.Compared with ACE inhibitors, the angiotensin receptor blockers (ARBs) are no less likely to induce deterioration in renal function or cause hyperkalemia. The ARBs are less likely, however, to cause cough and other sometimes troubling side effects. Generic ARBs aren't available but should be in a few years, Dr. Rich said.Spironolactone also has been shown to improve outcomes, including hospitalization and mortality, in patients with advanced systolic heart failure (an ejection fraction of 30%–35% or less) and persistent symptoms despite the use of ACE inhibitors, beta-blockers, and diuretics. An ongoing National Institutes of Health trial is investigating the role of spironolactone in diastolic heart failure. For now, Dr. Rich said, “the risks outweigh the possible benefits” of the drug in diastolic heart failure.Dr. Ahmed said that in heart failure patients with hypokalemia, spironolactone may be superior to a potassium supplement. The drug may correct several electrolyte imbalances while it suppresses aldosterone, a harmful neurohormone in heart failure, he said. A recent study of patients with chronic heart failure did not find any long-term benefit from the use of potassium supplements, he noted.Dr. Rich said that when spironolactone is prescribed to elderly patients, it should be started at the lowest available dose (12.5 mg/day) and increased to no more than 25 mg/day. It should not be used in patients who have advanced renal insufficiency or a tendency to develop hyperkalemia, he added.Digoxin is “still a useful drug” for improving symptoms and reducing hospital admissions in patients with systolic heart failure “who continue to have significant symptoms” despite the use of ACE inhibitors, beta-blockers, and diuretics, Dr. Rich noted.An important but underappreciated caveat, Dr. Rich said, is that “digoxin needs to be given at a very low dose.” He recommended 0.125 mg/day for patients 70 years or older with normal renal function and half that amount if renal function is impaired.According to AMDA's 2002 guideline, as many as half of all heart failure patients in the nursing home may have diastolic dysfunction. Dr. Rich and Dr. Ahmed said that diastolic dysfunction may be even more prevalent. “It's probably higher than 50%,” Dr. Ahmed said. While the burden of symptoms and the risk of hospitalization are similar for diastolic and systolic heart failure, their prognoses and treatments differ substantially.Patients with diastolic dysfunction have the lower mortality risk, but the best treatment for them is murky. No major trial has shown that an ACE inhibitor or drug in any of other major class improves clinical outcomes for these patients, so practitioners have little evidence to guide their decision making.Diuretic therapy to decrease fluid volume is important for most heart failure residents regardless of left ventricular ejection fraction, but physicians and staff must appreciate that it requires attentiveness and individualization, said Charles Cefalu, MD, MS, chief of geriatric medicine at the Louisiana State University and director of the geriatric medicine program at the Medical Center of Louisiana at New Orleans. “Best practice means maximizing and customizing diuretic therapy” so that individuals achieve optimal fluid reduction while not becoming dehydrated or hypotensive or otherwise adversely affected from overdiuresis, he said.Most older patients—especially those with diastolic heart failure—also have systolic hypertension, which leads many experts to believe that blood pressure control may be the most important treatment for diastolic heart failure.Exactly how much blood pressure should be lowered in elderly individuals —nursing home residents, especially—is an issue of ongoing controversy, however. Dr. Rich explained that he doesn't aim for systolic blood pressures less than 140 mm Hg in a nursing home population because of concern over orthostatic hypotension and other side effects. Dr. Ahmed said he emphasizes the need for individualization of therapy because of the heterogeneous nature of nursing home residents. For medical directors, this means making sure that all patients who have systolic heart failure with reduced left ventricular ejection fraction—whether or not they have symptoms—are prescribed angiotensin-converting enzyme inhibitors and beta-blockers, unless they have clear contraindications. Both drugs, said Dr. Rich and others, can improve both quality and length of life but are underused in older patients. Major heart failure trials have enrolled mainly middle-age men with systolic dysfunction and therefore are hard to generalize to women, anyone with diastolic heart failure, and people over 75 years, said Dr. Rich. Several studies have observed the impact of ACE inhibitors in elderly patients with heart failure. One study with a 3-year follow-up found a 23% reduction in mortality in elders receiving an ACE inhibitor, and a 1-year study found a 26% reduction (Arch. Intern. Med. 2002;162:1682–8). But these and other results are “difficult to interpret” because of possible selection bias and other limitations, said Dr. Rich. Still, the cumulative results of these observational studies in elderly people, coupled with extrapolations of findings in younger patients, provide “firm and strong support,” Dr. Rich said, for the routine use of ACE inhibitors. In fact, the American College of Cardiology, the American Heart Association, AMDA, and other groups currently recommend the regimen in elders. Advanced age should not be a rationale for prescribing lower dosages of ACE inhibitors, emphasized Dr. Rich. It's true that older patients are more likely to have significant renal impairment, “so the risk of ACE inhibitors aggravating renal insufficiency or precipitating hyperkalemia is greater,” he said. “But one just has to be careful with how rapidly ACE inhibitors are titrated and be sure patients are appropriately monitored.” Ali Ahmed, MD, a geriatric heart failure expert, similarly asserted that heart failure patients with kidney disease are just as likely to benefit from ACE inhibitors as are patients without kidney disease. The rise in serum creatinine or serum potassium associated with ACE inhibitors generally is small and transient and should not be viewed as a reason to discontinue one of these drugs, he noted. Before discontinuing an ACE inhibitor for hyperkalemia, clinicians should consider stopping potassium supplements or the aldosterone antagonist spironolactone, said Dr. Ahmed of the University of Alabama, Birmingham, and director of the geriatric heart failure clinics at the university and the Veteran Affairs Medical Center in Birmingham. Compared with ACE inhibitors, the angiotensin receptor blockers (ARBs) are no less likely to induce deterioration in renal function or cause hyperkalemia. The ARBs are less likely, however, to cause cough and other sometimes troubling side effects. Generic ARBs aren't available but should be in a few years, Dr. Rich said. Spironolactone also has been shown to improve outcomes, including hospitalization and mortality, in patients with advanced systolic heart failure (an ejection fraction of 30%–35% or less) and persistent symptoms despite the use of ACE inhibitors, beta-blockers, and diuretics. An ongoing National Institutes of Health trial is investigating the role of spironolactone in diastolic heart failure. For now, Dr. Rich said, “the risks outweigh the possible benefits” of the drug in diastolic heart failure. Dr. Ahmed said that in heart failure patients with hypokalemia, spironolactone may be superior to a potassium supplement. The drug may correct several electrolyte imbalances while it suppresses aldosterone, a harmful neurohormone in heart failure, he said. A recent study of patients with chronic heart failure did not find any long-term benefit from the use of potassium supplements, he noted. Dr. Rich said that when spironolactone is prescribed to elderly patients, it should be started at the lowest available dose (12.5 mg/day) and increased to no more than 25 mg/day. It should not be used in patients who have advanced renal insufficiency or a tendency to develop hyperkalemia, he added. Digoxin is “still a useful drug” for improving symptoms and reducing hospital admissions in patients with systolic heart failure “who continue to have significant symptoms” despite the use of ACE inhibitors, beta-blockers, and diuretics, Dr. Rich noted. An important but underappreciated caveat, Dr. Rich said, is that “digoxin needs to be given at a very low dose.” He recommended 0.125 mg/day for patients 70 years or older with normal renal function and half that amount if renal function is impaired. According to AMDA's 2002 guideline, as many as half of all heart failure patients in the nursing home may have diastolic dysfunction. Dr. Rich and Dr. Ahmed said that diastolic dysfunction may be even more prevalent. “It's probably higher than 50%,” Dr. Ahmed said. While the burden of symptoms and the risk of hospitalization are similar for diastolic and systolic heart failure, their prognoses and treatments differ substantially. Patients with diastolic dysfunction have the lower mortality risk, but the best treatment for them is murky. No major trial has shown that an ACE inhibitor or drug in any of other major class improves clinical outcomes for these patients, so practitioners have little evidence to guide their decision making. Diuretic therapy to decrease fluid volume is important for most heart failure residents regardless of left ventricular ejection fraction, but physicians and staff must appreciate that it requires attentiveness and individualization, said Charles Cefalu, MD, MS, chief of geriatric medicine at the Louisiana State University and director of the geriatric medicine program at the Medical Center of Louisiana at New Orleans. “Best practice means maximizing and customizing diuretic therapy” so that individuals achieve optimal fluid reduction while not becoming dehydrated or hypotensive or otherwise adversely affected from overdiuresis, he said. Most older patients—especially those with diastolic heart failure—also have systolic hypertension, which leads many experts to believe that blood pressure control may be the most important treatment for diastolic heart failure. Exactly how much blood pressure should be lowered in elderly individuals —nursing home residents, especially—is an issue of ongoing controversy, however. Dr. Rich explained that he doesn't aim for systolic blood pressures less than 140 mm Hg in a nursing home population because of concern over orthostatic hypotension and other side effects. Dr. Ahmed said he emphasizes the need for individualization of therapy because of the heterogeneous nature of nursing home residents. Individualize and MonitorIn general, experts recommend a no-salt-added diet for residents with heart failure, but this issue also is not always straightforward.Dr. Rapp said that until more is learned about the value of a low-salt diet in nursing home residents with heart failure, she will advise nurses to watch each resident's response to various levels of salt intake and balance quality of life issues with the need to prevent hospitalizations.Similarly, she said that caregivers should be attentive to fluid intake “on an individual basis” since underhydration is more of a problem in nursing homes than overhydration is.There are good, long-standing data showing that a person's weight usually rises prior to his or her heart failure symptoms getting worse, so experts have traditionally recommended weighing heart failure patients and residents as frequently as possible. Daily weights are the standard recommendation in outpatient clinics.Given the staff shortages in nursing homes and the challenges of using wheelchair scales, it may be more cost effective and sensible—especially for fairly stable heart failure patients—to weigh residents less frequently but to devote more time to monitoring symptoms of heart failure.“Clinicians should recall that examination of the neck veins is one of the most sensitive tools for evaluating fluid status,” said Karl Steinberg, MD, CMD, a California medical director and editor-in-chief of Caring for the Ages.“A useful video is available [www.youtube.com/watch?v=tJzBKdKg2k0&feature=related]. Monitoring frequent weights is also a good idea, and protocols for physician notification and increased diuresis in response to weight gain can be helpful in reducing exacerbations and hospitalizations. The combination of heart failure and renal insufficiency carries a poor prognosis, and residents and their families should be counseled to prepare accordingly.”Said Dr. Rapp, “We can work with nurses' aides in asking, ‘What are the chief symptoms of heart failure for each individual? What symptoms are they going to manifest if their heart failure gets worse?’ For Mr. Jones it might be shortness of breath and cough, for Mrs. Smith it might be fatigue or getting fatigued more easily, and for Mrs. Anderson it might be getting confused.”Best practices then lie in effectively communicating the goals and integrating such individualized care into the each facility's care planning process, she and others said. In general, experts recommend a no-salt-added diet for residents with heart failure, but this issue also is not always straightforward. Dr. Rapp said that until more is learned about the value of a low-salt diet in nursing home residents with heart failure, she will advise nurses to watch each resident's response to various levels of salt intake and balance quality of life issues with the need to prevent hospitalizations. Similarly, she said that caregivers should be attentive to fluid intake “on an individual basis” since underhydration is more of a problem in nursing homes than overhydration is. There are good, long-standing data showing that a person's weight usually rises prior to his or her heart failure symptoms getting worse, so experts have traditionally recommended weighing heart failure patients and residents as frequently as possible. Daily weights are the standard recommendation in outpatient clinics. Given the staff shortages in nursing homes and the challenges of using wheelchair scales, it may be more cost effective and sensible—especially for fairly stable heart failure patients—to weigh residents less frequently but to devote more time to monitoring symptoms of heart failure. “Clinicians should recall that examination of the neck veins is one of the most sensitive tools for evaluating fluid status,” said Karl Steinberg, MD, CMD, a California medical director and editor-in-chief of Caring for the Ages. “A useful video is available [www.youtube.com/watch?v=tJzBKdKg2k0&feature=related]. Monitoring frequent weights is also a good idea, and protocols for physician notification and increased diuresis in response to weight gain can be helpful in reducing exacerbations and hospitalizations. The combination of heart failure and renal insufficiency carries a poor prognosis, and residents and their families should be counseled to prepare accordingly.” Said Dr. Rapp, “We can work with nurses' aides in asking, ‘What are the chief symptoms of heart failure for each individual? What symptoms are they going to manifest if their heart failure gets worse?’ For Mr. Jones it might be shortness of breath and cough, for Mrs. Smith it might be fatigue or getting fatigued more easily, and for Mrs. Anderson it might be getting confused.” Best practices then lie in effectively communicating the goals and integrating such individualized care into the each facility's care planning process, she and others said. Diagnosing Heart FailureEchocardiography is the best tool to determine whether an elderly patient has systolic or diastolic heart failure, said Michael Rich, MD, of Washington University, St. Louis. The procedure cost effectively assesses ventricular function and gives more information than other tests, he said.“You can get information that may be useful for managing the patient—information about the cardiac valves, the pericardium, and wall thickness and chamber size, for example, and about unsuspected problems that may be treatable,” said Dr. Rich. Left ventricular ejection fraction helps the physician decide on therapy.“Echocardiograms should not be ordered before a clinical diagnosis of heart failure has been made, however,” Ali Ahmed. MD, of the University of Alabama, Birmingham told Caring for the Ages. “The use of echo to diagnose heart failure can miss nearly half of all heart failure patients in the nursing home who have normal left ventricular ejection fraction.”Dr. Ahmed and his colleagues devised a pneumonic—DEFEAT-HF—to remind them of the steps involved in the assessment and management of heart failure in nursing homes. The letters in DEFEAT stand for diagnosis, etiology, fluid volume, ejection fraction, and treatment (J. Am. Med. Dir. Assoc. 2008;9:383–9).Assessing fluid volume and achieving fluid balance are among the most important clinical goals for patients with heart failure, said Dr. Ahmed. Doing so will improve a patient's quality of life and reduce hospital admissions. It also may help with the initiation and maintenance of therapy with drugs such as beta-blockers.Heart failure is a syndrome, not a disease, Dr. Ahmed said, so searching for the etiology of heart failure in the nursing home is important. Hypertension and coronary artery disease, the two most common causes of heart failure, can be controlled to minimize their continuing insult to the heart. Echocardiography is the best tool to determine whether an elderly patient has systolic or diastolic heart failure, said Michael Rich, MD, of Washington University, St. Louis. The procedure cost effectively assesses ventricular function and gives more information than other tests, he said. “You can get information that may be useful for managing the patient—information about the cardiac valves, the pericardium, and wall thickness and chamber size, for example, and about unsuspected problems that may be treatable,” said Dr. Rich. Left ventricular ejection fraction helps the physician decide on therapy. “Echocardiograms should not be ordered before a clinical diagnosis of heart failure has been made, however,” Ali Ahmed. MD, of the University of Alabama, Birmingham told Caring for the Ages. “The use of echo to diagnose heart failure can miss nearly half of all heart failure patients in the nursing home who have normal left ventricular ejection fraction.” Dr. Ahmed and his colleagues devised a pneumonic—DEFEAT-HF—to remind them of the steps involved in the assessment and management of heart failure in nursing homes. The letters in DEFEAT stand for diagnosis, etiology, fluid volume, ejection fraction, and treatment (J. Am. Med. Dir. Assoc. 2008;9:383–9). Assessing fluid volume and achieving fluid balance are among the most important clinical goals for patients with heart failure, said Dr. Ahmed. Doing so will improve a patient's quality of life and reduce hospital admissions. It also may help with the initiation and maintenance of therapy with drugs such as beta-blockers. Heart failure is a syndrome, not a disease, Dr. Ahmed said, so searching for the etiology of heart failure in the nursing home is important. Hypertension and coronary artery disease, the two most common causes of heart failure, can be controlled to minimize their continuing insult to the heart.