Heart failure is a condition that’s more common among the elderly population. It is vitally important for long-term care providers, including LTC pharmacy services, to stay up-to-date on condition and management strategies.
The Long-term Care Providers’ Guide to Heart Failure: Defining the Conditionm
Heart failure is a syndrome that presents with structural abnormalities of the heart. Symptoms include fluid retention, shortness of breath, fatigue, or exercise intolerance. It is a progressive state beginning from decreased function of the cardiac muscle. It then develops into difficulty with circulation of blood and delivery of oxygen to the tissues.
Types of Heart Failure
There are two types of heart failure distributed in relatively equal proportions throughout the population.
Heart failure with preserved left ventricular ejection fraction (HFpEF)
Heart failure with preserved left ventricular ejection fraction (HFpEF) includes residents who have abnormal relaxation of the cardiac muscle, abnormal filling, or stiffness of the ventricle. This results in a heart that can expel most of its blood with each contraction. But, it does not fill to the same maximum capacity as a normal heart would.
Heart failure with reduced left ventricular ejection fraction (HFrEF)
Heart failure with reduced left ventricular ejection fraction (HFrEF) includes residents who have damage to the cardiac muscle usually due to coronary artery disease. These residents’ hearts cannot contract hard enough to eject a normal amount of blood. Both of these etiologies result in residents with less ability to supply the body with oxygen. It also inhibits keeping fluids from accumulating in the periphery and the lungs.
Acute Decompensated Heart Failure
Residents who have heart failure with significant volume overload, congestion, and fatigue make up the majority of hospitalized heart failure residents. Progression of these symptoms in conjunction with worsening cardiac function may result in a diagnosis of acute decompensated heart failure. This indicates a time when the resident is at especially high risk of death and rehospitalization. Due to poor resident outcomes after progression to this stage of heart failure, the most important goal for long-term care providers is to prevent it. A frequent cause of this occurrence is the failure to adhere to medications or dietary restrictions. Comorbid conditions also play a large role.
The Long-term Care Providers’ Guide to Heart Failure: Current Management Recommendations
The type of heart failure is the first variable for long-term care providers to account for in treatment considerations. In heart failure with preserved ejection fraction, comorbidities play a much larger role in therapy considerations. Therapies may also affect these residents in a slightly different way. Preserved ejection fraction residents are more sensitive to diuresis. Controlling symptoms is a main goal of therapy for heart failure, which will, in turn, improve quality of life. Functional capacity includes residents’ ability to carry out everyday activities. It also includes the amount to which they are limited by heart failure related shortness of breath.
Further Considerations
A resident presenting with lower functional status may need additional medications and have a lower baseline quality of life. Volume status is an important consideration. It can optimize diuretic therapy to reduce edema in the periphery and in the lungs, if present. Comorbidities must also be taken into account when assessing a resident for appropriate therapies. Other disease states may define a resident’s risk for certain adverse effects related to heart failure medications. Comorbidities such as angina, sleep apnea, or syncope may indicate the need for additional treatments that will in turn help to control heart failure.
Nonpharmacologic Management
Sodium restriction is recommended in all residents with heart failure to help reduce volume overload and subsequent edema. Goal sodium intake should be 2–3g daily—and further reduced in residents with more severe disease. Fluid restriction should only be considered in residents who are experiencing fluid retention despite high-dose diuretic therapy and adequate sodium restriction. This should be monitored by obtaining weight daily to observe gain or loss of water weight. Smoking cessation is important in the setting of heart failure to improve hemodynamic symptoms. Nicotine’s role as a vasoconstrictor can contribute to these residents’ difficulty with circulation of blood and oxygen. Transdermal nicotine replacement therapy is acceptable for use with appropriate physician monitoring.
Heart Failure Medications
The table below details the medication classes commonly used for the treatment of heart failure, when they are used, and potential side effects.
The Long-term Care Providers’ Guide to Heart Failure: Management in the Long-term Care Setting
Residents with heart failure in long-term care come with their own set of complications and difficulties. The age and complexity of residents in long-term care are frequently elevated. This makes the population more prone to complications and difficulties with management. Cognitive issues in this population also make for more challenging residents who may be harder to involve in their own care. Having nursing staff as the key caretakers among long-term care providers comes with many benefits. These include skilled care, increased monitoring and supervision, and improved medication compliance. In addition to more robust clinical support, residents with heart failure also require additional social support. This is an important factor for residents managing chronic conditions. All of these aspects contribute to long-term care residents as a unique population who require specific care to manage heart failure. [Tweet “Making sense of #heartfailure management in #skillednursing. #longtermcarepharmacy”]
Transitions of Care
Residents in long-term care settings are frequently transitioning between acute and long-term care settings and back again. This occurs especially with a progressive condition like heart failure. In these circumstances, it can be difficult for long-term care providers to create the appropriate continuity of care to prevent readmissions.
The most important thing to consider when transitioning a resident in or out of a care setting is communication. Follow-ups should become commonplace to assist with understanding past medical history. This is useful if a resident is new to the staff or helping educate those who are receiving the resident. Telephone calls area useful resource as a means of confirming recent changes in care or status due to a transition.
Take Care in Transitions of Care
Putting into place protocols for heart failure in a long-term care facility can also help to create a smooth transition from acute care. Maintaining a consistent care procedure allows for less variability in care and more guideline-based implementation of procedures for residents affected with heart failure. Residents are more open to standardized care to other settings if protocols are in place.
Transitions to lower care settings may also occur when residents transfer to home or to personal care. In these circumstances, resident and caretaker education play an important role, ensuring the resident’s ability to be more independent in managing his or her own disease state and the medications that go along with it. Understanding signs of changes in condition or even a decline will help to prevent a rehospitalization because the resident will be able to initiate early action such as contacting a physician.
Team-based Approach
The long-term care setting includes nursing staff as well as many other specialized professionals that can help improve outcomes for residents with all disease states. Those with heart failure especially benefit from the inclusion of dietitians and therapists to their care team. Having access to multiple disciplines increases the ability of staff to work as a team engaged in all resident care.
Involving the resident’s cardiologist is another way to expand the care team for a heart failure resident. The off-site physician should be kept updated on the resident’s care and changes in status. The resident’s in-person appointments with the physician are also important and should occur every four to six months. A better informed physician is more prepared for proactive intervention. This avoids residents staying in the hospital with better quality of life.
Resident Education
Involved residents in their own care take initiative and invest in outcomes proposed by their healthcare providers. Heart failure is both chronic and progressive, meaning residents will need to do their part in managing the disease state for the remainder of their life. Without the appropriate education, they are less likely to be able to carry out self-care activities such as monitoring for fluid retention and medication adherence.
Diet is a specific area where residents have a large role, which they may need help understanding. Sodium restriction to the degree recommended for heart failure residents can be difficult and requires a lot of consideration at mealtimes. Often times, the foods that are easiest for an older adult to prepare or consume are those that contain the highest amounts of sodium. Better-educated residents who are involved with their healthcare team prevents exacerbations and maintains their health.
Staff Education
A lot of monitoring is required on a daily basis to optimally manage heart failure. The staff in a long-term care setting must be active in this area. Helping to monitor for medication-related changes and diuresis needs are key roles in disease management. Dietary restriction assistance is also important to keep in mind to assist residents in their compliance with sodium or fluid restricted diets.
Implementation of protocols also requires in-depth and ongoing staff education because compliance cannot occur without understanding. When staff members understand the expectations, they are better able to carry out protocol requirements and improve the consistency of care in the long-term care facility.
Medication Management
Medication regimens in heart failure residents are frequently long and complicated. These regimens help to decrease exacerbations and maintain quality of life, but they also require a good deal of monitoring. Diuretics frequently need resident-based day-by-day titration to maintain fluid balance.
When to Intervene
Nursing staff should know how to intervene with diuretic medications when a resident is showing signs of increased water weight or edema. In turn, noting when levels restore to equilibrium. They need to obtain weight needs for heart failure residents at as close to the same time as possible on a daily basis to monitor fluid load. This can be best achieved if nursing staff assigns this role to one nurse’s aide.
Side Effects to Note
Side effects such as hyperkalemia and hypotension are common with many heart failure medications and require careful daily monitoring. Take blood pressure daily. Note symptoms of dizziness, nausea, blurred vision, or lightheadedness for residents who may be at increased risk of falls and in need of medication adjustment. If possible, observe serum electrolytes frequently, especially while titrating diuretics to detect low levels of potassium before symptoms appear. Monitor kidney function less frequently but still consistently.
Frequent Medication Reconciliation
Frequent medication reconciliation is the final aspect of proper medication management in this population of residents. Initiate a review of the resident’s medications and any discharge orders during any care transition to ensure the most recent and accurate regimen. Lack of compliance to the most current medication regimen could be a reason for worsening condition and hospitalization of a resident.
As discussed, the management of heart failure in long-term care is a complex topic, which requires a multidisciplinary approach in order to optimize resident outcomes, improve care transitions, and minimize rehospitalizations. Although heart failure can be challenging, the potential for improved outcomes is plentiful through communication, collaboration, and standardization.
It’s difficult to stay up-to-date on the latest in pharmacy best practices. Our Grane Rx long-term care pharmacy services team is here to advise your SNF on all aspects of medication usage. Discover the Grane Rx difference today by calling (866) 824-MEDS (6337).]]>