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114

Table 9 New York Heart Association functional classication of heart failure

Class Patient symptoms

Class I No limitation of physical activity. Ordinary physical activity does not cause symptoms

of HF

Class IISlight limitation of physical activity. Comfortable at rest, but ordinary physical activity

results in symptoms of HF; can walk two blocks or climb two ights of stairs

Class

Marked limitation of physical activity. Comfortable at rest, but less than ordinary

III

activity causes symptoms of HF; e.g., walking two blocks

Class IVUnable to perform any physical activity (including ADLs) without symptoms of HF; or

symptoms of HF at rest

N. Pandya

examination should be performed in residents with shortness of breath, reduced exercise tolerance, edema, or other symptoms suggestive of HF.Review of prior records, current medications, use of alcohol, and/or illicit drugs and alternative therapies, as well as chemotherapy agents should be considered as contributing factors to HF.

The manifestations of heart failure may be atypical in long-term care residents with frailty, cognitive impairment, and multimorbidity. They may present with

fatigue, malaise, lethargy, declining function, neurological symptoms such as confusion, restlessness, sleep disturbance, orthopnea, dyspnea with exertion, cough, and edema. Gastrointestinal manifestations of HF can include anorexia, nausea, abdominal discomfort, and altered bowel function. Remember that exertional symptoms may be less prominent in older adults due to a more sedentary lifestyle.

Patients who have HFpEF are more often female, have a fourth heart sound, sustained PMI, absence of jugular venous distension, absence of peripheral edema, normal heart size on chest -ray, and left ventricular hypertrophy (LVH) on the electrocardiogram (EKG). By contrast, patients with HFrEF are more often male, have a third heart sound, displaced PMI, jugular venous distension, pitting edema, and Q waves on the EKG.There can be up to 8 lbs. of uid weight gain before a patient may develop peripheral edema.

Remember that peripheral edema may also be caused by venous insufciency, hepatic or renal failure, hypoalbuminemia, or medication such as calcium channel blockers, and should not be attributed to HF without a more detailed review of comorbidities and the medication regimen. The clinical and laboratory evaluation of HF is summarized in Table10.

Electrolytes and renal function should be measured regularly. Hypokalemia is a common adverse effect of diuretics and may increase the risk of fatal arrhythmias. Many residents with hypokalemia also have hypomagnesemia, which can result in an inadequate response to potassium supplementation. Hyperkalemia can be associated with ACE inhibitors, angiotensin II receptor blockers, angiotensin receptorneprilysin inhibitor (ARNI), and worsening renal function. The development of hyponatremia may be an indication of disease progression and is associated with

Common Clinical Conditions inPost-Acute andLong-Term Care

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Table 10 Initial evaluation of heart failure

Test Purpose

Physical examination; essential

CBC, CMP, magnesium, calcium

Lipid prole Evaluate for comorbidities TSH, free T4 Exclude hypothyroidism or hyperthyroidism Hemoglobin A1C Evaluate for presence of diabetes NT-proBNP or BNP Assist in the diagnosis of HF if cause of dyspnea is unclear (increase

Urine microalbumin Indicates risk for developing HF Chest X-ray Pulmonary congestion (may be absent in HF), effusion, exclude

EKG Evaluate LVH, ischemia, prior MI, atrial brillation (does not diagnose

Echocardiogram with doppler

Additional tests for selected patients

Ferritin, TIBC, transferring saturation

HIV Evaluate suitability for particular treatments and detect reversible/

Cardiac MRI- ordered by cardiologist

Stress test (echo or nuclear)

Assess weight, edema, jugular venous distension, cardiac rhythm, third heart sound, hepatojugular reux, crackles at lung bases, or diminished breath sounds due to pleural effusion

Evaluate underlying causes of HF, and suitability for treatment with certain medications

with age, in women, with renal impairment). For age >75years, NT-proBNP >1800pg/mL consistent with HF. If BNP <100pg/mL, HF is unlikely, but likely if BNP >500pg/mL.Serial measurements are not recommended

pneumonia or chronic lung disease; serial studies not recommended

HF) Determine EF, ventricular size and function, evaluate pericardium, and

valvular or other structural heart disease; may be repeated in 3–6months

Evaluate existing anemia, and exclude hemochromatosis

treatable causes of HF Evaluate for myocardial inltration (e.g., amyloid), or scar tissue from

previous cardiac event If patient has suspected CAD and is willing to undergo cardiac

catheterization and surgery for revascularization

115

reduced survival in the elderly with HF.The resident’s functional status should be monitored in addition to the physical examination to include the sitting and standing BP when possible.

Common Precipitants ofHeart Failure

In addition to identifying the cause of heart failure, it is also important to assess for conditions that may precipitate an exacerbation of heart failure. Evidence-based medication management and the treatment of coexistent medical conditions can optimize treatment of HF (see Table11). Cardiologist consultation may be required in some instances.

116

Table 11 Common factors that precipitate HF

Cardiac

Myocardial infarction or ischemia Poorly controlled hypertension Excess of dietary sodium Medication nonadherence Excess uid intake (oral or IV) Arrhythmias—supraventricular (especially atrial brillation with rapid rate), bradycardia, sick

sinus syndrome Associated medical conditions—pulmonary embolism, hypoxia due to chronic lung disease,

infection (pneumonia, viral illness, sepsis), anemia, hyperthyroidism, chronic kidney disease (eGFR <30mL/min)

Medications—alcohol, -β adrenergic blockers (including ophthalmic agents), calcium channel- blockers, NSAIDS, glucocorticosteroids, mineralocorticoids, antiarrhythmic drugs

Provider/system problems (e.g., medication reconciliation errors)

N. Pandya

Disease Management andCare Considerations inHF

Close observation and early detection of symptoms and signs which may precede an acute HF episode by several days. Close follow-up may be required for days or months, with the risk of rehospitalization high. The following suggestions can improve patient outcomes of HF:

• Education of rst-line caregivers, and nurses to improve recognition, assessment,

and monitoring of HF patients.

• Timely intervention by the practitioner (with evaluation of weights, chest X-ray,

laboratory tests (see Table10), determine type of HF, initiation and adjustment

of therapy, determination of target weight.

• Determine a regular schedule of clinical follow-up (in person or virtual), weights

(3/week, before breakfast, on the same scale), and laboratory testing.

• Engage the interprofessional team (e.g., pharmacists, dietitians, physical thera-

pists) and nurse aides who are essential for care delivery.

• Establish an individualized care plan: Assess patient’s self-care ability, cogni-

tion, health literacy, and support system in order to plan for appropriate discharge

planning and subsequent follow-up.

• Consult a cardiologist or HF nurse specialist for patients who are responding

poorly, or experiencing repeated exacerbations and/or hospitalizations.

• Evaluate facility performance by developing team-based quality improvement

programs to track hospitalizations, rehospitalizations, symptom relief, physical

function, and strategies to improve outcomes

• Patients with both frailty and HF are likely to have higher morbidity so optimize

nutrition and rehabilitation.

>70

Common Clinical Conditions inPost-Acute andLong-Term Care

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117

Management

The following are guidelines and recommendations for the management of HF applicable to NH residents [13, 15]. The choice of pharmacologic and nonpharmacologic therapy will depend on the patient’s clinical status, goals of care, comorbid conditions, and frailty. Current treatment recommendations are designed to optimize outcomes, reduce morbidity and mortality, and to break the vicious cycle of hospitalization, hospital discharge, and rehospitalization. Mortality signicantly increases with a cardiac ejection fraction <30–35%.

Nonpharmacologic therapy is essential:

• Promote smoking cessation.

• Moderate sodium restriction <3 g/day (unless hyponatremic; worse outcome

associated with low sodium diets.)

• Avoid excessive uid intake, but restriction is not usually necessary.

• Record daily weights especially in short stay patients in whom home discharge

is anticipated.

• Regular physical activity to the extent tolerated (combine strengthening and gait

training if possible).

• Evaluate for anemia and thyroid dysfunction.

In the last 4years, signicant evidence has emerged from large clinical trials on the use of angiotensin receptor-neprilysin inhibitors (ARNIs), sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors), and ivabradine (an If calcium channel blocker highly specic for the sinoatrial pacemaker current), to improve HF symptoms, reduce hospitalizations, and prolong survival. The SGLT2 inhibitors are benecial in patients with and without diabetes. There is no new data on the use of loop diuretics and digoxin. Figure 1 illustrates a pharmacological approach to HFrEF.The indications, caveats for using medication classes, monitoring, and potential adverse effects in older adults are summarized in Table12. After the initial diagnosis of HFrEF, it is recommended that medications be adjusted every 2weeks when indicated, in order to achieve guideline directed medical therapy.

HFrEF Stage C treatent

ARNI/ARB/ACEI (ARNI

preferred) and beta

blocker, with diurec if

needed

Add aldosterone

angonist

Add SGLT2 inhibitor

Titrate diurec agent if

ﬂuid overload

Add hydralazine and

isosorbide dinitrate for

Black paents with

persistent symptoms

Add ivabradine if HR

on maximally tolerated

Fig. 1 Pharmacological approach to the management of HFrEF (adapted from the ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment, 2021 [15])

beta blockers

118

Check BP, renal function,

and K level weekly when

Adverse events in

older adults Caveats

Cough, mild renal

function impairment,

starting and titrating to

maximum tolerated dose

Eplerenone benecial in

HF following MI.Check

renal function and K level

2–3day after initiation, at

7th day, then monthly for

hypotension,

hyperkalemia,

angioedema (rare)

Mild renal function

impairment,

hyperkalemia

3months

Check BP, renal function,

and K level weekly when

starting and titrating to

maximum tolerated dose

Mild renal function

impairment,

hypotension,

hyperkalemia

Combining ACEI and ARB

not benecial and increases

adverse events

Hyperkalemia may be

managed by low

potassium diet or

Benet only demonstrated

with carvedilol, metoprolol

succinate and bisoprolol.

scheduled use of

potassium binders

Worsening of HF

(usually transient)

N. Pandya

Greatest impact when

resting HR <70/min, and

patients are “dry”

Medication

class Indication Outcomes in HF Contraindications

Table 12 Pharmacotherapeutic strategies and selection of treatments for older adults with HFrEF [13, 15, 16]

Hyperkalemia (K

>5.5mEq/L), hypotension

(syst BP <80 mm, estimated

Cr clearance <30mL/min

Serum creatinine >2.5mg/

dL, or K >5.0mEq/L

Reduced mortality and

Improved outcomes,

reduced mortality

whom use of ARNI is not

possible

ACE inhibitors Consider in patients in

hospitalizations

NYHA class III-IV and

low EF <35%

Aldosterone

antagonists

(MRA)

Hyperkalemia (K

>5.5mEq/L), hypotension

(syst BP <80mm, estimated

Cr clearance <30mL/min

Improved outcomes,

reduced mortality

Alternative to ACEI in

HF, consider in patients

in whom ARNI is not

possible

Angiotensin-

receptor

blockers

(ARBs)

Severe decompensated HF,

marked bradycardia (HR

<45–50/min), active

bronchospastic lung disease,

signicant heart block,

relative hypotension (SBP

<90–100mmHg)

Improved ventricular

function, reduced cardiac

deaths

Stage C

Beta-Blockers Newly diagnosed HFrEF,

Common Clinical Conditions inPost-Acute andLong-Term Care

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Valsartan plus sacubitril is

the rst in this class

Can be used instead of

ACEI, avoid starting within

36h of last ACEI dose

Serum levels of 0.5–0.9ng/

mL are optimal. Lower

doses 0.125mg/day

recommended

QOD dosing in patients

with renal impairment

50% dose reduction if on

verapamil, amidarone, or

quinidine

Check BP, renal function,

and K.If furosemide dose

exceeds 80md BID,

consider a different loop

Adverse events in

older adults Caveats

Mild renal function

impairment,

hypotension,

hyperkalemia,

angioedema (rare)

Nausea, visual

disturbances, cardiac

arrhythmias

(bradycardia and SVT

or VT)

“Therapeutic

concentrations” may

be associated with

toxicity and mortality

Hypotension,

orthostatic

hypotension,

hypokalemia

diuretic (e.g., bumetanide)

or add a thiazide diuretic

(e.g., metolazone)

nitrates (resolves with

continued use);

palpitations, nausea,

119

(continued)

and dizziness with

hydralazine

Hypotension before

treatment, history of

angioedema

Reduced mortality and

HF admissions

Newly diagnosed HFrEF,

Stage C, and NYHA

class II+III symptoms

Medication

class Indication Outcomes in HF Contraindications

ARB/

Neprilysin

inhibitors

Reduced HF

hospitalizations, but not

mortality

symptoms or recurrent

hospitalizations

Digoxin Persistent limiting HF

Improved survival Headaches with

edema

Diuretics HF with congestion and

For Black patients with

Hydralazine

persistent symptoms

despite use of ACEi/

ARBs and beta-blockers,

and in HF patients who

and ARBs

and nitrates

120

Initiate and titrate

beta-blockers to target

doses when possible

Adverse events in

older adults Caveats

Transient brightness in

some areas of the

visual elds

Monitor for bradycardia

Dapagliozin is the current

FDA-approved SGLT2

inhibitor for HFrEF

Uncommon but

potentially serious

genital infections,

Fournier gangrene,

lower extremity, and

For anticoagulation,

warfarin or one of the

acute kidney injury

newer oral anticoagulants

may be used

N. Pandya

(continued)

Medication

class Indication Outcomes in HF Contraindications

Table 12

Reduced hospitalizations

for HF in patients with

NYHA class II–III

HFrEF

HFrEF in sinus rhythm

with persistent HR >70/

min on maximally

Ivabradine NYHA class II–III

Improved hospitalization

and CV mortality in

tolerated beta-blocker

doses

Consider in patients with

HFrEF, NHHA class

SGLT2

inhibitors

patients with and without

diabetes. Reduced

decline in kidney

function in HFrEF and

CKD

Long-term

anticoagulation in

patients with HF and

II–IV

Routine anticoagulation

in HF patients without

atrial brillation is not

Antiplatelet or

Anticoagulant

therapy

comorbid atrial

brillation is indicated in

most patients

recommended

ACEi angiotensin-converting enzyme inhibitor, ARB angiotensin receptor blocker, ARNI angiotensin receptor neprilysin inhibitor, SGLT2i sodium glucose

transporter 2 inhibitor

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121

Rehospitalization forHF

Studies have shown that 20% of patients admitted to the SNF/NF with HF are readmitted to the hospital within 30days, and up to 50% within 6months. Not all these rehospitalizations are due to HF; COPD, pneumonia, sepsis, other cardiac events and arrhythmias are contributing causes [17]. The percentage of short stay and long stay patients who are rehospitalized after nursing home admission are CMS nursing home quality measures. Contributing factors for rehospitalization due to HF include:

• Severity of HF and presence of comorbidities.

• Quality of care issues, and suboptimal use of evidence-based therapies for

chronic HF.

• Inconsistent availability of practitioners especially during night-time

exacerbations.

• Problems with medication administration and weight monitoring, use of NSAIDS.

• Nonadherence to sodium restriction and lack of food choices.

• Problems with care delivery, miscommunication, and with discharge procedures

(optimally should include medication reconciliation, transfer of information to

community providers, and follow-up appointments).

Refractory HF

HF can have an unpredictable course and a high incidence of sudden death despite intensive medical management. Older adults with HF who are discharged to skilled nursing facilities are known to have high mortality rates (14.4% within 30days and

53.5% within 1 year). Referral to an advanced heart failure specialist should be considered in patients who have required IV inotropes, had two or more emergency room visits or hospitalizations in the past 12months for HF exacerbations, persistent fatigue, edema with rising BNP or NT-proBNP, renal failure (creatinine >1.8 mg/dL or BUN >43 mg/dL), inability to tolerate appropriately dosed beta blockers, and/or ARB/ACEI/ARNI and/or aldosterone antagonists, development of atrial brillation, ventricular arrhythmias or repeated ICD shocks.

Palliative care and end-of-life care should be discussed and considered for those with refractory HF, recurrent hospitalization, and persistence of severe disabling symptoms such as dyspnea, fatigue, pain, sleep disturbance, and functional decline. Palliative care for HF patients has been shown to improve physical, psychosocial, and spiritual well-being. Palliative care consultation is appropriate before placement of an ICD or left ventricular assist device (LVAD) is considered. In addition, an ICD should be inactivated upon admission to hospice if it is consistent with the goals of care [15, 18].

122

N. Pandya

Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is an insidious, progressive lung disease characterized by airow obstruction that is not fully reversible. It is the third leading cause of death in older adults. COPD can be difcult to diagnose because persons gradually modify their lifestyle to compensate for progressive fatigue and dyspnea. The main symptoms are dyspnea, cough, and sputum production. COPD continues to be underdiagnosed and undertreated, and often difcult to differentiate from asthma, HF, and other conditions that limit physical activities. One in six patients admitted to a nursing facility may have COPD or emphysema. COPD is responsible for high utilization of acute health care and 34% probability of death in 180 days post hospital discharge to nursing facilities [18, 19].

Identication ofCOPD

Smoking (90% of cases), advanced age, repeated pulmonary infections, prior tuberculosis, exposure to biomass fuel, air pollution, and alpha-1 antitrypsin deciency are risk factors for COPD.Early identication of COPD is important since 50% of lung function is lost by the time mild exertional dyspnea occurs and only 30% of lung function remains when there is dyspnea at rest. Residents with dyspnea and other recurrent pulmonary symptoms should be screened for COPD utilizing the clinical indicators listed in Table13 [18, 19]. A screening tool that uses caregivers to rate residents’ symptoms was validated by Zarrowitz etal. who reported that a history of asthma, shortness of breath at rest and shortness of breath on exertion, and smoking are likely to be consistent with a diagnosis of COPD [20].

Table 13 Clinical indicators of COPD in long-term care [18]

Dyspnea (progressive over time, worse with exertion) Abnormal pulse oximetry

Cough (may be intermittent and unproductive) Chronic sputum production (any pattern)

Wheezing and chest tightness Avoidance of activities that lead to dyspnea or impaired performance of ADLs History of smoking Recurrent pulmonary infections Occupational or environmental exposure to occupational dust and chemicals Weight loss, fatigue, anxiety, cognitive impairment, or sleep disorders

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123

Diagnosis ofCOPD

On examination, residents with advanced disease may be barrel-chested, have prolonged expiration, use accessory muscles for inspiration, and have wheezing, rhonchi, or distant heart sounds. The signs of cor pulmonale, i.e., right-sided HF, include jugular venous distension, hepatic congestion, and pedal edema.

The clinical indicators of COPD and the review of past medical records may help in the diagnose of COPD.Although the denitive method of diagnosis is spirometry, which usually measures FEV1 (volume of air exhaled in 1s) to FVC (forced vital capacity or total volume of air able to be exhaled), this is usually not practical in the PALTC setting. The FEV1 to FVC ratio decreases with aging and hence can lead to overdiagnosis of COPD.Spirometry should be performed in symptomatic individuals when feasible. However, its use in frail or cognitively impaired residents is usually not feasible.

• Normal: FEV1/FVC≥70% or FEV1≥80% of predicted

• COPD: FEV1/FVC≤70%

• Restrictive lung disease: FEV1/FVC ≥ 90% (pulmonary brosis, severe

kyphosis)

Other tests may provide useful information when evaluating for the presence of COPD or other conditions with similar signs and symptoms.

• The CBC may have an abnormally high Hb level due to hypoxia

• The chemistry panel may show a high bicarbonate level (metabolic alkalosis)

due to hypercapnia

• Chest X-rays are not diagnostic, but may show HF, bullae, pneumonia, pulmo-

nary scarring, hyperination, and increased retrosternal airspace, to sug-

gest COPD

• An EKG may show atrial arrhythmias or right heart strain

Pulmonary consultation may be helpful if the cause of dyspnea is not clear or the resident exhibits a poor response to treatment. Clinical judgment is important since the differential diagnosis of COPD can include asthma, heart failure, bronchiectasis, recurrent aspiration, ACE-inhibitor induced cough, vocal cord dysfunction, pulmonary emboli, and respiratory tract tumors. The GOLD criteria classify the severity of COPD (Table14) [21].

The GOLD ABCD staging [20], may be clinically useful and guide referral to a pulmonologist.

• GOLD A—Fewer symptoms and <2 exacerbations a year

• GOLD B—More symptoms and <2 exacerbations a year

• GOLD C—Fewer symptoms and >2 exacerbations a year

• GOLD D—More symptoms and >2 exacerbations a year

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