Heart of the Matter

Providers advise that diagnosis & treatment of cardiac complications should fit with overall goals of care, providers advise

by Gretchen Henkel

Striking a balance between risk and benefit is perhaps the biggest dilemma that physicians face when caring for long-term care residents with cardiac conditions. At least half of any long-term care physician's patients most likely have one or more forms of heart disease.

The National Health and Nutrition Examination Survey IV (www.americanheart.org) found that 59% of men and 71.3% of women age 75 and older have high blood pressure (defined as systolic pressure of 140 mmHg or higher, diastolic pressure of 90 mmHg or higher, or taking antihypertensive medication). The National Heart, Lung, and Blood Institute estimates that 56 in 1,000 nonblack men over 75 have angina pectoris, and that 30 in 1,000 nonblack women over 75 have the condition. The rates of angina are even higher among elderly blacks.

Given the prevalence of heart disease in the elderly and the barriers to specialist care for nursing home residents (distance, cost, risk to patient), many long-term care physicians elect to manage their patients' heart conditions within the facility.

"The main goal in the nursing home setting," said Charles A. Cefalu, MD, MS, professor and chief, Section of Geriatric Medicine, Department of Family Medicine at Louisiana State University Health Sciences Center in New Orleans, "is to, above all else, maintain an acceptable quality of life for those residents [with cardiac problems], and to help them be pain-free and symptom-free as much as possible."

These goals extend to every aspect of cardiac care, from diagnosis to treatment and monitoring to comfort care at the end of life.

Achieving these objectives is no easy task, due to time limitations and physician reimbursement issues. Todd King, PharmD, CGP, director of clinical services for Neil Medical Group in Kinston, N.C., notes that cardiac complications tend to be multifactorial.

"Heart disease in our patients is not just one process," said Dr. King. "Many of the disease processes can overlap." Although elderly living at home or in assisted living facilities may carry hypertension as their only cardiac diagnosis, hypertension is often coupled with other diagnoses in nursing home residents.

A study by Valerie Ziesmer, MD, and colleagues from the Divisions of Cardiology and Geriatrics at Westchester Medical Center in Valhalla, N.Y., found that 51% of the nursing home patients they focused on had hypertension and that 94% of those with hypertension also had clinical cardiovascular disease, target organ damage, or diabetes mellitus (Use of antihypertensive drug therapy in older persons in an academic nursing home. J Am Med Dir Assoc. 2003;Mar-Apr:S20-22).

The presence of dementia may also complicate the diagnosis and management of cardiac conditions because some tests and procedures must be conducted in the hospital or outpatient setting, thus risking additional disorientation and deterioration for the resident with dementia.

Within the parameters of the long-term care population, what should the goals of therapy be? How closely should physicians adhere to national guidelines on hypertension and cholesterol levels when trying to prevent further cardiovascular events in their patients?

Whether residents' conditions result from atherosclerotic or valvular disease, hypertension, or cardiomyopathy, their care management should always be viewed from a holistic perspective, according to those interviewed for this report. This means that physicians and facility administrators must enlist the skills of each member of the interdisciplinary team. A holistic approach to care also necessitates educating and involving family members in devising a care plan.

Assessment Basics

Dr. Cefalu believes it is important for the physician to assess risks and benefits of a workup and treatment for the atherosclerotic heart patient on a case-by-case basis, then choose the least invasive tests and treatments. Basic assessments should include a physical examination, chest x-ray, electrocardiogram, and an echocardiogram. These tests should be performed elsewhere--not as routine screening exams in individuals with heart disease--as the yield is low.

To help slow atherosclerosis, physicians may prescribe medications from several drug classes to lower blood pressure (diuretics, beta-blockers, calcium channel blockers, or angiotensin-converting enzyme inhibitors). Nitroglycerin will help with angina, and lowering blood cholesterol may help to prevent further adverse events.

It is important, note cardiologists and pharmacy consultants, for the physician to titrate dosages in the elderly. Many specialist societies have produced diagnostic and treatment algorithms based on sound clinical evidence.

"Relative to the issue of having the right diagnosis, or if medications do not control symptoms, a consultation with a cardiologist may also be warranted," said Dr. Cefalu. However, he notes, many cardiologists are unwilling to visit nursing facilities. Indeed, even if a consultation is feasible, the cardiologist may recommend further testing that is relatively invasive. (In rural areas served by his company in North Carolina, Dr. King reports that cardiologists may be hundreds of miles from nursing homes.)

Conferring with residents and their family members is critical to ascertain their wishes on this issue: How willing is the resident to have an angiogram, a treadmill, or a stress or echo test to discern what kind of disease he or she has? Further, is an invasive procedure likely to be of any clinical benefit relative to treatment? The logistics of transporting the resident to the hospital for testing should also be factored into the decision-making process.

For the patient with valvular disease, medications such as selective beta-blockers, calcium channel blockers, and diuretics can often control symptoms. Depending upon the severity of disease, however, these patients may be at risk for heart failure or stroke from arrhythmias. Most long-term care physicians would probably still elect to control symptoms with pharmaceutical options such as ACE inhibitors, notes Dr. Cefalu, because of the morbidity associated with operative interventions, including heart valve surgery. For those same reasons, most physicians opt not to recommend bypass surgery or angioplasty for residents with atherosclerotic disease.

Monte Harding, RN, clinical care manager at the 200-bed Eden Park Health Care nursing home in Poughkeepsie, N.Y., believes that, at this juncture, physicians must have a frank discussion with family members.

"If the patient is not a candidate for surgery, why go through invasive testing?" she asked. Additional precautions for patients with valvular disease include prophylactic antibiotics before dental procedures, to prevent endocarditis (American College of Cardiology/American Heart Association Task Force on Practice Guidelines for Management of Patients with Valvular Heart Disease; 1998).

Additional issues, such as anticoagulation therapy to prevent stroke, may become more prominent in residents with cardiomyopathy. The question of anticoagulant therapy, however, induces other risk-benefit ratios. Although it is easier to monitor blood levels of Coumadin in the nursing home as opposed to community setting, use of the drug may put a particular resident at increased risk of falling, bruising, and bleeding. In addition, said Dr. Cefalu, "Coumadin is a highly variable drug. It can be affected by liver disease or green leafy vegetables, for instance."

Antiarrhythmic drugs may be an option for some patients, but even placement of a pacemaker may be contraindicated in patients with several comorbidities if these drugs do not control symptoms. Diagnosis may also be elusive in these patients with atypical presentations.

Adhering to Guidelines

When physicians elect to manage their patients' cardiac conditions in the facility, "They should make sure that they are up to date and using medications and treatment algorithms that are based on current evidence, and that they use medications that are appropriate for the elderly," advised Dr. King.

Controversy abounds regarding adherence to current recommendations for controlling high blood pressure and serum lipid levels in frail elderly patients. For example, the recently released Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (or JNC-7, Chobanian, et al. Hypertension, 2003;42:1206-1252) recommends controlling blood pressure at 140/90 instead of 160/90 in all those over the age of 50. For those patients with diabetes as well as hypertension, the blood pressure should be maintained at 130/80. In patients whose blood pressure is more than 20 mmHg above the systolic blood pressure goal or more than 10 mmHg above the diastolic blood pressure goal, physicians should consider initiating therapy using two agents--one of which will usually be a thiazide diuretic, the JNC-7 report advises.

The Third Report of the National Cholesterol Education Program (Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults--Adult Treatment Panel III, or ATP-III) presents another dilemma for long-term care physicians. The ATP-III now recommends that in patients with one or two risk factors (over age 45 in men, or over 55 in women; family history of premature coronary heart disease; hypertension; HDL less than 40 mg/dL; and smoking) that LDL levels be kept at 100 or lower.

"If the patient has hyperlipidemia, which may be an additional risk factor for further complications, such as angina or stroke, how far do you go in treating that?" queried Dr. Cefalu.

According to Dr. King, the question becomes more relevant given the risk of liver toxicity and myopathies with the statin drugs.

Wilbert S. Aronow, MD, CMD, argues that the benefits of treating hypercholesterolemia with statin drugs outweigh the risks and can reduce mortality due to stroke, heart failure, and coronary artery disease (Should hypercholesterolemia be treated in frail elders? J Am Med Dir Assoc. 2002;March/April;66-68).

Dr. Cefalu points out that benefits may outweigh the risks if these new events can be prevented in an otherwise functional patient. "On the other hand, treatment in a patient with tertiary disease--moderate to severe dementia, cardiomegaly, chronic renal failure, liver failure, hemiparesis, dysphagia, aphasia, or immobility--may not achieve much," he said.

Parameters of Responsibility

Successfully managing cardiac conditions requires pertinent input from direct care staff. Harding notes that nursing staff are responsible for medication monitoring, including obtaining blood levels of prescribed medicines, and improvement of symptoms or side effects.

It is important for nurses to work in tandem with front-line caregivers who may notice changes in residents before the nursing staff does. Successful facilities, she says, instruct CNAs to alert nursing staff to any significant change in residents' symptoms or conditions, and get nurses to appropriately evaluate signs or symptoms in detail before reporting them to the physician.

Dr. Cefalu believes that the nurse assigned to the respective patient should be aware of the normal parameters of each resident's vital signs. For example: Does a particular patient have chronic atrial fibrillation, valvular disease, or angina? If the patient has an irregular heartbeat, is that normal for that patient? During daily activities of daily living evaluations of their patients, CNAs should recognize if the resident has any bruising.

Any changes from their last encounter with the patient should be reported to the nurse. A change in condition should trigger a reassessment by the respective nurse. It is within the nurse's domain, said Dr. Cefalu, "to recognize that a bruise may be a sign of too much Coumadin, that an elevated pulse might be a sign of too much digoxin, that a very low pulse may be a sign of too much beta-blocker, and that shortness of breath may be a sign that their valvular disease is causing heart failure."

Certified nursing assistant Joan Williams is the CNA coordinator at the 100-bed Ross Memorial Health Care Center in Kennesaw, Ga. "[The CNAs] are the eyes and ears of the facility," she said. "The CNAs here are very aware of everything going on [with their patients]."

Williams trains CNAs to not only listen to residents' complaints, but to observe their clinical symptoms. Clammy skin, bluish fingernails, restlessness, or difficulty breathing are all triggers for checking the patient's vital signs.

"I think the biggest challenge is learning to know the difference between a resident complaining to get attention and a real problem," she said.

Responding to CNA reports, a staff nurse then assesses the resident and makes necessary adjustments. For a person with known heart failure who is short of breath, this might include placing an oxygen mask and elevating the head of the bed; for chest pain from known angina, giving nitroglycerin; for other types of known pain, administering a PRN medication.

"If these efforts are successful, we might not call the doctor at that time," explained Harding. "If the measure is not successful, we would call the doctor right away to get further instructions."

Comfort & Reassurance

Some residents, especially those with end-stage disease who may have do-not-hospitalize and do-not-resuscitate advance directors, may receive only comfort care. "For these residents, we just continue to make them comfortable," said Harding.

CNAs rely on intuition when offering support to their patients. "We do a lot of ambulation, and if I see that somebody's feet are really swollen, I'm not going to push them. I'm going to try to make them comfortable," explained Williams. "Sometimes [the patients] get so anxious with any kind of breathing problem. Just to sit and hold their hand for a little while calms them right down and reassures them that somebody's there for them."

Challenges of Nonmedical Treatments

Harding agrees that the number-one consideration for any long-term care resident with cardiovascular disease is quality of life. "We do discuss what the patient wants," she said. "If patients are not able to articulate what they would like, we do have their families quite involved with the decisions that we make in regard to aggressive diagnostic tests. This takes quite a bit of education because families do not understand what is going on physiologically and don't understand what tests might need to be done.

"Sometimes, families want all the tests done," Harding continued. "But they have to understand--what do you do next [after the test]? If someone does not want surgery or is not a candidate, then why go through with these invasive tests?"

Quality of life is relative, Harding believes. Even nonmedical treatments, such as dietary restrictions, must be weighed according to their pros and cons. One example is restriction of salt for hypertensive patients.

"Everybody wants salt for their food," she said. "We have herb supplements such as Mrs. Dash to try to improve the taste of the food. In the end, it's really the resident's decision. If they want salt, they get salt. If it's the only thing that will make them eat their food and that's going to improve their quality of life, they get what they want."

Dr. Cefalu also believes that quality of life can make a big difference in alleviating depressive symptoms in the long-term care patient with heart disease. Instead of a two-gram sodium diet that may be unpalatable for the heart failure patient, facilities might consider a "no-added salt" (simply not putting extra salt on the tray) as a compromise.

Physicians must also address residents' code status at regular intervals--not just upon admission. "For the cardiomyopathy patient, it may be preferable just to treat the patient in the nursing home with diuretics, digoxin, and ACE inhibitors," said Dr. Cefalu. "To go back and forth to the hospital may not be the right thing to do."

Physicians must explain to patients and their families the risks and benefits of pharmaceutical versus surgical treatments, and understand how families want to handle the issue of emergencies before they develop so there is no misunderstanding. Avoiding miscommunication is key, he said, and the process of caring for those with chronic cardiac conditions "is all about patient and family satisfaction. And last, documentation of the testing, risks, and benefits of the various treatments and that these issues have been fully communicated to the patient and/or family is critical."

Conclusion

Treatment of heart disease in the frail elderly requires a holistic, interdisciplinary approach. When making decisions about diagnostic procedures, treatments, or palliative care, physicians must carefully consider the overall goals for each individual cardiac patient. Every treatment or monitoring procedure should be viewed within the context of maximizing that resident's quality of life.

The first step in designing an effective care plan should be to communicate to resident and family members realistic outcomes for types of treatments and diagnostic procedures. Then, by enlisting the support of family members and all staff in the interdisciplinary team, physicians can successfully manage each resident's cardiac complications within facilities.

Gretchen Henkel is a longtime contributing writer for Caring.

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