Prevalence, diagnosis and management of heart failure in nursing home residents

Heart failure is an increasing clinical problem in western countries and
particularly a disease of the elderly. The prevalence and incidence of heart
failure are expected to increase within the near future, because of the higher
survival rates for myocardial infarction and cerebrovascular diseases. In
western countries the prevalence of heart failure in the community ranges from
3-13% for those aged over 65 years. In the Netherlands the prevalence of heart
failure in the general population is estimated at 13% in persons of 75 or older.
Heart failure is characterized by a poor prognosis and quality of life. It is
known that early diagnosis and treatment may prevent progression of heart
failure and lead to improvement of symptoms and quality of life.
Most of the older persons over 65 years live independently in their own homes
and only a small proportion live in special institutions for chronic care
(residential care and nursing homes). The older persons in nursing homes are
mostly the frail elderly representing a specific patient group. They show high
levels of care dependency because of their disabillities, resulting from their
multimorbidity. Heart failure is expected to be particularly prevalent in the
nursing home population but reliable data about heart failure in nursing homes
in general and in the Netherlands in particular, are lacking. The most
important reason for this is that nursing home residents are often not included
in clinical and epidemiological studies.
A recent literature study on the prevalence of heart failure in nursing homes
confirmed that studies on the prevalence of heart failure are lacking and has
emphasized the need for research on the prevalence of heart failure in this
environment. Data from the few included studies reveal a prevalence of heart
failure in this vulnerable population of about 20% (range 15-45%); a figure
that indeed is higher than in the general population (3-13%). However most
studies included in the review, used a retrospectiv design and consisted of
gathering data from patient records instead of actually diagnosing the disease
by concrete examination. There was one small study in wich residents were
diagnosed after concrete clinical examination and this study demonstrated a
prevalence of heart failure of 45%.
Because of the fact that, the improvement of symptoms and quality of life are
very important aspects of the care for nursing home residents, it is very
relevant to know more about the problem of heart failure in this specific group
of elderly; especially because literature reveals that there is still a lot to
do in long-term care settings to improve care for residents with heart failure.

The objective of the current study is:
- to enlarge the knowledge of the prevalence of heart failure and its
management of nursing home residents with heart failure.
- to get insight into the care dependency and quality of life of nursing home
residents with heart failure.
- to optimize the diagnostic proces and treatment of heart failure in nursing
homes


This objective has resulted in the following research questions:
1. What is the prevalence of HF in nursing homes in the southern part of the
Netherlands for both somatic and psychogeriatric residents ?
2. What are the characteristics (such as demographics, cognitive status,
cardiovascular risk factors and history) of nursing home residents with heart
failure?
3. How is HF currently treated pharmacologically and non-pharmacologically in
Dutch nursing homes?
4. What is the relation between heart failure and respectively the care
dependency and quality of life of nursing home residents in both somatic and
psychogeriatric residents?
5. What is the predictive value of an onsite assessment (or elements) of heart
failure in nursing home residents using a clinical assessment
(history, physical examination, ECG and NT-pro BNP) in the nursing home versus
the golden standard of an overall judgement of this assessment by a panel of
cardiologists, including additional echocardiography?
6. How is the course of heart failure in nursing home residents after 1-year
follow-up with outcomes of: heart failure events, hospital admissions for heart
failure and mortality?
7. How is the course in care dependency and quality of life look like among
patients with heart failure in comparison to those with no heart failure after
1-year follow-up?

For this study a multi-centre cross-sectional design will be used.
After informed consent the specially trained nursing home physicians starts to
examine the included participants by performing the history and physical
examination. An electrocardiography is made and a venous bloodsample is taken
to determine the NT-pro BNP value (5ml). An echocardiographist will perform the
echocardiography with a mobile echo device.
The research assistant and the NHP/researcher are responsible for gathering the
data from the medical records, the questionnaires, to perform the ECG and the
measurement of the NT-pro BNP marker.
After one year data are gathered from the medical records regarding any heart
failure events, hospital admission for haertfailure and mortality.

The clinical examinations including a blood sample, ECG and an echocardiography
are conducted conform the accepted guidelines and is regular medical care. All
the examinations take place in the nursing homes. Complementary data are
gathered from the medical records and questionnairies (SF-12, Qualidem, MDS,
MMSE). In two weeks time all parts of the examinations are performed at a time
that has the accordance of the resident and/or the nursing staff.
The burden of the examinations probably might be the time- investment and for
some residents the blood sample that is taken.
There are no special risks for participating nursing home residents.
In the pilot study (The prevalence of heart failure in a nursing home; a pilot
study NL 23691.068.08), that anticipates on this study, included residents
experienced the participation as a "pleasant" variance of their daily
activities. An important detail is that appoinments should be made in
accordance with the residents and/or nursing staff, so there is no interference
with the personal care and the use of meals.
The burden for the psychogeriatric residents is more difficult to estimate.
Besides the bloodsample that is taken, probably the performance of the
echogardiography will be experienced as a burden.
From the TIME-CHF study (2006) , where also residents with cognitive impairment
were included, it is known that when the echocardiogram takes more than 20
minutes agitation might arise. In the pilot all the echocardiographies were
finished within 20 minutes. By presence of two persons at time of the
echogardiography there will be enough attention for the residence as turned out
in the pilot and will prevent an uncomfortable feeling about the examination.
Attentiveness on any kind of resistance against the examinations in
psychogeriatric residents remains necessary.

In Dutch nursing homes residents are living on a somatic ward when they suffer
from disabillities and functional loss because of their somatic illnesses and
on a psychogeriatric ward if they suffer from severe cognitive impairments or
dementia. However, in real life there is not always a sharp distinction caused
by the fact that some somatic diseases are accompanied by cognitive impairment
(such as M. parkinson or in cerebrovascular accidents).
For the purpose of this study we intend to investigate nursing home residents
of both groups. An important reason to include residents with dementia or
cognitive impairment in this study is evidenced by the fact that cerebral blood
flow may decrease due to heart failure resulting in further worsening of the
cognitive impairments. It is expected that adequate treatment will improve the
cognitive impairment and probably due to this also the quality of life.
Heart failure is expected to be prevalent in nursing home residents. The
performance of this study may lead to the benefit that an unknown heart failure
resident is detected. If so, adequate treatment for heart failure can be
started which may lead to a better prognosis and improvement of quality of life.
In addition by including both groups of nursing home residents we can research
if there is a difference in prevalence, diagnosis, management and care
dependency due to heart failure.