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End-Stage Congestive Heart Failure in the Nursing Home Setting

      Graphical abstract

      Mrs. D is an 89-year-old African American woman who has moved into the nursing home directly from her home. Her husband became ill and could no longer care for her. She has a history of heart failure and was seeing her cardiologist for weekly weights, but she stopped because she could no longer tolerate the outings. She has had multiple falls at home; most recently, she sustained a left wrist fracture. Her past medical history includes allergic rhinitis, arthritis, esophageal reflux, hyperlipidemia, hypertension, chronic kidney disease, a herniated cervical disc, osteoporosis, and situational depression. She also has had shingles and a hysterectomy in the past.
      Her medications include Lasix, 80 mg twice a day, for congestive heart failure and hypertension; ferrous sulfate, 325 mg once daily, for iron deficiency; sertraline, 75 mg once daily, for depression; potassium chloride, 20 milliequivalent (mEq) twice a day, for potassium replacement; rabeprazole, 20 mg once a day, for reflux; and atorvastatin, 10 mg daily, for hyperlipidemia.
      Since admission, her weight has increased from 102 pounds to 104 pounds, and she is exhibiting increased abdominal distention. Her admission laboratory results showed the following levels: sodium, 140 mmol/L; potassium, 3.7 mmol/L; chloride, 100 mmol/L; total carbon dioxide, 30 mmol/L; blood urea nitrogen, 30 mg/dL; creatinine, 1.56 mg/dL; glomerular filtration rate, 34 mL/min; hematocrit, 35.7%; hemoglobin, 11.0 g/dL; and platelets, 207 x 109/L.
      Mrs. D is willing to transfer from her bed to a chair, but she resists walking because she finds it difficult and fears falling. She sips liquids throughout the day, but her exact intake isn’t known. She describes feeling depressed about the move to the nursing home, and she hopes to return to her own home despite the fact that her husband cannot care for her anymore.

      Attending Physician

      Michele Bellantoni, MD, CMD
      Dr. Bellantoni is an associate professor in the Department of Medicine at the Johns Hopkins University School of Medicine. She is also the clinical director of the Division of Geriatric Medicine and Gerontology, and medical director of the Specialty Hospital Programs at Johns Hopkins Bayview Medical Center.
      Mrs. D’s weight gain and abdominal distention may be signs of decompensated heart failure, possibly due to increased fluid intake and the stress of relocation. Findings such as increased jugular venous distension, pulmonary rales, dullness to percussion of the lung bases, edema, abnormal cardiac rhythm, murmurs, and presence of S3 would confirm the clinical diagnosis. Her abdominal distension also may be explained by constipation or less commonly by urinary retention. The skilled nursing facility’s medical provider may confer with her cardiologist and review the most recent echocardiogram to understand structural abnormalities such as aortic valve stenosis and left ventricular function, and to plan her medication adjustments to reduce congestion.
      Addressing her “broken heart” requires a different approach, however. Far better than increasing her sertraline, the interdisciplinary team (IDT) should seek to understand what gives Mrs. D joy and meaning in her life and then incorporate those elements into her daily life in the nursing home. The staff should give her choices about her daily routine, facilitate introductions to the other residents, and encourage her participation in group activities, if she is willing. Perhaps Mrs. D would benefit from counseling as well, either by a professional social worker or another mental health provider. Also the IDT should consider physical therapy to address her fear of falling and develop an exercise program for her. Occupational therapy could help improve her self-care through using energy conservation techniques.
      Every member of the IDT has a role in assisting Mrs. D and her husband, whose heart is also likely broken by her physical dependence and her illnesses. Hope can be powerful: although full functional recovery and a return to her home may not be realistic, I would help her see the current barriers and engage her in solutions, including self-monitoring of weight, a healthy diet, and increased physical activity and personal care.

      Pharmacist

      Nicole Brandt, PharmD, MBA
      Dr. Brandt is a professor and the executive director of the Lamy Center on Drug Therapy and Aging at the University of Maryland School of Pharmacy.
      Mrs. D’s fear of falling is certainly impacting her quality of life and function, so it’s important to investigate the risk factors for falls and determine if her medications are increasing her risk. I recommend that the IDT identify her treatment goals and priorities and develop a person-centered care plan.
      Based on review of her medications, the following areas/concerns should be addressed.
      • 1.
        Could the twice-daily dosing of furosemide be increasing her fall risk in the evening? Has she experienced orthostatic hypotension or dizziness?
      • 2.
        Could the daily ferrous sulfate be causing her constipation and abdominal distension? Also, her laboratory results do not show a compelling indication for her taking daily iron.
      • 3.
        Because sertraline is associated with falls/fracture, we must reevaluate its continued use. How long has she been taking sertraline at the current dose? Although her target symptoms are still present, her depression and feelings of “hopelessness” may be related to her current situation and thus are not treatable with medication. She may benefit more from counseling.
      • 4.
        It is unclear why she is on rabeprazole for gastroesophageal reflux disease (GERD). Is there still a compelling need for this treatment? It may be impacting her bone health and decreasing the absorption of elements such as potassium and iron and levels of B12 and magnesium.
      • 5.
        It would be helpful to determine whether osteoporosis treatment is indicated. Perhaps in Mrs. D’s case vitamin D supplementation is indicated, along with a discussion of options such as denosumab, which is safer than bisphosphonates for patients with chronic kidney disease/GERD.
      • 6.
        The team should address pain management and consider giving Mrs. D acetaminophen regularly. Also Mrs. D should be engaged in physical therapy.
      • 7.
        The team should discuss the risks/benefits of continuing the atorvastatin. There are no noted “events” in Mrs. D’s case (such as stroke or myocardial infarction) that warrant its use.
      • 8.
        The IDT also should address Mrs. D’s health maintenance and vaccinations, including providing her with the influenza, pneumonia, and shingles vaccines.

      Activities Director

      Diane Mockbee, BS, AC-BC
      Ms. Mockbee is an Activity Consultant/Educator – Board Certified through the National Association of Activity Professionals Credentialing Center. She had worked as an activity director and dementia trainer in long-term care for over 28 years until retiring in 2018. She currently consults and speaks in a variety of settings.
      The activities director should coordinate with therapy and nursing to engage Mrs. D in an exercise plan to increase her activity level and potentially lower her risk for heart-related events. The activities and exercise plan should incorporate her favorite music to make it more enjoyable and enhance her mood. Helping Mrs. D regain her confidence and develop her endurance is an important step toward determining whether a walking program can be recommended.
      I would also encourage Mrs. D to dine and socialize with others. After a thorough assessment of her interests, I would also invite her to join in various activities.

      Behavioral Health Specialist

      Lori Nisson, MSW, LCSW
      Ms. Nisson is family & community services director at Banner Alzheimer’s Institute/Banner Sun Health Research Institute. She has spent more than 20 years specializing in clinical and leadership positions, serving the needs of patients and families coping with emotional, neurological, and behavioral problems.
      If Mrs. D’s depression is connected to her move into long-term care, a transitions or loss support group may be a helpful intervention. Another important intervention would be facility-based, individual counseling to help Mrs. D adjust to her declining health and manage her anxiety related to fear of falls as well as her transition into long-term care.
      If counseling demonstrates a benefit (reassessment using the Patient Health Questionnaire-9), her husband might be included in her future sessions to help support their relationship during their separate living arrangements.

      Social Worker

      Paige Hector, LMSW
      Ms. Hector is a social work expert and a coeditor of this column.
      Mrs. D is experiencing multiple life transitions and changes that may also be experienced as losses: declining health and a new living arrangement that involves a separation from her husband. In addition to a thorough depression assessment, the staff should screen Mrs. D for the presence of trauma; if appropriate, she should be engaged in counseling to assist her with these life changes.
      Using a trauma-informed lens, the staff should approach Mrs. D from a perspective of what is happening in her life rather than what is wrong with her. To assess her strengths, the questions should include “What makes a good day for you?,” “How many good days have you had in the past two weeks?,” “How have you overcome obstacles in the past?,” and “What do you consider your strengths?” Then we should incorporate a strengths approach into her care plan to help empower her, given her current life circumstances and challenges.
      The social worker should collaborate with Mrs. D and her husband to complete a thorough biopsychosocial-spiritual assessment to identify their goals, resources, and backup plans. Each of their perspectives on the current situation should be explored, including whether discharge is a viable plan.
      The social worker also should be skilled with contributing to a pain assessment from a biopsychosocial perspective, which includes questions such as “What does the pain mean to you?,” “When is the pain not happening?,” “What has this been like for you?,” “What have you given up to accommodate the pain?,” “What has been the most difficult adjustment?,” “What do you miss the most?,” and “What are you most afraid of?” These questions embrace a person-centered approach to care and can help validate Mrs. D’s experiences as well as facilitate insight into her current situation.

      Summary

      The IDT identified helpful suggestions and emphasized a person-centered approach to care and quality of life. The team recognized the strength of other disciplines in helping Mrs. D with medical and pharmacological management, with an emphasis on deprescribing and eliminating medications that might be causing harm. The philosophy of care is to engage Mrs. D in meaningful activities, engender hope, and bolster her motivation. Nursing was not specifically included in this IDT review, but the informal input was that the nursing staff would focus on helping Mrs. D optimize her cardiac function by monitoring her fluids, encouraging her dietary intake, managing her pain, and encouraging her to engage in activities. Likewise, a dietician and therapy would help optimize Mrs. D’s intake, function, and physical activity.
      The interdisciplinary approach was important in combining each discipline’s unique perspective in a balanced set of recommendations:
      • Address the medical issues and optimize Mrs. D’s cardiac function to decrease her symptoms and improve her quality of life.
      • Deprescribe as appropriate to decrease the negative impact of medications and optimize the value of appropriate medication use.
      • Implement interventions to assist adjustment to the long-term care community for Mrs. D while maintaining her hope of improvement.
      • Develop a person-centered care approach that recognizes the traumas of her decline in health and change in living environment.
      • Engage Mrs. D in activities that she enjoys, that incorporate her strengths and resilience. This will include working with her husband to ensure that he is able to participate in her plan of care.
      Dr. Resnick is the Sonya Ziporkin Gershowitz Chair in Gerontology at the University of Maryland School of Nursing in Baltimore. She is also a member of the Editorial Advisory Board for Caring for the Ages.
      Ms. Hector is a clinical educator and professional speaker specializing in clinical operations for the interdisciplinary team, process improvement and statistical theory, risk management and end-of-life care, and palliative care, among other topics. She is a member of the Editorial Advisory Board for Caring for the Ages. She is passionate about nursing homes and supporting staff to care for the most vulnerable people in their communities.