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Prevalence of heart failure in nursing homes: a systematicliterature review Marie¨lle A. M. J. Daamen MD (Nursing Home Physician)1, Jos M. G. A. Schols MD, PhD (Nursing HomePhysician, Professor)2, Tiny Jaarsma RN, PhD (Associate Professor)3 and Jan P. H. Hamers RN, PhD (Professor)41MeanderGroep Zuid-Limburg Kerkrade and School for Public Health & Primary Care, Department of Health Care and Nursing Science,Maastricht University, Maastricht, 2School for Public Health & Primary Care, Department of General Practice, Maastricht University,Maastricht, 3Department of Cardiology, University Medical Center Groningen, Groningen and 4School for Public Health & Primary Care,Department of Health Care and Nursing Science, Maastricht University, Maastricht, The Netherlands (range 15–45%) and that there is a significant level of co- Prevalence of heart failure in nursing homes: a obstructive pulmonary disease) in nursing home residentswith heart failure.
Introduction: Heart failure is an important problem in Conclusion: The reported prevalence of heart failure in western countries. In nursing home residents heart failure nursing home residents is higher than in the general is expected to be highly prevalent. However, accurate population and is associated with considerably co- diagnosis of heart failure in these patients is often ham- morbidity. However there are also indications that the pered due to atypical findings and concomitant co-mor- prevalence of heart failure in nursing home residents is bidity. In order to deliver adequate nursing care and underestimated, negatively affecting quality of life and medical treatment, it is important to get insight into the quality of care. Therefore, prospective prevalence studies prevalence of heart failure in this target group of patients.
and studies aiming to improve the care for nursing home Objectives: To assess the prevalence of heart failure as well residents with heart failure are warranted.
as the co-morbidity interfering with heart failure in nurs-ing home residents.
Keywords: heart failure, prevalence, elderly, nursing Methods and results: A systematic literature review was homes, co-morbidity, literature review.
conducted in Medline, Embase, Cinahl and the CochraneLibrary. Ten studies were ultimately included. Findings Submitted 18 September 2008, Accepted 1 March 2009 indicate that the mean prevalence of heart failure is 20% The mean age of the heart failure population is currently 74 years and incidence and prevalence increase with age Heart failure is particularly a disease of the elderly and an (5, 6). Frail elderly persons living in nursing homes rep- increasing clinical problem in western countries (1).
resent a specific patient group, with high levels of care Its prevalence and incidence are expected to increase in dependency due to their disabilities, resulting from disease the future, mainly as a result of reduced mortality from (7). Heart failure is expected to be particularly prevalent in coronary heart disease and stroke. In western countries the this population, but reliable data are lacking because prevalence of heart failure in the general population ran- nursing home residents are often excluded from clinical ges from 3–13% for those over 65 years (2): in the Neth- erlands the prevalence is estimated at 13% in persons of 75 Heart failure is a clinical syndrome that in general is or older (3) and patients are treated both by cardiologists diagnosed by way of symptoms and physical findings.
Many definitions of heart failure exists, but in recent years,most definitions of heart failure have emphasised the needfor both the presence of symptoms of heart failure andphysical signs of fluid retention (5).
However, diagnosis of heart failure in elderly patients, Marie¨lle A. M. J. Daamen, School for Public Health & Primary Care, including nursing home residents, is often delayed due Department of Health Care and Nursing Science, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands.
to an atypical presentation of clinical findings (8).
Accurate diagnosis of the presence and aetiology of heart Ó 2010 The Authors. Journal compilation Ó 2010 Nordic College of Caring Science Prevalence of heart failure in nursing homes failure in older patients is even more difficult and hampered by the often concomitant co-morbidity. Fre-quent concomitant diseases in older patients with heart To evaluate the quality of the included studies, we adapted failure are hypertension (38%), obstructive lung disease criteria from existing scales for assessing the quality of (25%), diabetes (29%) and stroke (26%) (9). These other designs (13, 14) into an assessment scale for diseases often show characteristic signs and symptoms descriptive studies. To assess face validity, the scale was simillar to those of heart failure (e.g. breathlessness, judged by two experts on research methodology and sys- ankle swelling and fatigue) and thus may be difficult to tematic reviews affiliated with Maastricht University.
The items included in the scale were divided into: aim and Early diagnosis and treatment may therefore prevent research question, design, sample, datacollection, data- progression of heart failure and lead to improvement of analysis and conclusion. In total there were 13 items to symptoms and quality of life (10). Results of clinical trials answer. Criteria could be rated as no (0), doubt (1) or yes (2).
have established that adequate pharmacologic therapy The theoretical score on the assessment scale ranges from 0 reduces morbidity and mortality in heart failure patients (very poor quality) to 26 (excellent quality). Two reviewers (5, 10–12). Improvement of symptoms and quality of life (reviewers’ names on request) have assessed the quality of are especially important in the care for nursing home the selected articles. The empirical scores ranged from 7–24.
residents. Up until now, however, knowledge regarding Studies that scored less than 10 were considered to be of diagnosis and treatment of heart failure in this growing poor quality, and excluded from the review.
and vulnerable population is lacking. It must be em-phasised especially that early diagnosis and subsequent tailor made therapy may lead to improvement of qualityof life in this specific group of patients. Therefore more Inclusion and quality assessment of studies knowledge about heart failure in this specific group isnecessary.
The first selection was performed by one reviewer We performed a literature review on heart failure in screening all hits on title and/or abstract. After including nursing home residents, using the following research all abstracts containing ‘heart failure and the elderly patient’ or ‘heart failure and nursing home/long-term care’ • What is the prevalence of heart failure in nursing 40 abstracts remained. Of these 18 were excluded because they did not meet specific inclusioncriteria (prevalence, • Which co-morbidity interferes mostly with the diagnosis diagnosis, symptoms, co-morbidity and clinical character- of heart failure in elderly nursing home residents? istics) as judged by two reviewers or because they were notwritten in English, Dutch, German or Italian. The full textof the remaining 22 was screened by two reviewers to judge their relevance to the research questions. Finally, 12articles were included in the review (15–26). Though there was no specific time period, the most dated publication was We conducted a systematic literature review using the following computer databases: Medline, Embase, Cinahl There was complete consensus between the reviewers and the Cochrane Library. In addition Evidence-Based on quality assessment for seven articles, three turned up Cardiovascular Medicine as a secondary journal as well as minor disagreement and two (20, 24) required further research and trial registers were searched. References and discussion due to pronounced disagreement. For a final citations in selected journals were screened.
reliability check two articles were assessed by a third re-viewer. This assessment resulted in complete consensusbetween the reviewers.
Subsequently, two studies (20, 22) were excluded for Selected keywords were used in several combinations; having scored <10 on the quality assessment scale, due to these were, heart failure, congestive heart failure, left limitations in the data collection and analysis.
ventricular dysfunction, diastolic heartfailure, cardiac Ultimately leaving 10 studies which met the inclusion failure, elderly, older patients, ageing population, aged, criteria and were of sufficient methodological quality.
geriatrics, nursing home residents, long-term care resi-dents, chronic care, prevalence, diagnosis, co-morbidity, symptoms and diagnostic interfering.
The search was not limited to a specific period but arti- The studies described the clinical and functional charac- cles (written in English, Dutch, German and Italian) teristics of residents in long-term care, nursing homes or should have been published before January 2008.
geriatric centres (summarised in Table 1). The number of Ó 2010 The Authors. Journal compilation Ó 2010 Nordic College of Caring Science Ó 2010 The Authors. Journal compilation Ó 2010 Nordic College of Caring Science Prevalence of heart failure in nursing homes Ó 2010 The Authors. Journal compilation Ó 2010 Nordic College of Caring Science patients in the studies included varied from 80 patients (24) to 86.094 (23). More women participated than menand the mean age ranged from 79 to 89 years. Three Coronary artery disease and arrhythmias (most frequent studies used a cross- sectional approach (16, 24, 25), while atrial fibrillation) were the most common primary cardiac the others used retrospective designs.
diagnoses underlying heart failure. Noncardiovascular co-morbidities also were very common, especially diabetesmellitus (11–38%), chronic obstructive pulmonary disease (COPD) (12–36%), dementia (9–73%) and hypertension The prevalence of heart failure in nursing homes was determined in five studies (15, 16, 23–25). In four studiesits prevalence in long-term care settings varied from 15– 20% with one exceptional prevalence rate of 45% in thefifth study (24). In this study by Butler, heart failure was This is the first systematic literature review of the preva- diagnosed in every patient after concrete examination by a lence of heart failure in nursing home residents and its geriatrician, while in the other four, information from associated co-morbidity. Though the number of studies medical records was used to confirm the diagnosis of heart included is low, they show that, heart failure in nursing homes is indeed prevalent and that COPD, dementiaand diabetes mellitus are frequently associated with itsdiagnosis.
The studies indicate that about 20% (range 15–45%) of The criteria for verifying the diagnosis of heart failure were nursing home residents suffer from heart failure. This fig- based on different criteria in each study (see Table 2).
ure is higher than in the general population (3–13%) and Three studies (17, 19, 21) used the international classifi- can be explained by the fact that prevalence increases with cation of diseases codes, two (15, 25) were based on age; the mean age of the studypopulations ranged between pharmaceutical data, four (16, 18, 23, 25) on clinical and radiological signs and in the final study a staff physician As shown in the results, there was one exceptional coded the diagnosis. In two studies (16, 19) the diagnosis prevalence value of heart failure (45%). In this study (24) was confirmed, one used the ‘Boston criteria’ (27) and the heart failure was diagnosed after concrete examinination other used the modified Framingham criteria (28).
by a geriatrician. It may be possible, that in studies using Criteria used to verify the diagnosis of heart failure Presence of heart failure was defined as documentation by a physician in the pharmacy database or health record Diagnosis heart failure if pulmonary edema or symptomatic left ventricular dysfunction was record in the chart.
The adequacy of information supporting the diagnosis of heart failure was gauged against the boston criteria Identification was done using the ICD-9 CM codes 428 and 402.91. The diagnosis of heart failure was verified Presence of either documented pulmonary edema on chest X-ray in the nursing home or a hospital discharge diagnosis of heart failure and two or more of the following clinical signs/symptoms: increased dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, massive edema or altered sensorium Identification was done using the International Classifications of Disease 9th Revision, clinical Modification modes 428 (heart failure) and 402.91 (Hypertensive Heart Disease with congestive heart failure) and the DRG code 127 (Heart Failure) Modified Framingham heart failure diagnostic criteria based on the available data were used to Discharge diagnosis was identified by any of the following ICD-9 codes 402.01, 402.11, 402.91, 404.01, 404.11, 404.91, Staff physician coded a diagnosis of heart failure using information obtained from the medical record, including the physical examination of the resident, medication and other treatment orders and hospital discharge documentation (available for 78%) Interrater trials, kappa coefficient for the diagnosis of chronic heart failure was >80 Examination by a consultant geriatrician. Blood tests were completed if they had not been performed in the previous year.
Diagnosis reviewed with hospitel records where possible Using the pharmacy databases to identify patients with a recorded diagnosis of heart failure. Diagnosis from pharmacy databases verified by identifying a similar diagnosis in patients medical records in the facilities Congestive heart failure defined as with symptoms and signs of chronic heart failure and chest radiograph showing Ó 2010 The Authors. Journal compilation Ó 2010 Nordic College of Caring Science Prevalence of heart failure in nursing homes only medical records the prevalence of heart failure is medical and nursing practise for heart failure in this target underestimated. The study of Barents 2008 (29) con- cluded that both undetected and incorrect diagnoses of Recognising, diagnosing and treating heart failure early chronic heart failure in nursing home residents were and adequately remains a real challenge. Early diagnosis and treatment may prevent progression of the disease and Concomitant co-morbidity may also interfere with heart lead to the improvement of disabling symptoms, ultimately failure diagnosing in nursing home residents. Our results resulting in an overall improvement in quality of life.
show that nursing home residents indeed experience Nursing home residents should not be excluded from considerable co-morbidity. However, this is to be expected given the fact that nursing home admission usually takesplace when there is high care dependency due to restric- tions and disabilities caused by several diseases (7).
Dementia, diabetes mellitus and especially COPD are fre- MvdV search strategy, review of the literature, preparation quently associated with heart failure as is shown in the of the manuscript. JS review of the literature, discussion of studies reviewed. However, Rutten 2005 (30) showed that the manuscript. JH review of the literature, discussion of unrecognised heart failure was present in about 21% of the manuscript. TJ discussion of the Manuscript.
elderly in the general COPD population. It can be assumedthat this also concerns nursing home residents. This means that a characteristic symptom of heart failure such asbreathlessness often may be misinterpreted.
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