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Optimisation of Heart Failure Management in Nursing Homes Using Point-of-Care Ultrasonography: Harmonious Trial Rationale and Design. Zdr Varst 2020; 59:128-136. [PMID: 32952713 PMCID: PMC7478089 DOI: 10.2478/sjph-2020-0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 05/07/2020] [Indexed: 12/28/2022] Open
Abstract
Introduction Heart failure is common in the nursing home population and presents many diagnostic and therapeutic challenges. Point-of-care ultrasonography is a bedside method that can be used to assess volume status more reliably than clinical examination. This trial was conceived to test whether point-of-care ultrasonography-guided management improves heart failure outcomes among nursing home residents. Methods Nursing home residents with heart failure will be enrolled in a multi-centre, prospective, randomised controlled trial. Residents will first be screened for heart failure. Patients with heart failure will be randomised in 1:1 fashion into two groups. Nursing home physicians will adjust diuretic therapy according to volume status for six months. Point-of-care ultrasonography will be used in the test group and clinical examination in the control group. The primary endpoint will be heart failure deterioration, defined as a composite of any of the following four events: the need for an intravenous diuretic application, the need for an emergency service intervention, the need for unplanned hospitalisation for non-injury causes, or death from whatever cause. Expected results The expected prevalence of heart failure among nursing home residents is above 10%. Point-of-care ultrasonography-guided heart failure management will reduce the number of deteriorations of heart failure in the nursing home population. Conclusion This study will explore the usefulness of point-of-care ultrasonography for heart failure management in the nursing home population.
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Homar V, Mirosevic S, Svab I, Lainscak M. Natriuretic peptides for heart failure screening in nursing homes: a systematic review. Heart Fail Rev 2020; 26:1131-1140. [PMID: 32200491 DOI: 10.1007/s10741-020-09944-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The high burden of heart failure in nursing-home populations is due to advanced age and comorbidities. Heart failure is often undiagnosed or misdiagnosed in this population and therefore remains untreated. We review the use of natriuretic peptide biomarkers for screening heart failure in nursing-home residents. The study was performed in accordance with recommendations from the Cochrane Collaboration using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) and is registered in PROSPERO Register of Systematic Reviews. Databases PubMed, Embase, and Trip were searched from 2000 to March 2019, supplemented by hand-searching of references. Studies investigating the nursing-home population were included. The prevalence of heart failure among nursing-home residents was higher than in the general population of comparable age (23% vs 10%, respectively). The rate of misdiagnosis in nursing homes ranged from 25 to 76%. NT-proBNP was the most commonly used natriuretic peptide biomarker for heart failure screening. The mean value of NT-proBNP was significantly higher in residents with heart failure than in residents overall (pooled means of 2409 pg/mL vs 1074 pg/mL, respectively). In comparison with current guidelines, the proposed cut-off values for ruling out heart failure were higher in the analyzed studies, with ranges of 230-760 pg/mL for NT-proBNP and 50-115 pg/mL for BNP. NT-proBNP and BNP are used for screening heart failure in the nursing-home population. The current screening cut-off values are probably too low for use in nursing homes. Our most conservative estimation for ruling out heart failure is an NT-proBNP cut-off value of 230 pg/mL.
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Affiliation(s)
- Vesna Homar
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, 56 Poljanski nasip, 1000, Ljubljana, Slovenia. .,Community Health Centre Vrhnika, Vrhnika, Slovenia.
| | - Spela Mirosevic
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, 56 Poljanski nasip, 1000, Ljubljana, Slovenia
| | - Igor Svab
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, 56 Poljanski nasip, 1000, Ljubljana, Slovenia
| | - Mitja Lainscak
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, 56 Poljanski nasip, 1000, Ljubljana, Slovenia.,Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia
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Westerlind B, Östgren CJ, Midlöv P, Marcusson J. Diagnostic Failure of Cognitive Impairment in Nursing Home Residents May Lead to Impaired Medical Care. Dement Geriatr Cogn Disord 2020; 47:209-218. [PMID: 31269489 DOI: 10.1159/000499671] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 03/09/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND/OBJECTIVES Dementia and cognitive impairment are common in nursing homes. Few studies have studied the impact of unnoted cognitive impairment on medical care. This study aimed to estimate the prevalence of diagnostic failure of cognitive impairment in a sample of Swedish nursing home residents and to analyze whether diagnostic failure was associated with impaired medical care. METHOD A total of 428 nursing home residents were investigated during 2008-2011. Subjects without dementia diagnosis were grouped by result of the Mini Mental State Examination (MMSE), where subjects with <24 points formed a possible dementia group and the remaining subjects a control group. A third group consisted of subjects with diagnosed dementia. These three groups were compared according to baseline data, laboratory findings, drug use, and mortality. RESULTS Dementia was previously diagnosed in 181 subjects (42%). Among subjects without a dementia diagnosis, 72% were cognitively impaired with possible dementia (MMSE <24). These subjects were significantly older, did not get anti-dementia treatment, and had higher levels of brain natriuretic peptide compared to the diagnosed dementia group, but the risks of malnutrition and pressure ulcers were similar to the dementia group. CONCLUSIONS Unnoted cognitive impairment is common in nursing home residents and may conceal other potentially treatable conditions such as heart failure. The results highlight a need to pay increased attention to cognitive impairment among nursing home residents.
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Affiliation(s)
- Björn Westerlind
- Department of Geriatrics, County Hospital Ryhov, Region Jönköping County, Jönköping, Sweden, .,Geriatric Medicine, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden,
| | - Carl Johan Östgren
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Patrik Midlöv
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Malmö, Sweden
| | - Jan Marcusson
- Geriatric Medicine, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Kańtoch A, Gryglewska B, Wójkowska-Mach J, Heczko P, Grodzicki T. Treatment of Cardiovascular Diseases Among Elderly Residents of Long-term Care Facilities. J Am Med Dir Assoc 2019; 19:428-432. [PMID: 29402648 DOI: 10.1016/j.jamda.2017.12.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 12/29/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND The prevalence of cardiovascular diseases among nursing home residents is high but little is known whether pharmacologic therapy recommended by actual medication guidelines is followed by facility's staff. AIM To evaluate the adherence to actual guidelines for treatment of cardiovascular diseases among older adult residents of long-term care (LTC) facilities. MATERIAL AND METHODS The cross-sectional study was performed from December 2009 to November 2010 among 189 elderly residents aged ≥60 years in 3 LTC facilities in Poland: 1 long-term care hospital (LTCH) and 2 nursing homes (NHs). The initial evaluation included analysis of medical documentation (all diagnosed diseases and used drugs), blood pressure (BP) measurements and performance of Mini Nutritional Assessment Short-Form (MNA-SF), Abbreviated Mental Test Score (AMTS), Activities of Daily Living (ADL) score, and Barthel Index. Prescribed medication for hypertension (HT), heart failure (HF), and coronary heart disease (CHD) were compared to current European Cardiology Society (ESC), and European Society of Hypertension (ESH) medication guidelines. Residents were divided into 3 subgroups: with HT, HF, and CHD. Results were presented as means and standard deviation. Groups were compared using Mann-Whitney U test for nonparametric data and chi-square test to assess differences in distribution of categorical variables. P values <.05 were considered statistically significant. RESULTS CHD was diagnosed among 114 residents (60.3%) but only 60.5% of them were treated with aspirin (ASA), 45.6% with beta-blockers (BBs), 60.5% with angiotensin-converting enzyme inhibitor (ACEI), and 24.6% with statins. HF observed in 75% of cases was treated by using ACEI (54.7%), BBs (45.3%), loop diuretics (LDs, 36%), mineralocorticoid-receptor antagonists (MRAs, 21.3%). HT was diagnosed among 98 study participants (51.9%) and in the majority of cases (76.6%) was well controlled (mean BP: 133.7 ± 17.6/73.8 ± 10.2 mmHg). The most popular antihypertensive drugs were ACEIs (77.6%), BBs (40.8%) and calcium channel blockers (CCBs, 26.5%) whereas thiazides, alpha-blockers (ABs), and angiotensin receptor blockers (ARBs) were used less frequently. CONCLUSION In summary, the study showed that insufficient treatment of cardiovascular diseases among elderly residents of LTC facilities could be a potential risk factor of poor prognosis.
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Affiliation(s)
- Anna Kańtoch
- Department of Internal Medicine and Gerontology, Faculty of Medicine, Jagiellonian University Medical College, University Hospital in Kraków, Kraków, Poland.
| | - Barbara Gryglewska
- Department of Internal Medicine and Gerontology, Faculty of Medicine, Jagiellonian University Medical College, University Hospital in Kraków, Kraków, Poland
| | - Jadwiga Wójkowska-Mach
- Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Piotr Heczko
- Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Faculty of Medicine, Jagiellonian University Medical College, University Hospital in Kraków, Kraków, Poland
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Koudstaal S, Pujades‐Rodriguez M, Denaxas S, Gho JM, Shah AD, Yu N, Patel RS, Gale CP, Hoes AW, Cleland JG, Asselbergs FW, Hemingway H. Prognostic burden of heart failure recorded in primary care, acute hospital admissions, or both: a population-based linked electronic health record cohort study in 2.1 million people. Eur J Heart Fail 2017; 19:1119-1127. [PMID: 28008698 PMCID: PMC5420446 DOI: 10.1002/ejhf.709] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 10/25/2016] [Accepted: 11/04/2016] [Indexed: 12/11/2022] Open
Abstract
AIMS The prognosis of patients hospitalized for worsening heart failure (HF) is well described, but not that of patients managed solely in non-acute settings such as primary care or secondary outpatient care. We assessed the distribution of HF across levels of healthcare, and assessed the prognostic differences for patients with HF either recorded in primary care (including secondary outpatient care) (PC), hospital admissions alone, or known in both contexts. METHODS AND RESULTS This study was part of the CALIBER programme, which comprises linked data from primary care, hospital admissions, and death certificates for 2.1 million inhabitants of England. We identified 89 554 patients with newly recorded HF, of whom 23 547 (26%) were recorded in PC but never hospitalized, 30 629 (34%) in hospital admissions but not known in PC, 23 681 (27%) in both, and 11 697 (13%) in death certificates only. The highest prescription rates of ACE inhibitors, beta-blockers, and mineralocorticoid receptor antagonists was found in patients known in both contexts. The respective 5-year survival in the first three groups was 43.9% [95% confidence interval (CI) 43.2-44.6%], 21.7% (95% CI 21.1-22.2%), and 39.8% (95% CI 39.2-40.5%), compared with 88.1% (95% CI 87.9-88.3%) in the age- and sex-matched general population. CONCLUSION In the general population, one in four patients with HF will not be hospitalized for worsening HF within a median follow-up of 1.7 years, yet they still have a poor 5-year prognosis. Patients admitted to hospital with worsening HF but not known with HF in primary care have the worst prognosis and management. Mitigating the prognostic burden of HF requires greater consistency across primary and secondary care in the identification, profiling, and treatment of patients. TRIAL REGISTRATION NCT02551016.
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Affiliation(s)
- Stefan Koudstaal
- Farr Institute of Health Informatics ResearchLondonUK
- UCL Institute of Health InformaticsUniversity College LondonLondonUK
- Department of CardiologyUniversity Medical Centre UtrechtUtrechtThe Netherlands
| | - Mar Pujades‐Rodriguez
- Farr Institute of Health Informatics ResearchLondonUK
- UCL Institute of Health InformaticsUniversity College LondonLondonUK
| | - Spiros Denaxas
- Farr Institute of Health Informatics ResearchLondonUK
- UCL Institute of Health InformaticsUniversity College LondonLondonUK
| | - Johannes M.I.H. Gho
- Department of CardiologyUniversity Medical Centre UtrechtUtrechtThe Netherlands
| | - Anoop D. Shah
- Farr Institute of Health Informatics ResearchLondonUK
- UCL Institute of Health InformaticsUniversity College LondonLondonUK
| | - Ning Yu
- Farr Institute of Health Informatics ResearchLondonUK
- UCL Institute of Health InformaticsUniversity College LondonLondonUK
| | - Riyaz S. Patel
- Farr Institute of Health Informatics ResearchLondonUK
- UCL Institute of Health InformaticsUniversity College LondonLondonUK
- UCL Institute of Cardiovascular SciencesUniversity College LondonLondonUK
| | - Chris P. Gale
- Leeds Institute of Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
| | - Arno W. Hoes
- Julius Centre for Health Sciences and Primary CareUniversity Medical Centre UtrechtUtrechtThe Netherlands
| | - John G. Cleland
- Faculty of Medicine, National Heart & Lung InstituteImperial College LondonLondonUK
| | - Folkert W. Asselbergs
- Farr Institute of Health Informatics ResearchLondonUK
- UCL Institute of Health InformaticsUniversity College LondonLondonUK
- Department of CardiologyUniversity Medical Centre UtrechtUtrechtThe Netherlands
| | - Harry Hemingway
- Farr Institute of Health Informatics ResearchLondonUK
- UCL Institute of Health InformaticsUniversity College LondonLondonUK
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Bolmsjö BB, Mölstad S, Gallagher M, Chalmers J, Östgren CJ, Midlöv P. Risk factors and consequences of decreased kidney function in nursing home residents: A longitudinal study. Geriatr Gerontol Int 2016; 17:791-797. [DOI: 10.1111/ggi.12789] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 02/16/2016] [Accepted: 02/24/2016] [Indexed: 01/04/2023]
Affiliation(s)
| | - Sigvard Mölstad
- Department of Clinical Sciences; Lund University; Malmö Sweden
| | - Martin Gallagher
- The George Institute for Global Health; Sydney Medical School, University of Sydney; NSW Australia
| | - John Chalmers
- The George Institute for Global Health; Sydney Medical School, University of Sydney; NSW Australia
| | - Carl Johan Östgren
- Department of Medical and Health Sciences, Primary Care; Linköping University; Linköping Sweden
| | - Patrik Midlöv
- Department of Clinical Sciences; Lund University; Malmö Sweden
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Abstract
Background For the treatment of chronic heart failure (HF), both pharmacological and non-pharmacological treatment should be employed in HF patients. Although HF is highly prevalent in nursing home residents, it is not clear whether the recommendations in the guidelines for pharmacological therapy also are followed in nursing home residents. The aim of this study is to investigate how HF is treated in nursing home residents and to determine to what extent the current treatment corresponds to the guidelines. Methods Nursing home residents of five large nursing home care organizations in the southern part of the Netherlands with a previous diagnosis of HF based on medical records irrespective of the left ventricle ejection fraction (LVEF) were included in this cross-sectional design study. Data were gathered on the (medical) records, which included clinical characteristics and pharmacological- and non-pharmacological treatment. Echocardiography was used as part of the study to determine the LVEF. Results Out of 501 residents, 112 had a diagnosis of HF at inclusion. One-third of them received an ACE-inhibitor and 40% used a β-blocker. In 66%, there was a prescription of diuretics with a preference of a loop diuretic. Focusing on the residents with a LVEF ≤ 40%, only 46% of the 22 residents used an ACE-inhibitor and 64% a β-blocker. The median daily doses of prescribed medication were lower than those that were recommended by the guidelines. Non-pharmacological interventions were recorded in almost none of the residents with HF. Conclusions The recommended medical therapy of HF was often not prescribed; if prescribed, the dosage was usually far below what was recommended. In addition, non-pharmacological interventions were mostly not used at all.
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Bolmsjö BB, Strandberg EL, Midlöv P, Brorsson A. "It is meaningful; I feel that I can make a difference" -A qualitative study about GPs' experiences of work at nursing homes in Sweden. BMC FAMILY PRACTICE 2015; 16:111. [PMID: 26316028 PMCID: PMC4552343 DOI: 10.1186/s12875-015-0326-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/20/2015] [Indexed: 11/13/2022]
Abstract
Background Swedish nursing homes (NH) have limited capacity. As a result elderly people living in NH represent the part of the elderly population in most need of care. In Sweden a General Practitioner (GP) is usually responsible for the medical care of all subjects living in a NH. The residents in NH seldom have adequate pharmacological treatment according to diagnosis and often have polypharmacy and/or inappropriate medical treatment regarding concerns of declining renal function. What prevents optimal care for the elderly is multifaceted, but there is limited research on how GPs experience their work with the elderly in NH in Sweden. This study aims to illuminate the GPs’ work with the elderly in NH to provide input on how the care can be improved, as well as to identify potential obstacles for good quality of care. Methods This qualitative study is based on individual semi-structured interviews with 12 GPs and a follow-up focus group discussion with six of the interviewed GPs. The interviews were analysed with systematic text condensation, with the process leading to identify categories and themes. Thereafter, the themes were discussed among six of the participating GPs in a focus group interview. Results Two main themes were identified: concern for the patient and sustainable working conditions. The principal focus for the GPs was to contribute to the best possible quality of life for the patients. The GPs described discordance between the demand from staff for medications and the patients’ actual need of care. GPs found their work with NH enjoyable. Even though the patients at the NH often suffered from multiple illnesses, which could lead to difficult decisions being made, the doctors felt confident in their role by having a holistic view of the patient in tandem with reliable support from the nurse at the NH. Conclusion Working with NH patients was considered important and meaningful, with the GPs striving for the patient’s well-being with special consideration to the continuum of ageing. A continuous and well-functioning relationship between the GP and the nurse was crucial for the patients´ well-being.
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Affiliation(s)
- Beata Borgström Bolmsjö
- Center for Primary Health Care Research, Department of Clinical Sciences in Malmö, Lund University, Jan Waldenströms gata 35, SE 205 02, Malmö, Sweden.
| | - Eva Lena Strandberg
- Center for Primary Health Care Research, Department of Clinical Sciences in Malmö, Lund University, Jan Waldenströms gata 35, SE 205 02, Malmö, Sweden. .,Blekinge Centre of Competence, Karlskrona, Sweden.
| | - Patrik Midlöv
- Center for Primary Health Care Research, Department of Clinical Sciences in Malmö, Lund University, Jan Waldenströms gata 35, SE 205 02, Malmö, Sweden.
| | - Annika Brorsson
- Center for Primary Health Care Research, Department of Clinical Sciences in Malmö, Lund University, Jan Waldenströms gata 35, SE 205 02, Malmö, Sweden.
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Latini R, Masson S. NT-proBNP: A Guide to Improve the Management of Patients with Heart Failure. EJIFCC 2014; 24:78-84. [PMID: 27683441 PMCID: PMC4975180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
N-terminal prohormone of brain natriuretic peptide (NT-proBNP) is a versatile biomarker, that has been extensively studied in large cohorts of individuals in the general population, in subjects at risk for developing left ventricular dysfunction and cardiovascular events, and in patients with chronic or acutely decompensated heart failure (HF). In this paper, the pros and cons of using natriuretic peptide testing to manage patients with HF are presented and discussed over 3 broad areas: (1) dyspnea triage in the emergency room, (2) natriuretic peptide-guided treatment of chronic HF, and (3) management of patients with HF in primary care and nursing homes.
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Affiliation(s)
- Roberto Latini
- Istituto “Mario Negri” via Giuseppe La Masa 19 20156 Milan - Italy +39 239 014 454+39 233 200 049
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