Transcript Slide 1

Transitioning to Adult-Gerontology
APRN Education: Slide Library
Assessment and Management of Hypertension
and Heart Failure in Older Adults
Authors: Deborah A. Chyun, PhD, RN, FAHA, NYU College of Nursing
Jessica Coviello, MSN, APRN, Yale University School of Nursing
Sharon A. Stephen, PhD, RN, GNP-BC, xxx
Adult-Gerontology APRN Slide Library
• The APRN Slide Library is a resource of
“Transitioning to Adult-Gerontology APRN
Education” a project of AACN and the Hartford
Institute for Geriatric Nursing 2010-2012
• The project is funded by the John A. Hartford
Foundation
Adult-Gerontology APRN Slide Library
"All materials are jointly copyrighted by the American
Association of Colleges of Nursing (AACN) and The Hartford
Institute for Geriatric Nursing, College of Nursing, New York
University or are used with permission from the original source.
Permission is hereby granted to reproduce, post, download,
and/or distribute, this material for not-for-profit educational
purposes only, provided that the American Association of
Colleges of Nursing (AACN) and The Hartford Institute for
Geriatric Nursing, College of Nursing, New York University are
cited as the source. They may not be used for ANY commercial
or other purpose."
Available at www.hartfordign.org
E-mail notification of usage to: [email protected]
Further information about the APRN program can be found at
www.aacn.nche.edu/APRN Gerontology.htm
Purpose of the APRN Slide Library –
Hypertension and Heart Failure
• To provide APRN faculty with an overview of
hypertension (HTN) and heart failure (HF) in older
adults*
• To introduce APRN faculty to print and web
resources on assessment, diagnosis & management
of HTN and HF
• To provide APRN faculty with slides on HTN and HF to
use in class & to share with APRN students
* These slides have been modified from slides prepared for the Geriatric
Nursing Education Consortium (GNEC) program (www.aacn.nche.edu)
Web Resources
http: //www.ConsultGeriRN.org Try This ® and How to Try This
Specialty Practice Assessment Series, e.g.
• Cardiac Risk Assessment for the Older Cardiovascular Patient:
The Framingham Global Risk Assessment Tools
• SP4: Vascular Risk Assessment of the Older Cardiovascular
Patient: The Ankle-Brachial Index (ABI)
http: //www.ConsultGeriRN.org select Evidence-based Geriatric
Topics, e.g. protocol on Age Related Changes, Hydration, Urinary
Continence, Falls
Web-based Resources
Web-based Resources
Preventive
Cardiovascular Nurses
Association: Available on
line at: www.pcna.net
American Heart
Association Council on
Cardiovascular
Nursing: Available on
line at: http:
my.americanheart.org
Joint National Committee
on Prevention, Detection,
Evaluation, and
Treatment of High Blood
Pressure,
www.nhlbi.nih.gov/guideli
nes/hypertension/ -
Additional information
Available at:
www.learn.gwtg.ameri
canheart.org
Web-based Resources
American Association of
Heart Failure Nurses:
Available on line at:
http:www.aahfn.org
Failure is
Not an
Option
campaign
Patient education
modules
The University of Iowa College
of Nursing Evidence-based
Practice Guideline: Order
sheets available on line at:
www.nursing.uiowa.edu/
centers/gnirc/rtdcore.htm
Assessing Heart Failure in
Long Term Care Facilities
Web-based Resources
Practice Guidelines from American
Medical Directors Association (AMDA):
Available online at: http:www.amda.com/
Dehydration and
Fluid
Management
HeartFailure
Source Books: Geriatrics
Auerhahn, C., Capezuti, E., Flaherty, E., & Resnick, B. (eds.) (2007). Geriatric Nursing
Review Syllabus: A Core Curriculum in Advanced Practice Geriatric Nursing, 2nd
Edition: New York: American Geriatrics Society. (3rd Edition, May, 2011)
•
•
•
A concise & comprehensive text developed by the American Geriatrics Society (AGS) & the
NYU Hartford Institute for Geriatric Nursing , adapted for APRNs from the AGS Geriatrics
Review Syllabus: A Core Curriculum in Geriatric Medicine, 6th Edition
Authored by > 100 interdisciplinary experts in care of older adults
59 chapters on prevailing management strategies, extensive reference, appendix with
assessment instruments, 100 case-oriented, multiple choice questions and a self-assessment
tool. (www.americangeriatrics.org/.../the_geriatric_nursing_review_syllabus_2nd_edition/
Auerhahn, C. & Kennedy-Malone, L. (2010). Integrating Gerontological Content into
Advanced Practice Nursing Education. New York: Springer Publishing Co.
•
•
•
•
Clear, user-friendly guidelines for integrating gerontological content into non-gerontological
APRN programs
Detailed lists of print resources and e-Learning materials
Utilizes a competency-based framework
“Success stories” written by APRN faculty who have integrated gerontological content into
non-gerontological courses
Module Objectives*
 Modify the APRN Hx and PE for older adults with HTN and HF
 Assess older adults for imminent and urgent emergencies arising
from moderate to severe HTN and HF
 Recognize risk for co-morbidities associated with HF in older
adults such as dehydration or fluid overload
 Develop and co-manage care plans for older adults with moderate
to severe HTN who are at risk for geriatric syndromes (e.g., take
diuretic medications and are at risk for urinary incontinence)
* Note: this module focuses only on HTN and HF as it pertains to
older adults
Background: Demographics
of HTN
 Untreated or under-treated
HTN leads to left ventricular
hypertrophy (LVH)
 Important marker for adverse
cardiac outcomes
 LVH increases with age
Incidence of HTN
Younger than 60 yo age had 26.9%
incidence
60-79 yo 58% incidence
Over 80 yo 70.9% incidence
 LVH occurs
 For over 70 yo ~
33% men; 49% women
Etiology: HTN in Older Adults
HTN is not an inevitable consequence of aging
Age-related changes in the cardiovascular system associated with HTN
 Arterial wall stiffening
 Aorta enlarges and decrease in compliance
 Increased systemic vascular resistance
 Increased systolic blood pressure (SBP)
 Decreased diastolic blood pressure (DBP)
 Widened pulse pressure result
 leading to an age-associated increase in left ventricular
(LV) mass
Etiology: HTN in Older Adults
 Increased LV mass places an increased mechanical demand upon
the heart.
 The pulse pressure is determined by the interaction between the
direct effect of ventricular ejection and the elastic properties of
the large arteries.
 After age 60, SBP continues to rise while DBP decreases creating
a wide pulse pressure.
HTN & Co-existing Orthostatic
Hypotension
 Blood pressure drops with changes in
position (orthostatic hypotension)
 Postural symptoms of lightheadedness or
dizziness with standing
 Symptoms of lightheadedness may be
delayed or absent altogether, giving no signal
or warning of an impending fall
HTN and Co-existing Orthostatic
Hypotension
 Autonomic nervous system responds to changes in position by
constricting veins and arteries and increasing heart rate and cardiac
contractility
Healthy Young
 Causes of orthostatic hypotension
 Medications
 Impaired venous return
 Hypovolemia and impaired cardiac
contractility
 Multi-system atrophy
 Diabetic neuropathy
Patients
muscle contraction
increases venous
return to the heart
and prevents blood
from pooling in the
lower extremities
HTN & Co-existing Orthostatic
Hypotension
 Detected on PE by measuring postural vital
signs
 Coexist with elevated blood pressure
 Systolic blood pressure of 190/60 supine and
170/50 standing
 Diagnostic for both orthostatic hypotension
and systolic HTN
Co-morbidities contributing to orthostatic
hypotension in older adults
Comorbidity / condition
Parkinson’s
Disease
Diabetes
Mellitus Type
2
Medications
(diuretics,
vasodilators)
Autonomic
Dysfunction
Volume Depletion
(dehydration)
Screening for HTN in Older Adults
 Screening essential for adequate treatment
 Current recommendations re-affirm the benefits
of screening in older adults
 Even for persons aged <80, treatment of HTN
reduces CVD morbidity and mortality
Demographics of Heart Failure (HF)
 Development of HF is associated with:
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Male sex
Lower level of education
Low levels of physical activity
Cigarette smoking
Obesity
DM
HTN
Valvular heart disease
LVH
CHD
75% affected
are over 65 yo
5M
HF
75% with HF have antecedent
HTN. Both the incidence and
prevalence of HF will rise as
population ages
Demographics of HF in Older Adults
 Multiple co-morbidities complicate assessment
and management of HTN and HF
 DM is a potent contributor to HF
Note
Note
DM associated with
higher HF-related
morbidity and mortality
Older patients with DM,
22% HF diagnosis with
the prevalence
increased with
increasing age
Note
High Risk for
HF: Women
with DM &
those treated
with insulin
Demographics of HF
Note
Older age, female gender, insulin
treatment, previous MI, coronary artery
bypass graft surgery, renal insufficiency,
or HTN, low left ventricular ejection
fraction or clinical HF are all associated
with an increased risk of subsequent HF
admission
Demographics of HF
25%
17%
Note
11%
After MI or coronary revascularization
procedures, individuals with DM high
morbidity and mortality, partly due to the
development of HF
Note
Year following MI, 11% of patients without DM, 17% of patients
with DM on oral agents 25% of those treated with insulin were
admitted for HF
Etiology: HF
 Atherosclerotic CHD is the most common etiology of HF in the
US, followed closely by HTN alone and valvular disease
 Thyroid dysfunction and excessive alcohol
intake
 Abnormalities in contractile function (systolic
dysfunction) and filling (diastolic dysfunction)
may result from myocardial ischemia.
Consider the possibility of
asymptomatic or silent
ischemia or infarction as a
cause of HF
Risk Factors: HF

24% of the cases of HF
Without CHD HTN is the most
common cause of HF
 40-60%
HTN is common in type 2 DM

Women
Extremely high-risk of developing HF

(ejection fraction > 40%)
Individuals with HTN and
DM often develop HF despite normal systolic function
Etiology: HF
Case Study
 70 year-old female newly diagnosed with isolated systolic HTN
managed with oral diuretic [Hydrochlorothiazide (HCTZ)].
 Consumes little oral fluids during the day
 After 2 wks of treatment she complains of dizziness and a
recent fall.
 Found to have orthostatic hypotension.
 The result of diuretic use, there’s risk for




orthostatic hypotension
fluid disturbances
additional falls
geriatric syndromes
Factors Contributing to HF



Presence of LVH, which may lead to myocardial ischemia, HF, and sudden
cardiac death
 Reductions in coronary blood flow
 Lethal ventricular arrhythmias
 Systolic and diastolic dysfunction
Pre-existing comorbidities contributing to LVH
 Valvular regurgitation
 Obesity
Pre-existing comorbidities accentuating orthostatic hypotension
 Plasma volume depletion from fluid loss or dehydration,
Easy to
 Parkinson’s disease
Recognize
 Numerous medications
HF Risk in People with DM
 Linked with increased risk of HF in individuals with DM

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Lower socioeconomic status
Older age
Female sex
Longer diabetes duration
Insulin use
Poorer glycemic control
Higher serum creatinine
Presence of diabetes-related
co-morbidities
Nephropathy
HF in LTC Facilities
Prevalence of HF in LTC facilities:
 39% of those with DM develop HF
 23% of those without diabetes develop HF
Medications to treat HF in LTC are
DM
typically:
 underutilized
 Improperly utilized
HF
coexist
HTN
Age Changes Associated with HF
 Severe calcific changes leading to aortic
stenosis
 Degenerative calcific changes of the mitral or
tricuspid valves can lead to biventricular
dysfunction & HF
 Chronic obstructive pulmonary disease (COPD)
contributes to right ventricular dysfunction
 Diastolic dysfunction caused by HTN, aortic
stenosis or CHD
 Cardiomypopathies (dilated; hypertrophic;
restrictive)
Decreases in valve
circumference and
mild valvular
calcification
9%
Critical aortic
stenosis
HF Risk Reduction
Co-morbidities that contribute to high risk of
developing HF
Older
age
Male
Smoker
Obese
Myocardial
ischemia or
infarction
Arrhythmias
Cardiac
tamponade
Co-existent HTN,
valvular heart
disease, cardiomyopathy or
diabetes
Uncontrolled
HTN
Restrictive
pericarditis
Aortic or
ventricular
aneurysms
HF Risk Reduction
Presence of other co-morbidities may contribute to the
development of HF
High Risks
Dietary Aggressive IV
sodium
fluid
& fluid
excess replacement
HyperthyroidismInfection/
hypofever
thyroidism
thyrotoxicosis
Blood transfusions
Hypoxemia pulmonary
embolism/mechanical
ventilation with use of
positive end expiratory
pressure (PEEP)
Renal
insufficiency/
decrease in
glomerular
filtration rate
Thiamine
deficiency/
Beriberi &
Paget’s
disease
Anemia
Drugs
History: Older Adults
with HTN and HF

Assess
 Awareness of why they sought
medical care
 Detailed analysis of the symptoms
 Patient’s and caregiver’s ability to
identify symptoms
 Knowledge & prognosis regarding
their heart condition
 General health beliefs
 Prior ability to manage their medical
conditions
History: Older Adults with HTN and HF
Consideration of Co-Morbidities
 DM may affect central and peripheral CV function
 Renal and liver disease may affect
pharmacodynamics
 Anemia may affect oxygenation
 COPD may necessitate special precautions when
assessing and managing oxygen therapy and betablockers
 Undernourishment or malnutrition Check
History: Older Adults with HTN and HF:
Medications


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Current prescription
Over-the-counter medications
Alternative therapies
Eligible for aspirin, beta-blockers and angiotensin-converting
enzyme (ACE) inhibitors but do not receive these medications
Medications to treat HTN and lipid abnormalities
may not be well tolerated
side effects
drug interactions
History: Older Adults
with HTN and HF

Other factors contributing to management of chronic
disease
 Psychosocial factors
Ensure
 Personal beliefs and behaviors
 Environmental and cultural influences
Ensure that you assess
depression and social
support
History: Older Adults with HTN
and HF
Health history questions
Difficulty in
breathing
Orthopnea/Par
oxysmal
nocturnal
dyspnea
Shortness
of breath at Dyspnea on
rest or with exertion
talking
Fatigue,
Swelling in
weakness,
feet,
and a
ankles, and
legs
decrease in
(edema) or
exercise
ascites
tolerance
Tachypnea
(respiratory rate of 26
breaths per minute or
more at rest)
History: Older Adults with HTN
and HF
Health history questions
Weight
gain
Weakness,
dizziness, or
lightheadedness
(presyncope)
Disrupted
sleep from
nocturia or
paroxysmal
nocturnal
dyspnea
Taking BP in Older Adults
Presence of HTN requires careful measurement of SBP and DBP in
varying positions; a procedure that is often performed
haphazardly.
Employ best practice as to:
 Attention to environment
 Positioning arm, cuff size & placement
 Auscultory practice
 Number of readings necessary for accuracy
 Pseudohypertension is a phenomenon resulting from noncompressibility of thickened arteries, & thus recording falsely
high BP
PE: Older Adults with HF



Accurate measurement of
 Height
 Weight
 Waist circumference
 Apical and peripheral pulses
 Absence or presence of edema
Body mass index (BMI) computed from
height and weight
Measurement of oxygen saturation when obtaining vital signs in
patients with HF
Limiting Fatigue during PE of
Older Adults with HF
 Efforts to prevent fatigue include:
 Limiting the frequency in which the patient position
is changed
 Take time between positional changes
 Continually re-assessing the older adult for
symptoms of compromise
PE Findings Consistent with HF
in Older Adults (in addition to typical PE
findings)
 Diastolic HF

Increased resistance to passive filling of the ventricles
during early diastole or relaxation
 Systolic HF

Decrease in the contractility of the heart
 Both the high ventricular filling pressure and the
poor pumping ability of the heart can lead to ????



Pulmonary congestion
Diminished cardiac output
Similar presentation of both diastolic and systolic HF
Atypical Presentation of HF in
Older Adults
 Unreliable diagnostic signs
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Dyspnea may be absent
Presence of peripheral edema and basilar rales
 Low cardiac output and decrease in perfusion to the
periphery and other organs

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Gangrenous extremity
Confusion
Worsening dementia
Additional Signs & Symptoms of
HF in Older Adults
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cognitive impairment
memory and attention deficits
slowed motor response times
difficulties in problem solving
probably resulting from ~
 cerebral infarction
 cerebral hypoperfusion
PE of Older Adults with HF: GI
Symptoms
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Gastrointestinal symptoms
Anoxexia
Early satiety
Postprandial hypotension
Abdominal fullness
Fatigue during meals
Advanced HF with restricted cardiac output
Mesenteric ischemia following meals
Warfarin = unexplained elevation in protime due to
hepatic congestion meaning HF prior to overt symptoms
Labs: Older Adults with HF
 Request these serial measures
 Fasting blood glucose & lipid profile
 Hematocrit
 Serum electrolytes
 Creatinine
 Calcium
 Urinalysis
 Baseline thyroid studies (TSH)
Management of Older Adults
with HTN and HF

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
With HF
Prior MI
High CHD risk
DM
Chronic kidney disease
or stroke
 Anti-hypertensive drugs
(diuretics
 ACE inhibitors
 Angiotensin-receptor blockers
(ARBs)
 Beta-blockers
 Calcium channel blockers)
 In individuals without these conditions
 Stage 1 HTN
 Thiazide diuretics
 Stage 2 HTN
 2-drug combination
Management of Older Adults
with HTN and HF
 Dosages and additional drugs are
added until the blood pressure
goal is reached
 Lower initial doses may be
required to avoid symptoms and
orthostatic hypotension
Note
Diuretics may be
especially
effective in the
elderly as well as
in AfricanAmericans
Management of Older Adults
with HTN and HF
 Lifestyle modifications can contribute to blood pressure
reduction
 Weight reduction to BMI < 25 kg/m2
 Adoption of Dietary Approaches to Stop Hypertension (DASH)
eating plan
 Sodium restriction to 2.4 grams per day
 Increases in physical activity to at
least 30 minutes per day, most days
of the week
 Limiting alcohol consumption to < 2
drinks per day
Management of Older Adults
with HTN and HF
 4-8% decrease in body weight is associated with a 3 mm Hg
reduction in SBP and DBP
 Weight reduction = increased risk
of death and hip fractures
Management of Older Adults
with HTN and HF
 Initial Goals
 Alleviate symptoms and improve
oxygenation
 Improve circulation
 Correct the underlying causes of the HF
 Longer term goals
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Improve exercise tolerance
Functional capacity
Reduce hospital readmission rates
Decrease mortality
Management of Older Adults
with HTN and HF
 Intensive treatment
 Coexistent HTN, CHD, and renal disease
 Optimal treatment of HTN is critical to both the
prevention and treatment of HF
 Blood pressure should be reduced to below 130/80
mm Hg
Management of Older Adults
with HTN and HF
 Greater risk of mortality when coupled with a
decrease in functional status

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Patients with renal dysfunction  HTN
Pulmonary disease
 Cancer
BMI of < 25
 Continue to smoke
Diabetes
 Functional deficit in activities of daily living

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Difficulty bathing
Managing finances
Walking several blocks
Pushing or pulling heavy objects
Management of Older Adults
with HTN and HF
 Reaching target goals ot BP, FBS, HgbA1c, and
cholesterol
 Stage A HF

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HTN and lipid disorders are treated
Smoking cessation
Regular exercise
Metabolic syndrome is controlled
Use of alcohol intake and illicit drug use
discouraged
is
 ACE inhibitors or ARBs are used to treat patients with
vascular disease and in those with DM
Management of Older Adults
with HTN and HF
 Stage B, same interventions plus:
 ACE inhibitors
 ARBs
 Beta-blockers
 Stage C
 Dietary sodium restriction is added
 Diuretics prescribed to treat fluid retention
 ACE inhibitors & Beta-blockers prescribed unless
contraindicated
 Aldosterone antagonists
 ARBs
 Digitalis
 Hydralazine/nitrates
 Patients with arrhythmias may require a pacemaker or
implantable defibrillator
Management of Older Adults
with HTN and HF
 Stage D
 Palliative care/hospice
 Symptom management
 End-of-life care
 Extraordinary measures
 Heart transplantation
 Chronic inotrope therapy
 Permanent mechanical support
 Experimental drugs
 Surgery
Management of Older Adults
with HTN and HF
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


Need for open discussions
Screen for depression
Ensure patient participation in decision making
Engage inter-disciplinary team approach including
spiritual and/or a psychological representative
Management of Older Adults
with HTN and HF
 Comprehensive transitional care interventions
 Reduce costs
 Improve cardiac outcomes
 Avoid hospitalization for comorbid conditions
Management of Older Adults
with HTN and HF
 Treatment of elderly persons with
HTN has been shown to reduce
CVD morbidity and mortality
 Monitor for adverse effects of
medications
 Patient and caregiver education
 Systolic HF
 ACE inhibitors
 Helpful in diastolic failure
Note
Heart Outcomes
Prevention Evaluation
(HOPE) Study, ACE
inhibitors prevented
cardiac events in
high-risk patients
without HF or known
low ejection fractions
Medication Management of Older
Adults
with HTN and HF

Consult appropriate resources for pharmacology of medications
used to treat HTN and HF.

Consider potential drug-to-drug interaction of cardiac meds and
meds used to treat co-morbidities in older adults

Attend to medications known to commonly cause side-effects in
older adults
Geriatric Syndromes Associated with the
Management of HTN/HF
Possible Adverse Effects from Medications Used in the Elderly to Manage Chronic Diseases
Treatment
Used
Diuretic
Medication
Volume
depletion
Electrolyte
imbalance
Effect
Geriatric Syndrome(s)
Involuntary
loss of urine
New urinary incontinence
Dehydration
Delirium
Volume
depletion +
orthostatic
hypotension
Falls
Management of Older Adults
with HTN and HF: Example
 Nocturia



Increases in vascular return when supine
Precipitate a need to get up more frequently at night to urinate
Possibility of the older adult incurring a nighttime fall
 Prevention of nighttime falls



Pre-existing co-morbidities
 visual impairment
 osteoarthritis of the hip and knees
Timing
Distance to the bathroom facilities
Management of Older Adults
with HTN and HF
 Management considerations
 re-evaluate medication choice, dosage, regimen
 activity tolerance considerations
 use of additional adaptive aides to minimize the risk of falls
 Other solutions
 nighttime urinal
 bedside commode
 frequent toileting rounds
 reduction of nighttime fluids
Management of Older Adults
with HTN and HF
 Warning signs of HF and recurrent MI :
 Chest pain or chest pressure
 Shortness of breath
 Indigestion
 Nausea
 Dizziness
 Palpitations
 Confusion
 Weakness
 Weight gain
Management of Older Adults
with HTN and HF
 Develop a "Rehearsed Plan" for
obtaining immediate medical
attention
 “Medical alert” system may be
helpful
Management of Older Adults
with HTN and HF

Uninterrupted use of cardiac meds is vital

Review all meds at each APRN visit with patient and their
caregivers
 Stress desired effects
 Check for common side effects
 Consider possible interactions with other prescription and
over-the-counter medications
 Counsel patient on what to do if medications are
accidentally omitted
 Address cost issues
Management of Older Adults
with HTN, HF and DM

Optimum management of co-existent:
 HTN
 CHD
 Left ventricular dysfunction
 Avoid
 Poorly controlled HTN
 Tachycardia
 Atrial fibrillation
 Active myocardial ischemia
 Volume overload
Aggressive blood
pressure control,
sodium restriction,
and diuretics even
more important in
symptomatic
individuals
Management of Older Adults
with HTN and HF and DM

Control hyperglycemia


Insulin and insulin secretagogues are considered safe


HF affects choice of medications selected to treat type 2 DM
Metformin and thiazolidinediones are not recommended when with
moderate-to-severe HF
 may lower the risk of death
Decreased clearance of metformin in individuals with HF due to


Hypoperfusion
Renal insufficiency
 potentially dangerous lactic acidosis
Management of Older Adults
with HTN and HF and DM

Thiazolidinediones
 fluid retention
 pedal edema
 weight gain, particularly when used
in conjunction with insulin
 contribute to HF
 occurring with higher doses
 concomitant insulin treatment
 active HF
Lower doses
with slow
dose
escalation
Careful clinical
assessment
Ongoing
monitoring
Management of Older Adults
with HTN and HF
 Presence of co-morbidities contributes to the
complexity of care
 Non-pharmacological interventions (exercise training;
relaxation) may improve physical symptoms & quality
of life
 More intervention studies are using technology to
improve adherence
 prescribed treatments
 improve quality of life
 reduce unplanned hospitalization
Management of Older Adults
with HTN and HF: Technology
 Nurse-delivered telephone intervention in outpatients
with chronic CF was effective in:
 Reducing hospital admissions
 Improving quality of life
 Providing education
 Providing counseling
 Monitoring of symptoms in
outpatients with chronic HF
Management of Older Adults
with HTN and HF: Technology
 Technology offers:
 Efficiency
 Automation
 Safety
 Receptiveness of elderly needs to be
evaluated