Ischemic Heart Disease in Older Adults
Ischemic Heart Disease in Older Adults
Older patients frequently suffer from ischemic heart disease either in isolation or in combination with other processes (Butler, 20120). As a common clinical syndrome, heart failure is the result of impaired cardiac functioning of the action of pumping the blood through the body. Signs and symptoms of ischemic heart disease include fatigue and an inability to tolerate exercise and edema of the abdomen, legs, ankles, and feet. Although heart disease has a poor rate of survival, early diagnosis and treatment may improve life expectancy. The goal of nursing intervention is to extend life expectancy and improve the quality of the patient’s life during that time.
Each nation has its own statistics on the epidemiology of heart failure. The European Society of Cardiology states that heart failure in the population of Europe is approximately two percent to three percent (European Society of Cardiology, 2011). Numbers issued by the United Kingdom place patients with heart failure in that country at 900,000 people (Nice.org.uk, 2010). In the United States, almost 801,000 people died from cardiovascular disease in 2013; this is approximately one out of every three deaths that take place in America from any reason (American Heart Association, 2016).
It is predicted that as people continue to live longer and survive heart attacks, they will struggle with lowered left ventricular function (Steward et al., 2003) and that there will be a more than 50 percent increase in incidence over the next 20 years (Gardner et al., 2007; American Heart Association, 2016).
The heart pumps the total circulating volume of the blood in the body, approximately five liters, in a complete circuit once every minutes in a resting state (Colbert et al. 2009). There are four factors that affect the heart’s contractile functioning: 1) preloading (left ventricular end diastolic pressure) matches stroke volume to venous return, but contractile ability drops, so does cardiac output, 2) contractibility (inotropic heart state) based on calcium moving into cardiac cells which results in shortened muscles and sustaining a contraction, 3) afterload (resistance to ventricles) results in pressure in systemic or pulmonary circulation with an increase leading to lower stroke volume and decrease in afterload resulting in higher stroke volume, and 4) heart rate, which when increased drops the ventricle filling time and lowered stroke volume while a lower heart rate increases the filling time of the ventricle and a higher stroke volume (Butler, 2012).
Special Considerations with Older Patients
For nursing professionals, addressing the consequences of cardiovascular accidents include decreasing disabilities and postponing mortality. Declining cognition, isolation socially, physical disabilities, and increased financial hardships are only a few of the problems individuals face living with ischemic heart disease. Current information suggests that by reducing risk factors, many challenges subsequent to developing ischemic heart disease can be prevented. According to Klieman, Hyde & Berra (2006) and Butler (2012), nursing interventions include counseling and patient education in pharmaceutical therapies, assistance in learning about the importance of exercise, and teaching the patient and his family about dietary management.
Ischemic heart disease is generally a malady of the elderly. Although heart failure occurs in all age groups, the average age of initial diagnosis is 66 years (American Heart Association). Approximately 38 percent of the 71,300,000 patients with cardiovascular disease in the United States are over the age of 65 (Cdc.gov, 2016). Death from heart failure in survivors of a first heart attack increases by 10 percent every year afterwards.
In addition, the expenses associated with ischemic heart disease are tremendous. In the United States, indirect and direct costs in 2008 are estimated to have been $156 billion with more than 50 percent of the direct costs from hospitalization. The Medicare program in 2003 paid $12.2 billion for patients with ischemic heart disease; the average cost for a patient discharged following a myocardial infarction was $12,321 and $11,783 for a patient diagnosed with coronary atherosclerosis (Fihn et al., 2012).
For nurses caring for older adults, there are improvements possible in the management and prevention of ischemic heart disease. The group of “older adults” covers a range of lifestyles and therapies since there are frequently co-morbidities present, multiple medications, demographic and social influences, personal goals and wishes, and ages from 65 and older. Patient care is based on values of minimizing potential harm while maximizing benefits, ethical risks weighed against benefits, and respecting the right of the patient to make decisions concerning their welfare ("Can Core Nursing Values and Ethics Be Taught?", 2007).
There are three specific nursing interventions concerning ischemic heart disease that are relevant to best nursing practices. First, since older patients have more complex heath issues, they generally are prescribed approximately three times as many medications as young people (Canadian Institute for Health Information, 2013). One study shows that two-thirds of the survey participants over the age of 65 take five or more prescription medications daily with one in five seniors taking 10 or more daily drugs, and one in twenty taking over 20 medications every day (Medco Health Solutions, Inc., 2009). In addition, patients over 65 years of age also take an average of 1 to 3.5 over-the-counter medications that are not prescribed by their physician (Stewart & Cooper, 1994). Nurses operate with a holistic attitude to care and have the ability to improve adherence to medication consumption through the use of calendar charts, trays that contain compartments and labels, and medications in blisterpaks to organize complicated schedules. Prior to hospital discharge, comprehensive counseling with the patient and family allows for medication review of reasons for the drugs, possible side effects, and other important information. The nurse may also arrange for home health agencies to follow up with telephone calls for answering questions after returning to the home environment. The goal of these types of actions is fewer side effects, less chance of missing doses, and improved patient results to prescriptions.
Another important nursing intervention for patient with ischemic heart disease is to address an exercise regimen. The benefits of regular aerobic physical activities include primary and secondary prevention of congestive heart disease, increased function including reducing falls, and positively influencing obesity, lipid blood levels, diabetes, and hypertension. The mental status of the patient is also improved with better health and socialization (Klieman, Hyde & Berra, 2006). As with other risk factors, the geriatric nurse is responsible for evaluating co-morbidities in order to recommend an exercise program that is safe for the individual patient. Guidelines for physical fitness for the older adult should address his physical condition, prescriptions, and possibly a stress test for cardiovascular patients. It is generally recommended that exercise be performed for 30 minutes every day and exercise prescriptions should include what type of exercises are allowed, the intensity, the frequency, and the duration. Including strength training and exercises for flexibility and balance are important.
Finally, dietary management with particular attention to improving lipid levels is a nursing intervention that is vital to patient morbidity after hospital discharge. To decrease the risk of heart disease and increase secondary incidence, the National Cholesterol Education Program encourages an approach to diet that includes reducing saturated fatty acids to less the 7 percent of the total caloric intake, keeping cholesterol ingestion to less than 200 milligrams per day, and eating as little trans-fatty acids as possible (Institute of Medicine, 2002). While dietary content is important, a nutrition consultation regarding drug interactions, total caloric intake for the patient’s size and activity level, and other considerations are needed. For instance, carbohydrate intake should be no more than 60 percent of the total intake and lower if the patient has a low HDL-C or elevated triglycerides. Soluble dietary fiber may be supplemented and a sodium intake of 1500 milligrams per day may lower blood pressure (Klieman, Hyde & Berra, 2006). As with other nursing interventions that influence home lifestyle behavior, a practitioner should encourage follow up with home health agencies or other community resources.
In today’s hospital environment, regulatory and accreditation agencies, organizations based on quality improvement, insurance plans, hospital associations, and medical societies have a vested interest in the quality of care in hospitals. In addition, health care facilities take part in multiple internal improvement activities in response to the feedback from employees and patients. Because nurses are the primary caregivers in the hospital setting, they have the ability to influence the quality of care and eventual outcome of treatment. It is for this reason that hospitals depend on nursing staff for front line quality improvement.
Because nursing is based in the values of caring and excellence in patient care, it is vital for nurses to consistently evaluate all aspects of patient care in order to promote the strategies and outcomes of therapies for their patients. For that reason, I suggest a Quality Initiative in the form of the creation of a formal educational program with instructors able to give special consideration for older patients with ischemic heart disease. While doctors and nurses strive to provide patients with the information they need to share in the decisions concerning their treatment and manage their disease after leaving the hospital, ischemic heart disease is a complex topic with individualized details. For that reason, I propose the hospital create an educational department responsible for formal instruction of patients on their disease, tests, medications, and treatments. Working with the patient and their families, this staff would present information accompanied by printed material and possibly videos or DVDs. Over the course of the hospital stay, instructors would return to the room as needed for updates on tests and medications. Prior to discharge, a summary would be presented and a form signed by the patient acknowledging their understanding of the material. This type of educational program not only allows the patient to participate in treatment decisions during his stay in the hospital and promotes compliance, it allows for continued options after discharge. The educational department would be available for questions after the patient returns home, freeing the doctor’s office of calls and assisting the patient with future developments that may require further medical evaluation. In addition, the documented efforts by the members of the educational team would be admissible in court in the event allegations arose concerning informed consent.
As research continues into the diagnosis and care of older adults suffering from ischemic heart disease, nurses play an important role and must take the position of a leader in assisting physicians and hospital administrators in determining ways to improve appropriate therapies as well as educating patients on lifestyle changes. The age of the general population is rising and as it does, the numbers of people living with ischemic heart disease increases. The challenge to nurses is to provide age-appropriate access to healthcare and promote research into treatment and strategies for the prevention of cardiovascular disease.
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