Patterns of pharmacologic treatment of congestive heart failure in elderly nursing home residents and related issues: a review of the literature

John Randolph Litaker, Jennie Yu Chou
Clinical Therapeutics 2003, 25 (7): 1918-35

BACKGROUND: Congestive heart failure (CHF) is a serious clinical syndrome associated with increased morbidity, mortality, and health-related expenditure. In the United States, the incidence and prevalence of CHF have been shown to increase with age, particularly among the elderly (age >/=65 years). In addition, more elderly persons are living in or will be living in nursing homes. Given these trends, it is important to consider the quality of care, including pharmacologic treatment, received by elderly nursing home residents with a diagnosis of CHE There is currently a lack of clinical trial data on the pharmacologic treatment of CHF among elderly nursing home residents and, therefore, no standard of care. In lieu of clinical trial data, empiric studies based on nursing home populations may be useful.

OBJECTIVE: This article reviews empiric studies concerning the pharmacologic treatment of CHF in elderly nursing home residents.

METHODS: Empiric studies on the use of angiotensin-converting enzyme (ACE) inhibitors, digoxin, and diuretics in elderly nursing home residents with a diagnosis of CHF were identified through searches of MEDLINE, Cochrane Trials, and International Pharmaceutical Abstracts using the terms elderly, nursing home, geriatric, and heart failure. The search was limited to the past 11 years (1991-2002) to identify current patterns of treatment in the population of interest. Additional studies were identified through a manual search of the reference lists of the retrieved articles.

RESULTS: Thirteen empiric studies were identified: 9 examined ACE-inhibitor use, 4 digoxin use, and 7 diuretic use. The findings of these studies indicated that ACE inhibitors are underused, are often prescribed at clinically inefficient doses, and are used more often in "young" elderly nursing home residents (age 65-74 years). Among patients who received a prescription for digoxin, many did not have an appropriate indication (eg, no documented atrial fibrillation, normal sinus rhythm). Similarly, diuretics were found to be inappropriately prescribed to elderly nursing home residents for the treatment of CHF.

CONCLUSIONS: Based on the available empiric studies, elderly nursing home residents with a diagnosis of CHF do not appear to receive adequate treatment with ACE inhibitors, digoxin, or diuretics based on the recommendations of clinical or als or clinical guidelines. However, the clinical trials and clinical guidelines target the general elderly population and thus may not be applicable to elderly nursing home residents. Future research should explore factors influencing the pharmacologic treatment of CHF in elderly nursing home residents, and trials of new pharmacologic treatments for CHF should include elderly nursing home residents.

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