Heart failure in the elderly

Heart failure in the elderly is caused by a complex of structural and functional changes in various organs and systems. These changes, on the one hand, are inherent in an aging organism, serve as a manifestation of natural physiological aging, and on the other hand, are caused by diseases that existed in mature and middle age or that joined in later periods. This layering of age-related and pathophysiological mechanisms, among which atherosclerosis plays the main role, leads to significant changes in the structure and function of the heart and blood vessels, and disturbances in metabolic processes in the heart muscle.

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How does heart failure manifest itself in older people?

Heart failure in the elderly depends on the degree of reduction of cerebral circulation due to age-related and sclerotic changes. Significant role is played by the severity of age-related emphysema, pneumosclerosis, which cause a decrease in the functional reserves of the lungs and an increase in vascular resistance, changes in blood circulation in the kidneys, functional shifts in their activity.

Often, signs of deterioration of blood supply to the brain due to a decrease in the stroke volume of the heart (SV) appear much earlier than the phenomena of congestion in other organs and systems. A decrease in the level of brain blood flow is indicated by sleep disturbances, general fatigue, dizziness, and tinnitus. Confusion, agitation, and motor restlessness, which increase at night and are often accompanied by insomnia, can be early symptoms of cerebral circulatory failure associated with a decrease in cardiac output.

An early sign of left ventricular weakness and pulmonary congestion may also be a slight cough, which often appears or intensifies after physical exertion or when moving from a vertical to a horizontal position. The appearance of shortness of breath during physical exertion is usually considered one of the earliest functional signs of developing cardiac decompensation. When assessing this symptom in geriatric practice, it is necessary to take into account the physiologically decreasing functional capabilities of not only the cardiovascular, but also the respiratory systems. Shortness of breath in older people may be due to concomitant lung diseases, and not to cardiac weakness. With aging, the threshold for its appearance during physical exertion decreases. Shortness of breath is the result of irritation of the respiratory center by excess carbon dioxide, which occurs when the blood is insufficiently saturated with oxygen due to impaired blood circulation in the vessels of the lungs (stagnation in the pulmonary circulation). The most common cause of asthma attacks in elderly and old people with atherosclerosis of the heart and blood vessels is a sudden increase in blood pressure (hypertensive crisis), circulatory disorders in the coronary vessels (angina pectoris, myocardial infarction), and sharply changing contractile capabilities of the heart muscle. During an asthma attack of cardiac origin, inhalation is difficult, that is, there is dyspnea of the inspiratory type, as opposed to expiratory, in which exhalation is difficult, for example, in bronchial asthma.

A patient with severe dyspnea without collapse should be placed in a semi-sitting position with lowered lower limbs (the amount of circulating blood decreases, the diaphragm descends), oxygen should be provided (intensive ventilation or oxygen therapy as prescribed by a doctor). If an attack occurs in a patient undergoing inpatient treatment, the nurse, having called a doctor, urgently prepares syringes and needles for intravenous manipulations, tourniquets for application to the limbs, the necessary medications (omnopon, morphine hydrochloride, strophanthin K, euphyllin, glucose, dibazol, nitroglycerin, no-shpa or papaverine hydrochloride, cordiamine, mesaton, etc.). Drug therapy is carried out taking into account the level of blood pressure.

In right ventricular failure, patients complain of loss of appetite, nausea, sometimes vomiting, bloating, heaviness in the right hypochondrium due to congestion in the liver; swelling in the ankles and feet.

Peripheral edema, and particularly edema of the lower extremities, may not in themselves be an early sign of heart failure; they are often associated with decreased protein content (hypoproteinemia), decreased skin turgor, and decreased tissue oncotic pressure. The tendency to edema increases with age.

An objective examination reveals a shift in the borders of cardiac dullness, predominantly to the left, a diffuse apical impulse; heart sounds are weakened. With sinus rhythm, systolic murmur is often heard over the apex of the heart. Rhythm disturbances - atrial fibrillation - are observed significantly more often than in younger people. It often occurs simultaneously with myocardial insufficiency. The appearance of atrial fibrillation during cardiac decompensation is a poor prognostic sign.

How is heart failure treated in the elderly?

Heart failure in the elderly should be treated in a comprehensive manner.

The main directions of pathogenetic treatment of heart failure:

• increasing the contractility of the myocardium;
• reducing sodium and water retention in the body;
• reducing the load and afterload on the heart. The following groups of drugs are used for these purposes:
• vasodilators:
  • with a predominant effect on venous tone (nitrates, cordiket, molsidomine);
  • with a predominant effect on arteriolar tone (hydralazine, phentolamine, nifedipine, corinfar);
  • with simultaneous action on the tone of arterioles and veins - mixed action (prazosin, captopril);
• cardiac glycosides (corglycon, digoxin);
• diuretics (hypothiazide, triampur, veroshpiron, furosemide, uregit).

Heart failure in the elderly: features of care

Patients with chronic heart failure, in addition to regular medication (cardiac glycosides, diuretics, etc.), also need careful care. Conditions of the course: emotional calm, control of diet No. 10, the amount of fluid drunk and excreted. Bed rest in old age brings more harm than good, as it leads to congestive pneumonia, thromboembolism, bedsores. Therefore, it is only necessary to limit physical activity, conduct training exercises "until the patient is tired." To reduce congestion in the pulmonary circulation, patients need to be given a position in bed with the head of the bed elevated.

The volume of liquid should be no more than 1500-1600 ml/day. The diet is low-calorie with sufficient amount of proteins, fats, carbohydrates, potassium and magnesium salts, limiting table salt to 6-7 g/day. Taking into account that such patients are prescribed cardiac glycosides and diuretics that promote the removal of potassium from the body, foods rich in potassium (dried apricots, raisins, baked potatoes and bananas, etc.) are included in the diet.

The dynamics of edema should be regularly monitored. An indicator of increasing fluid retention in the body is the predominance of the amount of fluid taken in during the day over the daily diuresis. There should be a certain correspondence between the limitation of table salt and the amount of fluid administered. In order to combat severe edema, fluid intake is limited (up to 1 liter per day), as well as the use of table salt to 5 g per day. When discharged from the hospital or treated at home, the patient and his relatives should be explained the need to take into account the amount of fluid consumed, including all liquid food (soup, compote, jelly, fruit, milk, tea, water, etc.), and the amount of daily diuresis in order to maintain a certain balance in water metabolism. The patient should communicate this information to the attending physician and nurse during their visit.

Long-term edemas lead, in some cases, to secondary changes in the skin, which changes its color, becomes thinner, and loses elasticity. Therefore, skin care and prevention of bedsores are of great importance. Rubbing and massage give a good effect, which should be done very carefully, given the thinness and vulnerability of the skin in elderly patients. In old age, dry skin is often noted, causing severe itching, the appearance of calluses, limiting the motor activity of patients. Dry areas of the skin should be lubricated with special creams with a moisturizing and bactericidal effect; calluses should be removed in a timely manner.

If there is a significant amount of fluid in the abdominal or pleural cavity that disrupts organ function, a puncture is performed. In elderly and old people, this procedure requires great caution due to the significant restructuring of blood circulation after the mechanical compression of the vessels by the released fluid has been eliminated and the possibility of acute vascular insufficiency (collapse). Before the puncture, especially in people with normal or low blood pressure, it is necessary to administer cardiac agents that maintain vascular tone (cordiamine, mesaton). The edematous fluid should be removed from the cavities slowly. The amount of fluid released should be indicated in the medical history. A laboratory study is necessary to determine the nature of the pathological process (cardiac decompensation, renal edema, fluid accumulation during a tumor process - damage to the pleura or abdominal organs by cancer metastases, etc.).

Elderly patients with circulatory failure are very sensitive to oxygen deficiency, so the air in the room where they are should be fresh and have sufficient humidity. If necessary, in cases of severe dyspnea, inhalations of an oxygen mixture passed through a foam suppressor (40-95° alcohol or 10% alcohol solution of antifoamsilane) are used.