Managing Heart Failure in the Community

1. Managing Heart Failure in the Community Francesca Leaton North Coast Area Health Service Heart Failure Liaison Nurse 7th September, 2013

2. Is heart failure on the rise?

3. MANAGING HEART FAILURE IN THE COMMUNITY • Good assessment includes: • Clinical history • Physical • Psychological/emotional • Social • Risk factor management • Symptom Management & Self Management

4. Assessment Clinical History • Diagnosis and co-morbidities, including relevant investigations • Symptoms - fluid retention, weight gain, dyspnoea, fatigue, exercise intolerance, orthopnoea, paroxysmal nocturnal dyspnoea. • Cardiovascular risk factors - smoking, diet, family history, caffeine and alcohol, drugs • Medications – • ACE-I/ARB and Beta Blocker and has the patient been titrated to the target dose? • Non prescribed medications – NSAIDS, soluble medications, herbal remedies

5. Assessment Clinical History • Exercise habits past and present, including lifestyle physical activity:- • Mobility status- are there issues with ambulation, balance, falls risk, neurological • Barriers to exercise – e.g. time, anxiety level, depression, orthopaedic limitations, personal safety concerns, financial constraints or access to services • Enablers to exercise – what things would make it easier to exercise or overcome barriers) • Cognitivefunction if required • NYHA classification - how severe are the symptoms?

6. NEW YORK HEART ASSOCIATION (NYHA) CLASS 1-1V • Class 1 • No limitation. • Ordinary physical activity does not cause excess fatigue, shortness of breath, or palpitations • Class 11 • Slight limitation of physical activity. • Patients are comfortable at rest but ordinary physical activity results in fatigue, shortness of breath, palpitations or angina. • Class 111 • Marked limitation of physical activity. • Although patients are comfortable at rest, less than ordinary activity will lead to symptoms. • Class 1v • Symptoms present at rest • Inability to carry on any physical activity without discomfort.

7. Physical Assessment • Resting heart rate and rhythm, BP, SpO2, Weight [dry], • Signs of fluid retention – ankle oedema, bloating, orthopnoea, exertional dyspnoea, paroxysmal nocturnal dyspnoea. • Height, weight (BMI) and waist measurement • Skin integrity – particularly diabetics / venous ulcers • Supplementary assessments, if needed – blood glucose levels and chest auscultation, jugular venous pressure • Sternal stability and wound integrity in post surgical patients

8. PSYCHOLOGICAL/EMOTIONAL • Often depression can be a barrier to behavioural changes. • According to Beyond Blue 1 million Australians experience depression and 2 million Australians experience anxiety each year. • There is a high prevalence of depression among patients with heart failure together with an increased risk of mortality and adverse clinical events.

9. PHQ2 – Depression Tool • Initial screening questions:- “Over the past two weeks, have you been bothered by any of the following problems?”(i) Little interest or pleasure in doing things.(ii) Feeling down, depressed, or hopeless. • If the answer is ‘yes’ to either question then proceed to PHQ9 and forward results to the GP.

10. PHQ9 [patient health questionnaire] Scale = 0 - 3 Over the past 2 weeks, how often have you been bothered by any of the following problems? (use “” to indicate your answer) • Little interest of pleasure in doing things • Feeling down, depressed, or hopeless • Trouble falling or staying asleep, or sleeping too much • Feeling tired or having little energy • Poor appetite or overeating • Feeling bad about yourself • Trouble concentrating on things • Moving or speaking so slowly that others have noticed • Thoughts that you would be better off dead, or of hurting yourself.

11. PHQ9 – How we use it • If suicide response is positive – contact the mental health care team initially, then send letter to GP.

12. PHQ9 Diagnosis PHQ9 Provisional Score Diagnosis Treatment Recommendations 5 – 9 Minimal symptoms 10 – 14 Minor Depression Dysthymia Major depression - mild 15-19 Major depression – moderately severe >20 Major depression, severe Support, educate, contact if worse in one month Support, watchful waiting Anti-depressant or psychotherapy Anti-depressant or psychotherapy Anti-depressant or psychotherapy Anti-depressant and psychotherapy (especially if not improved on monotherapy)

13. SOCIAL • What support does your client have • Is there family support? • Is there a network of friends? • Are they a carer? • Do they have a buddy to exercise with? • How different is their life now living with a chronic disease? • How has their lifestyle changed? • Is transport an issue? • Is finance an issue - making access difficult? • Do they have a low health literacy?

14. What is health literacy? Individual health literacy is:- • The knowledge, motivation and competencies of a consumer to access, understand, appraise and apply health information to make effective decisions and to take appropriate action for their health and health care. • Australian Commission on Safety and Quality in Health Care (2013)

15. Health Literacy – some facts In 2006 the Australian Bureau of Statistics found that almost 60% of adult Australians have low individual health literacy, which means they are not able to effectively exercise their choice or voice when making health care decisions.

16. Vulnerable population • The elderly • Low income • Did not finish high school – low literacy score • Minority ethnic groups • Indigenous population • English as a second language • Recent immigrants

17. Why is it important ? Lower levels of individual health literacy are associated with:- • Higher use of health services • Lower levels of knowledge among consumers • Poorer health outcomes • Increased hospitalisation and use of the ED • Poorer ability in medication adherence and poorer ability to interpret labels and health messages • Lower use of screening and vaccination

18. Why is it important ? • Poorer knowledge among consumers of their own disease • Poorer overall health status among older people • A high risk of death among older people • 1.5 – 3 times more likely to have an adverse outcome Low health literacy is related to the extent to which a client is engaged with the health care system and their own care and management

19. HOW CAN YOU SUPPORT YOUR PATIENT ? • Keep explanations simple • Not too much information at once • Draw diagrams • Ask the patient to explain it back to you, • Help them learn how to navigate the health system • Meet your patient where they are and NOT where you expect them to be.

20. RICk Principle (Health Change Australia) • How READY is your client to take some action to change? • How IMPORTANT is it to your client to improve their condition? • How CONFIDENT is your client about making change • Is your client equipped with the appropriate KNOWLEDGEnecessary to make these decisions. • If importance is low:  build motivation to raise the priority   • If confidence is low:  identify and  address  the barriers that are preventing CHANGE

21. HIGH RISK PATIENTS • >65 years • NYHA Class III or IV symptoms • 2 or more chronic diseases • LV EF < 30% • Living alone or in a remote location • Depression • Language and cultural differences • Lower socioeconomic status e.g. not able to afford meds or transport • Significant renal dysfunction • Low health literacy

23. Make the Connection • Use language the patient will understand or relate it to their everyday life • “Like a car only working on 2 or 3 cylinders” or the • “The irrigation pump that cannot supply the back paddock” • “Like stretched elastic that doesn’t go back to its normal shape”

24. Make the connection Between heart failure and symptoms. For example:- Cardiac pump failure means:- • Increased backpressure into the lungs = fluid leaks into the lung tissue = breathlessness • When you cannot lie down at night or wake up breathless, this means you have extra fluid in your lungs – warning sign • Increased coughing - warning sign • Increased backpressure in the body = swollen ankles and legs– warning sign Taking fluid tablets empties the lungs/body of extra fluid and lets you breathe easierand reduces your symptoms. • Putting on weight means putting on fluid – warning sign

25. Make the connection Less fluid in the body makes it easier for the heart to pump • FLUID MANAGEMENT – consider co-morbidities:- • Mild heart failure – 2000mls • Moderate heart failure – 1500mls [usual restriction] • Severe heart failure &/or CKD - 1000-1200 mls/day • May need more in hot weather • Teach about hidden fluids, how to measure, what to do for dry mouth, hot weather, sickness etc.

26. Make the connection • Keep a weight diary 4 w’s Wake Wee Weigh Write • Know your ‘dry weight’ when you are well • Putting on weight suddenly is the body retaining fluid • Seek help if you put on • 2 kgs over 2 – 3 days OR • Flash weight of 1.5 kgs. overnight • 1 litre fluid = 1 kg • Diuretic Titration –patients can be taught when to take extra diuretic based on their symptoms and weight. GP/Nurse supervision

27. Make the connection REDUCING SALT INTAKE REDUCES SYMPTOMS • Reduce processed and pre-packaged food, canned soup etc • Eat fresh food instead TAKING MEDICATIONS WILL REDUCE SYMPTOMS • Make sure they understand what their medications do and why it is important to take them as prescribed • Make sure they have a good system of taking their medications • Keep an ‘up to date’ medication list • Understand that some over the counter medications can be dangerous • Talk to their Dr or Pharmacist about their concerns

28. Make the connection REDUCING ALCOHOL REDUCES SYMPTOMS • Patients with alcohol-related cardiomyopathies should abstain which will slow down the progression of the disease or even improve their LV function. • Standard drinks/day has now been reduced to 1 std drink/day. REDUCING CAFFEINE REDUCES SYMPTOMS • Limit intake to 1 – 2 cups coffee per day • Excessive caffeine may exacerbate arrhythmias, increase heart rate and blood pressure. • May alter plasma electrolyte levels in patients taking diuretics.

29. Make the connection INCREASING EXERCISE REDUCES SYMPTOMS • When stable and with no contraindications • Incorporate exercise into daily life MAINTAINING A HEALTHY LIFESTYLE REDUCES SYMPTOMS • Pneumococcal and influenza vaccinations • Understand when to rest and when to play - resting will also improve diuresis and cardiac function • Make good choices every day

30. Make the connection The key to good self management is understanding why something is happening, and having the knowledge and confidence to act or seek appropriate help when needed • AN ACTION PLAN WILL ENABLE MORE CONTROL • When to seek help • How urgent is it • Where to go for help

32. In Summary • Refer to Heart Failure Nurse in your Community Health Centre • Fluid Restriction • Daily Weight / diary • Low Sodium diet • Medication adherence / titration schedule • Regular exercise • Identify early warning signs & use HF Action plan • Listen and connect with your patient

33. MAKING THE RIGHT CONNECTIONS TO SUPPORT YOUR BODY