Heart in Context

Heart disease is common in older adults and often is present with other chronic conditions. A chronic condition is one that requires treatment by a health care professional for longer than a year.

Often, heart disease must be treated in the context of these other conditions because treatment for one may hurt the other. For example, if you need to take blood thinners for atrial fibrillation, it is important to consider any history of bleeding. In addition, aging in the liver and kidneys changes how medications affect the older body.

When treatment is needed, setting goals for heart care can keep the focus on treatments most likely to achieve them, which is even more important when you have more than one condition. Your heart treatment plan should take into account all your conditions.

A geriatric cardiology approach to treatment considers the heart in context of other conditions, your goals for health, and prioritizes quality of life.

Frailty

How quickly people age varies. Lack of activity and poor diet are the largest modifiable risk factors – or risk factors that you can control – for declines with aging. Keeping a healthy body weight, normal blood pressure, normal blood sugar, and being active every day are important. Engaging with others and having a purpose for your life also support healthy aging. Heart disease risk factors are closely tied to risk factors for frailty and memory loss.

You are considered frail when your body no longer has the reserves of strength and ability to bounce back from illness it once had. Signs of frailty include:

• unexplained weight loss
• poor appetite
• difficulty walking or getting out of a chair
• unexplained fatigue
• low activity level

Conditions that can be treated — such as heart failure or an infection — may cause these symptoms. However, among people with heart and blood vessel disease, 3 out of 10 of those over age 80 and more than 4 out of 10 of those over age 90 have an underlying state of frailty. Frailty often comes before sharp declines in health. It also can signal a need for levels of care when considering procedures or high-risk treatments. Frail patients might need different care from patients who are not frail.

Memory Loss

Memory loss also is common with aging and more often seen in frail patients. Often it is a minor issue and can be managed with reminders. However, it can pose challenges to managing medication, understanding instructions, and keeping up with health needs.

More advanced memory loss poses great stress on the individual and caregivers. More help is almost always needed in this stage.

Medications are often a big challenge for older patients, especially in terms of finding the right doses. It’s good to start with a low dose of a medication and increase based on need and how well it’s tolerated because most side effects are related to dosing.

Age changes the makeup of your body and how it processes medicine, so some medications stay around longer in older adults. This difference also increases the risks of side effects at doses used in younger patients. If you have new symptoms after starting a medication, tell your doctor.

About 4 out of 10 older patients may be taking five or more medications. It is common for them to be on many more. “Polypharmacy” refers to the use of multiple medications, including those you can get over the counter without a prescription. You should be active in your care, especially if you are on many medications from different providers.

Discuss medications you are taking with your health care team, including nurses, pharmacists and physicians. Ask for ways to simplify them. Stopping therapy, or “de-prescribing,” should be considered to reduce the medication burden if possible.

Here are some questions to ask about each medication you take:

• Is it likely to treat my symptoms and make me feel better?
• Is it likely to reduce the risk of future illness?
• Is it likely to cause side effects?

Although many of us would prefer to care for ourselves until the day we die, the reality is that most of us will need support to maintain our safety and quality of life in later years.

A support network is very important in later years when declines in function, movement and thought make daily life difficult. You may find it hard to drive or get medications refilled. If you are able to live alone, a call button to summon people in your care circle is very important for those times when you can’t reach a phone.

Often, the shift to needing help is unexpected and sudden. That makes it very important to plan early on for help with appointments, medications, diet, and transportation.

Other changes are gradual and may go unnoticed by family and friends. Denial by loved ones in regard to someone’s need for help or concern by the older adult about being a burden often compounds the situation. Some signs that more help is needed include:

• Decreased judgment related to simple daily tasks (leaving stove turned on or doors unlocked).
• Mishandling finances or not paying bills.
• Making mistakes with medication or using the wrong dose.
• Becoming more easily moody, angry, suspicious or paranoid.
• Changes in grooming, such as stains on clothes and infrequent bathing.
• Reluctant to spend time with others or not wanting to do so.
• Sadness that lasts and results in loss of interest in normal activities.
• Increased confusion, such as missed doctor appointments or skipping family events.
• Changes in eating habits and less interest in nutritious meals.
• Difficulty walking, unsteadiness or frequent falls.

All transitions are challenging, so understanding the changes and preparing for them can make the difference between a smooth or a rocky course. Key conversations with family and neighbors about how you want future help should be as normal as talking about other life events like getting married, having children, or retiring. These talks need to begin when memory is failing, mobility is limited, or vision is impaired, but ideally they should happen well before that.

Caregiving may be provided by an informal network of family or neighbors, hired professionals, or both. Caregiving is hard work. Support, particularly for informal caregivers, is part of caring for the older adult. Often informal caregivers are also older, which poses concerns for the health and well-being of both caregiver and recipient.

People who take part in caregiving can turn to many resources for support. The CARE Act (Caregiver Advise, Record, Enable Act) has been passed in many states. This important legislation requires hospitals to identify and record the name of the caregiver and include that individual in discharge planning. This helps the caregiver during the key transition from hospital to home.

In the health care setting, things move quickly and focus on delivering the best treatments for specific conditions. This may not translate to the best treatments for an individual.

As a patient, you may have different goals of care than the emergency doctors do. This is why it is important to document and let others know (children, spouses, caregivers) what your goals are so that in an emergency, you are more likely to get the care you desire. Also, there will be no uncertainty or guilt on the part of your loved ones if asked to speak on your behalf.

If you have heart disease, you can benefit from sharing your goals of care with your advocates. With clear goals, your chances of getting the care you value goes up. To start planning, identify the things which are most important to you.

Palliative care is a philosophy of care that focuses on symptoms, such as pain or shortness of breath, to improve quality of life. It is given along with care that aims to lengthen life.

Palliative care might include medications or treatments, or it might focus on talking with you and your family to understand goals of care, answer questions and help make health decisions.

Any doctor, nurse, or other member of the health care team can provide palliative care. Sometimes, you may see a health professional who specializes in palliative care in addition to your usual doctor or at the same time.

Hospice care is an insurance benefit covering therapies that maintain or improve quality of life for a patient with a disease that will not be cured.

Patients can be on hospice care if they are expected to live less than six months. This assessment must be repeated every six months. Patients are either certified again or taken off hospice care if their condition improves.

Hospice can be started in many settings depending on severity of illness, degree of family support, money concerns, and what the patient prefers.

The team includes physicians, nurses, social workers, home health aides, spiritual advisers, therapists (physical, occupational, and speech), dietitians, and volunteers to help ensure a patient is comfortable and prepared for the end of life, striving to achieve a “good death.”

If you’re an older adult who has been diagnosed with heart disease, there are several key questions that you should ask your health care provider during your next visit. These questions will ensure that you and your doctor have discussed your major risk factors so that you can become or stay as healthy as possible.

• What does this health test involve and what are the risks for me? Will it lead to improving my symptoms or preventing future illness?
• Can we simplify my medication list?
• How long do I need to take this medication? Are there less expensive options? Is this medication going to help with symptoms or prevent future illness?
• How can we keep the things that matter most to me in mind?
• What can I do to make sure people know my wishes?
• How can I help you to take care of me better? What is the best way to contact your office between visits?
• How do I correctly check my blood pressure at home? How often should I check it?
• What do my blood pressure numbers mean?