Frequently Asked Questions About Chronic Care Management

Introduction: I felt strongly compelled to write this blog on heart failure as it is such a pertinent issue in the aging population today. Before I go into details on this, Id like to address the definition of this disease process. Heart failure occurs when the heart doesnt pump well and fails to deliver adequate oxygen to the body. As a result, fluid builds up in the body and vital organs dont get the blood that they need. This can make it harder for individuals to perform everyday tasks and can lead to eventual overall decline. Problem:Heart failure is the number one reason for hospital admissions in older adults, and often leads to multiple readmissions (Agarwal et. al., 2021). As a cardiac nurse for many years, I can attest to the fact that heart failure is the biggest reason for multiple hospitalizations in seniors. Patients come in and out for problematic symptoms, sometimes coming into the hospital as often as every month. The three biggest symptoms I see that result in hospital admissions are shortness of breath (particularly when lying flat), weight gain, and swelling in the legs.One reason for such frequent admissions is the complexity of heart failure itself. It is a complicated clinical syndrome and is notoriously difficult to manage. A lot is put on patients to manage their heart failure at home, and this can be a challenge. In addition, individuals may have some level of cognitive impairment or multiple other comorbidities, making it even more challenging to perform the extensive monitoring needed to prevent heart failure from worsening. The importance of education:Education is also important in the treatment of heart failure. Unfortunately, this often does not get done. When I first started working in acute care back in 2004, every patient received extensive education in managing their heart failure prior to discharge. Nurses would provide lengthy verbal education on the importance of medication adherence, daily weights, low salt diet, and other factors, in addition to providing the patient with a heart failure educational pamphlet prior to discharge. Over the years, however, hospitals have increasingly faced staffing shortages and high nurse turnover. As a result, a lot of important patient education is not getting addressed. A lack of awareness and understanding in patients on how to manage their heart failure is definitely a key reason for worsening heart failure and repeated hospitalizations. Management:From a clinician standpoint, the goal in addressing heart failure is twofold: we want to reduce symptoms and prevent mortality. The best way to do this is through patient/family education and implementation of a treatment plan. A proper treatment plan will include such lifestyle modifications as a low salt diet, quitting smoking, and getting regular physical activity. A low salt diet can be incredibly helpful in preventing further fluid build up in the body. The American Heart Association recommends that all individuals consume no more than 2,300 mg of sodium per day (AHA, 2024). In todays era of processed and packaged food, a majority of the American population consumes much more than that, and it comes in the food itself rather than the saltshaker. Maintaining a low sodium diet has one other priceless benefit that I often do not see emphasized enough in heart failure: it can help reduce blood pressure. Almost half of all heart failure patients have uncontrolled hypertension (Heart Failure, 2022). It is a major risk factor in the development of heart failure and managing it can greatly reduce heart failure symptoms and decrease stress on the heart. Current guidelines recommend maintaining a systolic blood pressure of less than 130. Medication management is another important factor in the management of heart failure. This often includes the use of diuretics, beta blockers, and other medication classes that I will not go into detail on. I wanted to discuss diuretics and beta blockers because these are the two medications in heart failure that I see non-compliance with the most. I witness individuals often not taking one or the other for two main reasons:  they either dont understand the importance of them or they dont like the side effects. Seniors can often have difficulty getting up to go to the restroom. Diuretics cause frequent trips to the restroom because their purpose is to get excess fluid off the body. Many individuals do not comply with their prescribed diuretic because of the hassle of frequent bathroom trips. Unfortunately, ineffective diuresis causes heart failure to worsen and puts further stress on the heart. I often see non-adherence to beta blockers due to their side effects. The two biggest symptoms that get reported to me are fatigue and dizziness. As in the diuretic, a beta blocker can also help reduce the stress on the heart, and heart failure symptoms can worsen if the prescribed dose is not adhered to. Its important to maintain prescribed medication regime and if any negative symptoms are experienced to discuss them with the doctor. One final thing:I wanted to touch on one final monitoring recommendation for heart failure because it so often gets missed: daily weights. Weighing oneself daily is of tantamount importance in heart failure and can identify early on if heart failure is worsening. This can lead to early intervention, thus decreasing potential hospitalization. Adherence to this all too often does not occur. I see patients come into the hospital for large amounts of weight gain often 20 or more lbs. Many patients report that they never stepped on the scale to assess for weight gain and often do not get admitted to the hospital until symptoms are severe such as severe weakness and shortness of breath. In heart failure its recommended to contact the doctor if weight goes up by more than 2 pounds in a day or greater than 4 pounds in a week. The doctor can make modifications in the treatment regime and hence reduce potential hospitalizations and mortality. Conclusion:Heart failure is complex but manageable. Early action can prevent hospital admissions, reduce mortality, and optimize quality of life. Having ongoing guidance from an experienced clinician can be of great benefit if you or your loved one is having difficulty managing heart failure and other disease processes. Please do not hesitate to reach out to me if you have any further questions. I want to help and make the process of aging as stress free as possible while promoting positive health outcomes.  My name is Laura Carson and I have been a Registered Nurse (RN) for over 20 years and have witnessed firsthand the challenges and complications that aging presents. It affects not only the aging themselves but also their families and loved ones. Health care is complex, and in this increasingly fragmented and overburdened system, it can be extremely helpful to have a professional oversee all aspects of care. As your eldercare manager, I will comprehensively assess the needs of your loved one and we will work together in establishing a care plan. I will assist you and your family with difficult decisions and help promote healthy communication on issues that are often difficult to address and navigate. Contact me for a 20 minute free consultation at 714-403-7040.  References:Blood Pressure and Glycemic Control Among Ambulatory US Adults With Heart Failure: National Health and Nutrition Examination Survey 2001 to 2018 (April 28, 2022). Heart Failure. Almost half of heart failure patients have uncontrolled hypertension and diabetesAgarwal, M., Fonarow, G., & Ziaeian, B. (February 10, 2021). National Trends in Heart Failure Hospitalizations and Readmissions From 2010 to 2017. https://pmc.ncbi.nlm.nih.gov/articles/PMC7876620/Weber, C. (May, 2023). Heart Failure Pharmacology.  How much sodium should I eat per day? (2024). American Heart Association. https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/sodium/how-much-sodium-should-i-eat-per-day  

Whether you're traveling from across the street or across the country, holiday gatherings provide an excellent opportunity to assess the well-being of your aging family members. These festive occasions, filled with dinners, gift exchanges, and parties, offer a natural setting to observe any changes in behavior or lifestyle that may have occurred since your last visit.Changes in an elderly relative's condition can range from obvious to subtle. To help you gauge their current physical and mental state, we've compiled a comprehensive list of areas to observe and questions to consider during your time together.EnvironmentThe condition of your loved one's living space can offer valuable insights into their ability to maintain their home and overall well-being. Look for the following:Signs of damage or disrepair in and around the houseAccumulation of trash or clutterBurned-out light bulbs left unchangedDecline in cleanliness, particularly in the kitchen and bathroomUnopened mail piling upItems stored in unusual or potentially hazardous locationsDamage to their vehicle, such as unexplained scratches or dentsThese observations can indicate difficulties with home maintenance, mobility, or cognitive function.Food and NutritionProper nutrition is crucial for seniors. During your visit, pay attention to:The quantity and quality of food in the refrigerator and pantryPresence of expired or spoiled food itemsSigns of weight loss or malnutritionIndications that meals are being skipped or forgottenPoor nutrition can significantly impact an elderly person's health and may signal the need for additional support.Mood and BehaviorChanges in mood or behavior can be early indicators of cognitive decline or other health issues. Watch for:Withdrawal from social activities or abandonment of once-enjoyed hobbiesNew friendships or organizational affiliations, especially those involving frequent contact or requests for donationsIncreased confusion or repetition in conversationsSigns of irritability, apathy, or sadnessGeneral withdrawal or changes in typical demeanorThese behavioral shifts may warrant further investigation or professional assessment.Personal HygienePersonal care habits can provide valuable clues about an individual's physical and mental state. Look for:Decline in overall grooming and appearanceWearing dirty clothes or not changing clothes regularlySkipping showers or bathsBruises or injuries that might indicate falls or accidentsPoor hygiene can be a sign of physical limitations, depression, or cognitive impairment.Financial ManagementWhile not always easy to observe, changes in financial management can be crucial indicators of cognitive decline or potential exploitation. If possible, discreetly assess:Bill payment habits and any signs of financial distressUnusual or large purchasesUnfamiliar names on financial documentsSudden changes in banking habits or account managementFinancial mismanagement can have serious consequences and may require prompt intervention.Medication ManagementFor seniors taking multiple medications, proper management is essential. Observe:Organization of medicationsPresence of expired prescriptionsSigns of missed doses or confusion about medication schedulesMedication errors can lead to serious health complications and may indicate the need for additional support.Social ConnectionsMaintaining social connections is vital for seniors' mental and emotional well-being. Take note of:Frequency and quality of interactions with friends and neighborsParticipation in community activities or religious servicesUse of technology to stay connected with family and friendsSocial isolation can contribute to depression and cognitive decline in older adults.Remember, this list is not exhaustive but serves as a guide to help you check in on your aging loved ones. By observing these areas and initiating conversations early, you can identify potential issues and provide timely support. If you notice concerning changes, consider consulting with healthcare professionals or senior care experts for guidance.The holiday season offers a wonderful opportunity to spend quality time with your elderly relatives. Use this time to observe, listen, and engage meaningfully. Your attentiveness can make a significant difference in ensuring their continued well-being and quality of life.Aging Life Care Managers are an excellent resource for support. Working with families, an Aging Life Care Manager is a strategic planner offering options and solutions that best fit a persons individual needs and resources. Their guidance leads families to the actions and decisions that ensure quality care and an optimal life for those they love, thus reducing worry, stress, and time away from work for family caregivers.

Caring for an older adult with cognitive difficulties, such as dementia or Alzheimers disease, requires patience, empathy, and a thoughtful approach to daily activities. As our loved ones with dementia might have communication challenges, we become more attuned to observing body language and facial expressions. The right activities can provide a sense of purpose, stimulate memory, and improve overall well-being. However, choosing the wrong activities can lead to frustration or confusion. This guide offers practical advice on the dos and donts of engaging loved ones with cognitive decline.Do:        Simplify tasks and break them down into smaller steps.For example, if your loved one enjoyed cooking, involve them in simple tasks like stirring ingredients or setting the table. This allows them to participate without feeling overwhelmed by the complexity of the activity.Familiar rote tasks can provide a sense of purpose and success i.e.: folding towels or setting the table.Dont:        Set up for failureAvoid setting high expectations for perfection or completion of tasks. The goal is engagement, not mastery. If your loved one loses interest or struggles with a task, its okay to move on to something else without pressure. Try active listening techniques.Do:        Promote social interactionEngage in activities that foster social interaction, like looking through old photo albums, reminiscing about the past, or participating in small group activities. Social engagement is crucial for older adults as it helps combat feelings of isolation and keeps their minds active. Offer prompting open-ended questions to encourage engagement. Consider looking for a local Adult Day Center near you that might offer activities and social interaction.Dont:        Overwhelm with large gatheringsAvoid large social gatherings or unfamiliar environments that could cause sensory overload or anxiety. Instead, keep interactions small and personal, with familiar faces and settings to provide a sense of security and comfort.Do:        Watch television: many of us utilize television for entertainment but it can often become the primary source of structure and activity for the day.Watching cooking shows can be good if you are looking to improve appetite but can also cause overeating.Watching nature programs with positive content is engaging, however cycle-of-life or aggressive programming (like natural disasters) can produce anxiety. Baby animal shows can be a particular favorite as there is no plot to follow.Watching beloved shows can be nostalgic and comforting, and comedy skit shows also have no plot to follow.Consider what types of programs are watched at different times of day something with no speaking and just photography is good for resting, and sports might spark a desire for more activity.Dont:        Allow TV to cause anxiety or be a substitute for activity or personal interactionWatching the news can be distressing for some and cause anxietyConfrontational talk show formats can be confusing and angry participants may display unwanted behaviors.Sitting in front of the TV all day isnt good for anyone, and this is not engaging in socialization or cognitive stimulation.Do:        Incorporate music and artUse music and art as therapeutic tools. Older adults with cognitive difficulties often respond well to music from their youth or simple art activities like coloring or painting. These activities can stimulate the senses and provide a creative outlet, even for those with advanced cognitive impairment.Dont:        Use Activities that require complex decision-makingAvoid activities that require complex decision-making or too many choices. This can be overwhelming and may lead to frustration. Instead, offer simple, clear options that allow for easy participation. Offer a choice between two things such as menu items or daily clothing choices.Do:        Accept help when caregiving becomes overwhelming.Consider hiring an Aging Life Care Manager.  An Aging Life Care Manager can provide expert guidance, help coordinate care, and offer support in making decisions for your loved one.  Dont:        Set your expectations too high or schedule too full.Try to go with the flow and understand things might not go exactly as planned and thats okay. Schedule in extra time for activities or to get to appointments. If you feel frustrated, step away, regain composure (your loved one if not being difficult on purpose) and try again with a new energy. Read tips on how to deal with caregiver stress.As you consider what activity choices to offer your loved one, consider variety and time of day. Include exercise and socialization, as well as hygiene and rest. Modify, modify, modify. If they seem overwhelmed with an activity, try simplifying to a point they can successfully engage. For example: a puzzle with fewer and larger pieces, simple matching games, and activities to stimulate fine motor skills. Remember not to infantilize your loved one, but rather adjust to their needs. Be mindful of your loved ones response to an activity and be flexible with both them and yourself.