Ageing

Tips to cope when you’re juggling several chronic health issues

Be proactive by learning about and tracking your conditions and medications, and by speaking up when you have concerns.

Published in Harvard Health Letter

We don’t want our golden years to be spent juggling a long list of health issues. But that’s the reality for most older adults in the United States.

The CDC reports that 75% of Americans ages 65 or older have several chronic health problems. And a 2013 analysis of Medicare claims published online by Preventing Chronic Disease found that 68% of beneficiaries had two or more chronic conditions and 36% had at least four.

“Having multiple chronic diseases is common because people are living longer. The older we are, the more chronic diseases we accumulate,” says Dr. Suzanne Salamon, associate chief of gerontology at Harvard-affiliated Beth Israel Deaconess Medical Center.

The challenges

Advances in medicine have improved treatment for many diseases and lengthened life. But those same advances mean that today’s medical care often involves seeing more types of doctors, having more tests, and getting more treatments than in earlier times. In other words, medical care in our golden years is better, but also more complicated.

“People take more medications, both prescription and over-the-counter, to manage these conditions. That’s because there are more effective medicines now than there used to be. However, medications can interfere with each other,” Dr. Salamon explains. In addition, treatment for one problem may make another problem worse. “For example, if you have high blood pressure and a history of falls, and lowering your blood pressure makes you feel lightheaded, your fall risk will increase,” says Dr. Erin Stevens, a geriatrician and palliative care physician at Harvard-affiliated Massachusetts General Hospital.

Doctors do their best to avoid prescribing medicines that are likely to cause problems, but the risk cannot be perfectly predicted. Bad things that are unlikely still can happen. “Another problem is that people get tired of taking medications, or find them too expensive — and so they don’t take them. This can lead to problems of untreated hypertension, diabetes, and other conditions,” Dr. Salamon explains.

Why do we accumulate chronic conditions?

Many factors play a role in the accumulation of health problems. Most diseases involve a combination of genetics and lifestyle. Being born with certain genes can make you more vulnerable than other people to certain diseases. An unhealthy lifestyle can further increase the risk.

Some genes, and some lifestyle factors, influence the risk for multiple diseases. And having one disease can increase your risk for another. “One disease can affect an organ system which then affects another. For example, diabetes can damage nerves, which can lead to loss of sensation in the extremities, which can lead to imbalance, a fall, and disability,” explains Dr. Erin Stevens, a geriatrician and palliative care physician at Harvard-affiliated Massachusetts General Hospital. Or you may have high blood pressure that damages blood vessels, which leads to a stroke.

And sometimes health conditions just go hand in hand, and we don’t know why. For example, depression often accompanies heart disease, diabetes, or Parkinson’s disease. Autoimmune diseases also can run in clusters. “So if you have thyroid disease, you may be predisposed to another autoimmune disease, like rheumatoid arthritis,” Dr. Stevens says.

Taking back control

To avoid missteps, be proactive in your health care with these strategies.

Get educated about your conditions. Talk with your doctor about what you can do (like exercise or eat a healthy diet) to take to control of any conditions you already have and to prevent conditions you worry about getting.

Become a medication expert. Find out what each of your medications does, why you need it, what side effects you should particularly watch for, and how it may interact with other drugs. You can get such information from your pharmacist or from online sources (such as the AARP website).

If you see many doctors, be sure each of them knows what medicines the other doctors have prescribed (they will, if they are all part of a hospital or health care system that shares electronic health records).

To be safe, Dr. Stevens recommends bringing all of your medications to each doctor appointment, including over-the-counter pills. “Then we can be sure the medication list on the computer matches the pills and doses that you’re taking,” Dr. Salamon says.

Keep track of your symptoms and treatments. If you’re having symptoms you think may be side effects of a medicine or an adverse interaction between drugs, use a notebook or a computer to record when you take medications, when symptoms develop, and how long the symptoms last.

Get a good CEO. Just as a corporation needs a chief executive officer to oversee its many departments, you may need a primary care physician to look at the big picture and help you make sure treatment for numerous conditions is well coordinated.

Consider palliative care. It’s a misconception that palliative care is only for the end of life. When you have serious degenerative illness — like heart failure, Parkinson’s disease, or a breathing disorder — your quality of life suffers. A palliative care physician can help you manage those conditions, maximize your function, and preserve as much quality of life as possible. “We want to meet people early on, not in crisis mode,” Dr. Stevens says. “Maybe we can prevent a fall or address pain. We can talk about what to expect, so when something happens over time, it won’t be a surprise.”

Be your own advocate. Finally, remember that no one understands how you’re feeling better than you do. Ask questions about your treatment, and don’t be afraid to speak up if you’re having trouble managing your conditions or if you’re concerned about the way your doctors are doing the job.

 

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How will population ageing affect future end of life care?

By Anna Bone

Increasing population ageing means that deaths worldwide are expected to rise by 13 million to 70 million per year in the next 15 years. As a result, there is an urgent need to plan ahead to ensure we meet the growing end of life care needs of our population in the future.

Understanding where people die, and how this could change in the future, is vital to ensuring that health services are equipped to support people’s needs and preferences at the end of life. As researchers at the Cicely Saunders Institute, King’s College London, we investigated trends in place of death in England and Wales, and found that deaths occurring in care homes could more than double in the next 25 years if recent trends continue.

Using official records on over five and a half million deaths, as well as population forecasts, we estimated the number of people who will die in a range of different settings in years to come. The intention behind this study is that it will help to guide future planning of health and social care. From 2004 to 2014, the proportion of deaths occurring in care homes increased from 17% to 21%, with numbers rising from 85,000 to 106,000 per year. If this trend continues, the number of people dying in care homes will double to over 220,000 per year by 2040, and care homes will overtake hospitals as the most common place to die. Home deaths are also projected to increase over this period to over 216,000 deaths a year. Together, this means that deaths in the community are expected to account for over two-thirds of all deaths by 2040.

We also know that, increasingly, people are living and dying with multiple illnesses and frailty, which adds complexity to their care needs. The rising number of people with complex illness in the community is a challenge for end of life care. A recent study has shown that palliative care needs are expected to increase by 42% by the year 2040. We need greater integration of specialist palliative care into primary care services, as well as more training in palliative care for general health professionals, to ensure that those with palliative care needs can access services they require.

The projected rise of deaths in care homes and in peoples’ own homes is striking. We must ask care home and community services whether they are equipped to both support such an increase in demand and provide high quality end of life care. How can we provide the workforce needed to care for this growing patient group? To enable people to die in their preferred place in future, we need to ensure adequate bed capacity, resources, and training of staff in palliative and end of life care in all care homes in the country. These projections warn of the urgent need to invest more in care homes and community health services. Without this investment, people are likely to seek help from hospitals, which puts pressure on an already strained system and is not where most people would prefer to be at the end of their lives.

The time has come to test new approaches to care in order to ensure that we address this growing need of our population in the years to come. There are promising examples of innovations in care to increase the reach of palliative care services in community settings, for example project ECHO, which facilitates knowledge-sharing between specialist palliative care services, such as hospices, and general health care professionals such as those in care homes. In an era of increasing need alongside constrained health and social care budgets, developing and testing innovative ways to provide high quality care with minimal resources is imperative.

In the words of Cicely Saunders, the founder of the modern hospice movement, “how people die remains in the memory of those who live on.”The inevitable population changes described here will affect all of us, directly or indirectly, in the years to come. It is time for us as a society to have an open discussion about how we want health services to be delivered to people towards the end of life. Crucially, we need better evidence on how we can best support a growing number of older people as they reach the end of their lives.

Anna Bone is a PhD Training Fellow at the Cicely Saunders Institute, King’s College London. The themes from this blog post come from The Changing Face of Volunteering in Hospice and Palliative Care, published by Oxford University Press.

 

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