Page 2 - Aging

Talking With Your Older Patient: A Clinician’s Handbook

Good communication is an important part of the healing process.

Studies find that effective physician-patient communication has specific benefits: patients are more likely to adhere to treatment and have better outcomes, they express greater satisfaction with their treatment, and they are less likely to bring malpractice suits.

Research also shows that good communication is a teachable skill. Medical students who receive communication training improve dramatically, not only in communicating with patients, but also in assessing and building relationships with them. Time management skills also get better. Communication skill is now a core competency identified by the Accreditation Council on Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS).

Learning effective communication techniques—and using them—may help you build more satisfying relationships with older patients and become even more skilled at managing their care.

Communicating with older patients involves special issues. For example:

  • How can you effectively interact with patients facing multiple illnesses and/or hearing and vision impairments?
  • What’s the best way to approach sensitive topics such as driving privileges or assisted living?
  • Are there ways to help older patients who are experiencing confusion or memory loss?

 

With questions like these in mind, the National Institute on Aging (NIA), part of the National Institutes of Health, developed this booklet.

Although referring to clinicians throughout the text, this booklet is intended for use by a range of professionals dealing directly with patients—physicians, physicians-in-training, nurse practitioners, nurses, physician assistants, and other health care professionals. The aim is to introduce and/or reinforce communication skills essential in caring for older patients and their families. Talking With Your Older Patient: A Clinician’s Handbook offers practical techniques and approaches to help with diagnosis, promote treatment adherence, make more efficient use of clinicians’ time, and increase patient and provider satisfaction.

Three points are important to remember:

  • Stereotypes about aging and old age can lead patients and health professionals alike to dismiss or minimize problems as an inevitable part of aging. What we’re learning from research is that aging alone does not cause illness and that growing older does not automatically mean having to live with pain and discomfort.
  • Many of this booklet’s suggestions may, at first glance, appear to be time-consuming, especially given the time constraints of most clinicians. However, an initial investment of time can lead to long-term gains for physicians and patients. Time-intensive practices need not be inefficient. You may get to know your older patient’s life history over the course of several visits rather than trying to get it all in one session.
  • Older patients are diverse and unique, just like your younger patients. You may see frail 60-year-olds and relatively healthy 80-year-olds. Your patients may be culturally diverse. Some may be quite active while others may be sedentary. The techniques offered here encourage you to view all older people as individuals who have a wide range of health care needs and questions.

Considering Health Care Perceptions

 

The best way to learn what is and is not acceptable is to communicate directly with patients and caregivers.

Mrs. Hill is an 85-year-old nursing home resident. She has lived in a facility since advanced heart disease made it impossible for her to live independently. Her adult children feel that life in a nursing home must be a nightmare. They want to do something, but they don’t know what. Moving her to one of their homes isn’t an option; visiting her makes them feel depressed. One day, her doctor chats with Mrs. Hill about life in the home. She tells him that this is one of the best times of her life—people prepare and deliver her meals, she has a comfortable room with a view of the gardens, and the place is very peaceful. Mrs. Hill is quite happy and has no desire to move.

For Mrs. Hill, a life her children find unacceptable is, in fact, just fine with her. What seems intolerable to a 40-year-old may actually be preferred by a 90-year-old.

In the past century, the nature of old age has changed dramatically. In the early 1900s, the average life expectancy was about 49 years—today, it is nearly 80 years. With longevity, however, comes the sobering news that older people may live for years with one or more chronic, potentially disabling conditions. This means they will have an ongoing need for medical services.

No single characteristic describes an older patient. Each person has a different view of what it means to be old. A 68-year-old woman with an active consulting business is likely to deal with a visit to the doctor quite differently from her frail 88-year-old aunt who rarely ventures beyond her neighborhood.

The perspectives that follow are common among older people—and important to consider when talking with older patients.

Views of Physicians and Clinicians
In the past, older people have held doctors in high esteem and treated them with deference. This view may change over time as aging baby boomers are likely to take a more egalitarian and active approach to their own health care.

Today, many older people don’t want to “waste the doctor’s time” with concerns they think the clinician will deem unimportant. Patients sometimes worry that if they complain too much about minor issues, they won’t be taken seriously later on. Or, they are afraid of the diagnosis or treatment. They may worry that the physician will recommend surgery or suggest costly diagnostic tests or medications.

Some patients do not ask questions for fear of seeming to challenge the clinician. On the other hand, some older people, having ample time and interest, will bring popular medical articles to the attention of their providers. This kind of active patient participation can provide an opportunity for communication.

Views of Aging

Ageism can work both ways. Doctors can make assumptions about their older patients. Older people may unwittingly assume the stereotypes of old age. Expectations regarding health diminish with age, sometimes realistically, but often not. Older people with treatable symptoms may dismiss their problems as an inevitable part of aging and not get medical care. As a result, they may suffer needless discomfort and disability. Some may not even seek treatment for serious conditions.

The process of aging may be troubling for older adults. It can be especially hard for people who once bounced back quickly from an illness or were generally healthy. Experts observe that baby boomers bring different expectations, experiences, and preferences to aging than did previous generations. For instance, some boomers are likely to want to participate actively in health care treatments and decisions. They may also search the Internet for health information.

Values About Health

Although physicians typically focus primarily on diagnosing and treating disease, older people generally care most about maintaining the quality of their lives. They are not necessarily preoccupied with death. In fact, many older people are relatively accepting of the prospect of death and seek chiefly to make the most of their remaining years. Younger family members, who commonly must make life-and-death decisions when an older person is incapacitated, may be unaware of the patient’s views and preferences.

  • Let older patients know that you welcome their questions and participation.
  • Encourage older adults to voice their concerns.
  • Be alert to barriers to communication about symptoms, such as fears about loss of independence or costs of diagnostic tests.
  • Expect those in the baby boom generation to be more active participants in their health care.

Effective communication has practical benefits. It can:

  • help prevent medical errors
  • strengthen the patient-provider relationship
  • make the most of limited interaction time
  • lead to improved health outcome

 

This chapter provides tips on how to communicate with older patients in ways that are respectful and informative.

Use Proper Form of Address

Establish respect right away by using formal language. As one patient said, “Don’t call me Edna, and I won’t call you Sonny.” You might ask your patient about preferred forms of address and how she or he would like to address you. Use Mr., Mrs., Ms., and so on. Avoid using familiar terms, like “dear” and “hon,” which tend to sound patronizing. Be sure to talk to your staff about the importance of being respectful to all of your patients, especially those who are older and perhaps used to more formal terms of address.

Make Older Patients Comfortable

Ask staff to make sure patients have a comfortable seat in the waiting room and help with filling out forms if necessary. Be aware that older patients may need to be escorted to and from exam rooms, offices, and the waiting area. Staff should check on them often if they have to wait long in the exam room.

Take a Few Moments to Establish Rapport


Introduce yourself clearly. Show from the start that you accept the patient and want to hear his or her concerns. If you are a consultant in a hospital setting, remember to explain your role or refresh the patient’s memory of it.

In the exam room, greet everyone and apologize for any delays. With new patients, try a few comments to promote rapport: “Are you from this area?” or “Do you have family nearby?” With established patients, friendly questions about their families or activities can relieve stress.

Try Not to Rush


Avoid hurrying older patients. Time spent discussing concerns will allow you to gather important information and may lead to improved cooperation and treatment adherence.

Feeling rushed leads people to believe that they are not being heard or understood. Be aware of the patient’s own tendency to minimize complaints or to worry that he or she is taking too much of your time.

Avoid Interrupting


One study found that doctors, on average, interrupt patients within the first 18 seconds of the initial interview. Once interrupted, a patient is less likely to reveal all of his or her concerns. This means finding out what you need to know may require another visit or some follow-up phone calls.

Older people may have trouble following rapid-fire questioning or torrents of information. By speaking more slowly, you will give them time to process what is being asked or said. If you tend to speak quickly, especially if your accent is different from what your patients are used to hearing, try to slow down. This gives them time to take in and better understand what you are saying.

Use Active Listening Skills


Face the patient, maintain eye contact, and when he or she is talking, use frequent, brief responses, such as “okay,” “I see,” and “uh-huh.” Active listening keeps the discussion focused and lets patients know you understand their concerns.

Demonstrate Empathy


Watch for opportunities to respond to patients’ emotions, using phrases such as “That sounds difficult” or “I’m sorry you’re facing this problem; I think we can work on it together.” Studies show that empathy can be learned and practiced and that it adds less than a minute to the patient interview. It also has rewards in terms of patient satisfaction, understanding, and adherence to treatment.

Avoid Jargon


Try not to assume that patients know medical terminology or a lot about their disease. Introduce necessary information by first asking patients what they know about their condition and building on that. Although some terms seem commonplace—MRIs, CAT scans, stress tests, and so on—some older patients may be unfamiliar with what each test really is. Check often to be sure that your patient understands what you are saying. You may want to spell or write down diagnoses or important terms to remember.

Reduce Barriers to Communication


Older adults often have sensory impairments that can affect communication. Vision and hearing problems need to be treated and accounted for in communication. Ask older patients when they last had vision and hearing exams.

Be Careful About Language


Some words may have different meanings to older patients than to you or your peers. For example, the word “dementia” may connote insanity, and the word “cancer” may be considered a death sentence. Although you cannot anticipate every generational difference in language use, being aware of the possibility may help you to communicate more clearly. Use simple, common language and ask if clarification is needed. Offer to repeat or reword the information: “I know this is complex; I’ll do my best to explain, but let me know if you have any questions or just want me to go over it again.”

Low literacy or inability to read also may be a problem. Reading materials written at an easy reading level may help.

Ensure Understanding


Conclude the visit by making sure the patient understands:

  • what the main health issue is
  • what he or she needs to do about it
  • why it is important to do i

One way to do this is the “teach-back method”—ask patients to say what they understand from the visit. Also, ask if there is anything that might keep the patient from carrying out the treatment plan.

Obtaining the Medical History

 

When patients are older, obtaining a good history—including information on social circumstances and lifestyle as well as medical and family history—is crucial to sound health care.

The varied needs of older patients may require different interviewing techniques. The following guidelines can help you to obtain a thorough history of current and past concerns, family history, medications, and socioeconomic situation. These suggestions are less time-consuming than they may appear. Some involve a single investment of time. Other health care professionals in the office or home may assist in gathering the information. You may want to get a detailed life and medical history as an ongoing part of older patients’ office visits and use each visit to add to and update information.

General Suggestions


You may need to be especially flexible when obtaining the medical history of older patients. Here are some strategies to make efficient use of your time and theirs:

  • If feasible, try to gather preliminary data before the session. Request previous medical records, or if there is time, mail forms that the patient or a family member can complete at home. Try to structure questionnaires for easy reading by using large type and providing enough space between items for people to respond. Questionnaires to fill out in the waiting room should be brief.
  • Try to have the patient tell his or her story only once, not to another staff member and then again to you. For older patients who are ill, this process can be very tiring.
  • Sit and face the patient at eye level. Use active listening skills, responding with brief comments such as “I see” and “okay.”
  • Be willing to depart from the usual interview structure. You might understand the patient’s condition more quickly if you elicit his or her past medical history immediately after the chief complaint, before making a complete evaluation of the present illness.
  • If the patient has trouble with open-ended questions, make greater use of yes-or-no or simple choice questions.
  • Remember that the interview itself can be beneficial. Although you see many patients every day, you may be the only person your patient is socially engaged with that day. Your attention is important. Giving your patient a chance to express concerns to an interested person can be therapeutic

Elicit Current Concerns

Older patients tend to have multiple chronic conditions. They may have vague complaints or atypical presentations. Thinking in terms of current concerns rather than a chief complaint may be helpful. You might start the session by asking your patient to talk about his or her major concern, “Tell me, what is bothering you the most?”

Resist the Tendency to Interrupt


Give the patient time to answer your questions. Giving someone uninterrupted time to express concerns enables him or her to be more open and complete.

Probe


Ask, “Is there anything else?” This question, which you may have to repeat several times, helps to get all of the patient’s concerns on the table at the beginning of the visit.

The main concern may not be the first one mentioned, especially if it is a sensitive subject. If there are too many concerns to address in one visit, you can plan with the patient to address some now and some next time.

Encourage the patient and his or her caregivers to bring a written list of concerns and questions. Sometimes an older patient will seek medical care because of concerns of family members or caregivers.

Ask About Medications


Side effects, interactions, and misuse of medications can lead to major complications in older people. It is crucial to find out which prescription and over-the-counter medications older patients are using and how often. Older people often take many medications prescribed by several different doctors, e.g., internists, cardiologists, urologists, or rheumatologists. Sometimes they take prescriptions intended for other household members.

Remember to ask about any alternative treatments, such as dietary supplements, homeopathic remedies, or teas that the patient might be using. Remind patients that it is important for you to know what over-the-counter medicines, such as pain relievers or eye drops, they use.

Ask patients to bring all medications, both prescription and over-the-counter, to your office. A good approach is to have the patient put everything he or she takes in a brown bag and bring it to each visit. Find out about the patient’s habits for taking each medication, and check to be sure that he or she is using it as directed.

Check to see if the patient has (or needs) a medical alert ID bracelet or necklace. There are several sources, including MedicAlert Foundation International.

Obtain a Thorough Family History


The family history is valuable, in part because it gives you an opportunity to explore the patient’s experiences, perceptions, and attitudes regarding illness and death. For example, a patient may say, “I never want to be in a nursing home like my mother.” Be alert for openings to discuss issues such as advance directives.

The family history not only indicates the patient’s likelihood of developing some diseases but also provides information on the health of relatives who care for the patient or who might do so in the future.

Knowing the family structure will help you to know what support may be available from family members, if needed.

Ask About Functional Status


Knowing an older patient’s usual level of functioning and learning about any recent significant changes are fundamental to providing appropriate health care. They also influence which treatment regimens are suitable. The ability to perform basic activities of daily living (ADLs) reflects and affects a patient’s health. Depending on the patient’s status, ask about ADLs such as eating, bathing, and dressing and more complex instrumental activities of daily living (IADLs) such as cooking, shopping, and managing finances. There are standardized ADL assessments that can be done quickly and in the office.

Sudden changes in ADLs or IADLs are valuable diagnostic clues. If your older patient stops eating, becomes confused or incontinent, or stops getting out of bed, look for underlying medical problems. Keep in mind the possibility that the problem may be acute.

Consider a Life History


If you plan to continue caring for an older patient, consider taking time to learn about his or her life. A life history is an excellent investment. It helps to understand the patient. It also strengthens the clinician-patient relationship by showing your interest in the patient as a person.

Be alert for information about the patient’s relationships with others, thoughts about family members or coworkers, typical responses to stress, and attitudes toward aging, illness, work, and death. This information may help you interpret the patient’s concerns and make appropriate recommendations.

Obtain a Social History


The social history also is crucial. If you are aware of your patient’s living arrangements or his/her access to transportation, you are much more likely to devise realistic, appropriate interventions. Ask about where he or she lives; neighborhood safety; eating habits; tobacco, drug, and alcohol use; typical daily activities; and work, education, and financial situations. It also helps to find out who lives with or near the patient.

Understanding a person’s life and daily routine can help you to understand how your patient’s lifestyle might affect his or her health care. To this end, determine if the patient is an informal caregiver for others. Many older people care for spouses, elderly parents, or grandchildren. A patient’s willingness to report symptoms sometimes depends on whether the patient thinks he or she can “afford to get sick,” in view of family responsibilities.

House calls by a health care professional are an excellent way to find out about a patient’s home life. If that’s not possible, try to learn some details about the patient’s home life: “Do you use oil or gas heat? Have steep stairs to navigate? Own a pet? Can you get to the grocery store or pharmacy on your own? Are you friendly with anyone in the neighborhood?” Learning about your patient’s home life will help you understand aspects of his or her illness and may improve adherence to treatment.

Exercise and Physical Activity


Exercise has proven benefits for older people. It reduces risk of cardiovascular disease, stroke, hypertension, type 2 diabetes, osteoporosis, obesity, colon cancer, and breast cancer. It also decreases the risk of falls and fall-related injuries.

Like the rest of us, older people may know that exercise is good for their health, but they may not have the motivation or encouragement to do it. You can guide your patients by asking about their daily activities and whether they engage in any kind of regular exercise or physical activity.

There are several ways to encourage older patients to exercise:

  • Whenever appropriate, let them know that regular physical activity—including endurance, muscle-strengthening, balance, and flexibility exercises—is essential for healthy aging.
  • Help patients set realistic goals and develop an exercise plan.
  • Write an exercise prescription, and make it specific, including type, frequency, intensity, and time; follow up to check progress and re-evaluate goals over time.
  • Refer patients to community resources, such as mall-walking groups and senior center fitness classes.

Nutrition
Older patients may develop poor eating habits for many reasons. These can range from a decreased sense of smell and taste to teeth problems or depression. Older people may also have difficulty getting to a supermarket or standing long enough to cook a meal. And although energy needs may decrease with age, the need for certain vitamins and minerals, including calcium, vitamin D, and vitamins B6 and B12, increases after age 50.

Try these strategies to encourage healthy diets:

  • Emphasize that good nutrition can have an impact on well-being and independence.
  • If needed, suggest liquid nutrition supplements, but emphasize the benefits of solid foods.
  • If needed, suggest multivitamins that fulfill 100 percent of the recommended daily amounts of vitamins and minerals for older people, but not megadoses.
  • Offer a referral to a nutrition services program, such as Meals on Wheels. Programs in your area are provided by the local Area Agency on Aging or Tribal Senior Services. Contact Eldercare Locator at 800-677-1116 for your Area Agency on Aging.

Many older people have a “don’t ask, don’t tell” relationship with health care providers about some problems, especially those related to sensitive subjects, such as driving, urinary incontinence, or sexuality. Hidden health issues, such as memory loss or depression, are a challenge. Addressing problems related to safety and independence, such as giving up one’s driver’s license or moving to assisted living, also can be difficult.

You may feel awkward addressing some of these concerns because you don’t know how to help patients solve the problem. This chapter gives an overview of techniques for broaching sensitive subjects, as well as resources for more information or support.

Try to take a universal, non-threatening approach. Start by saying, “Many people your age experience . . .” or “Some people taking this medication have trouble with . . .” Try: “I have to ask you a lot of questions, some that might seem silly. Please don’t be offended . . .” Another approach is to tell anecdotes about patients in similar circumstances as a way to ease your patient into the discussion, of course always maintaining patient confidentiality to reassure the patient you are talking to that you won’t disclose personal information about him or her.

Some patients avoid issues that they think are inappropriate for their own clinicians. One way to overcome this is to keep informative brochures and materials readily available in the waiting room. Along with each topic listed alphabetically below is a sampling of resources. Although the lists are not exhaustive, they are a starting point for locating useful information and referrals.

Advance Directives
Advance directives, including “living wills,” can help you honor individual end-of-life preferences and desires. You may feel uncomfortable raising the issue, fearing that patients will assume the end is near. But, in fact, this is a conversation that is best begun well before end-of-life care is appropriate. Let your patients know that advance care planning is a part of good health care. You can say that, increasingly, people realize the importance of making plans while they are still healthy. You can let them know that these plans can be revised and updated over time or as their health changes.

An advance care planning discussion can take about 5 minutes with a healthy patient:

  • Talk about the steps your patient would want you to take in the event of certain conditions or eventualities.
  • Discuss the meaning of a health care proxy and how to select one.
  • Give the patient the materials to review, complete, and return at the next visit. In some cases, the patient may want help completing the form.
  • Ask the patient to bring a copy of the completed form at the next visit for you to keep. If appropriate, share the plan with family members.
  • Revise any advance directives based on the patient’s changing health and preferences.

Be sure to put a copy of the completed form in the medical record. Too often, forms are completed, but when needed, they cannot be found. Many organizations now photocopy the forms on neon-colored paper, which is easy to spot in the medical record.

If your patient is in the early stages of an illness, it’s important for you to assess whether or not the underlying process is reversible. It’s also a good time to discuss how the illness is likely to play out. If your patient is in the early stages of a cognitive problem, it is especially important to discuss advance directives.

 

Driving Safety


Recommending that a patient limit driving—or that a patient give up his or her driver’s license—is one of the most difficult topics a doctor has to address. Because driving is associated with independence and identity, making the decision not to drive is very hard.

As with other difficult subjects, try to frame it as a common concern of older patients. Mention, for instance, that aging can lead to slowed reaction times and impaired vision. In addition, it may be harder to move the head to look back, quickly turn the steering wheel, or safely hit the brakes. Ask the patient about any car accidents. When necessary, warn patients about medications that may make them sleepy or impair judgment. Also, a device such as an automatic defibrillator or pacemaker might cause irregular heartbeats or dizziness that can make driving dangerous. You might ask if she or he has thought about alternative transportation methods if driving is no longer an option.

Elder Abuse and Neglect


Be alert to the signs and symptoms of elder abuse. If you notice that a patient delays seeking treatment or offers improbable explanations for injuries, for example, you may want to bring up your concerns. The laws in most States require helping professionals, such as doctors and nurses, to report suspected abuse or neglect.

Older people caught in an abusive situation are not likely to say what is happening to them for fear of reprisal or because of diminished cognitive abilities. If you suspect abuse, ask about it in a constructive, compassionate tone. If the patient lives with a family caregiver, you might start by saying that caregiver responsibilities can cause a lot of stress. Stress sometimes may cause caregivers to lose their temper. You can assist by recommending a support group or alternative arrangements (such as respite care). Give the patient opportunities to bring up this concern, but if necessary, raise the issue yourself.

End-of-Life Care
Most older people have thought about the prospect of their own death and are willing to discuss their wishes regarding end-of-life care. You can help ease some of the discomfort simply by being willing to talk about dying and by being open to discussions about these important issues and concerns. It may be helpful to do this early in your relationship with the patient when discussing medical and family history. Stay alert to cues that the patient may want to talk about this subject again. Encourage the patient to discuss end-of-life decisions early with family members and to consider a living will.

Of course, it is not always easy to determine who is close to death; even experienced clinicians find that prognostication can be difficult. Even if you have already talked with your patient about end-of-life concerns, it still can be hard to know the right time to re-introduce this issue. Some clinicians find it helpful to ask themselves, “Would I be surprised if Mr. Flowers were to die this year?” If the answer is “no,” then it makes sense to start working with the patient and family to address end-of-life concerns, pain and symptom management, home health, and hospice care. You can offer to help patients review their advance directives. Include these updates in your medical records to ensure that patients receive the care they want.

Financial Barriers
Rising health care costs make it difficult for some people to follow treatment regimens. Your patients may be too embarrassed to mention their financial concerns. Studies have shown that many clinicians also are reluctant to bring up costs. If possible, designate an administrative staff person with a good bedside manner to discuss money and payment questions. This person can also talk with your patient about changes in Medicare and the Part D prescription drug coverage plans.

Mental Health
Despite many public campaigns to educate people about mental health and illness, there is still a stigma attached to mental health problems. Some older adults may find mental health issues difficult to discuss.

Such conversations, however, can be lifesavers. Primary care doctors have a key opportunity to recognize when a patient is depressed and/or suicidal. In fact, 70 percent of older patients who commit suicide have seen a primary care physician within the previous month. This makes it especially important for you to be alert to the signs and symptoms of depression.

As with other subjects, try a general approach to bringing up mental health concerns. For example, “A lot of us develop sleep problems as we get older, but this can be a sign of depression, which sometimes we can treat.” Because older adults may have atypical symptoms, it is important to listen closely to what your patient has to say about trouble sleeping, lack of energy, and general aches and pains. It is easy to dismiss these as “just aging” and leave depression undiagnosed and therefore untreated.

Sexuality
An understanding, accepting attitude can help promote a more comfortable discussion of sexuality. Try to be sensitive to verbal and other cues. Don’t assume that an older patient is no longer sexually active, does not care about sex, or necessarily is heterosexual. In fact, research has found that a majority of older Americans are sexually active and view intimacy as an important part of life. Depending on indications earlier in the interview, you may decide to approach the subject directly (for example, “Are you satisfied with your sex life?”) or more obliquely with allusions to changes that sometimes occur in marriage. If appropriate, follow up on patient cues. You might note that patients sometimes have concerns about their sex life and then wait for a response. It is also effective to share anonymous anecdotes about a person in a similar situation or to raise the issue in the context of physical findings (for example, “Some people taking this medication have trouble . . . Have you experienced anything like that?”). Don’t forget to talk with your patient about the importance of safe sex. For example, “It’s been a while since your husband died. If you are considering dating again, would you like to talk about how to have safe sex?” Any person, regardless of age, who is not in a long-term relationship with a faithful partner and has unprotected sex is at risk of sexually transmitted disease.

Spirituality
For some older people, spirituality takes on new meaning as they age or face serious illness. By asking patients about their religious and spiritual practices, you can learn something about their health care choices and preferences. How a patient views the afterlife can sometimes help in framing the conversation.

For example, some patients feel that their fate is in the hands of a higher power, and this may prevent them from making treatment decisions. For patients who report suffering and distress about illness or end-of-life, a referral to a hospital or nursing home chaplain may be helpful.

Clinicians have found that very direct and simple questions are the best way to broach this subject. You might start, for instance, by asking, “What has helped you to deal with challenges in the past?”

Substance Abuse
Alcohol and drug abuse are major public health problems, even for older adults. Sometimes people can become dependent on alcohol or other drugs as they confront the challenges of aging, even if they did not have a problem when younger. Because baby boomers have a higher rate of lifetime substance abuse than did their parents, the number of people in this age group needing treatment is likely to grow.

One approach you might try is to mention that some medical conditions can become more complicated as a result of alcohol and other drug use. Another point to make is that alcohol and other drugs can increase the side effects of medication, or even reduce the medicine’s effectiveness. From this starting point, you may find it easier to talk about alcohol or other drug use.

Approximately 80 percent of older adults have at least one chronic disease, and of those, 50 percent have at least two chronic conditions. For many older people, coping with multiple chronic conditions is a real challenge. Learning to manage a variety of treatments while maintaining quality of life can be problematic. People with chronic conditions may have different needs, but they also share common challenges with other older adults, such as paying for care or navigating the complexities of the health care system.

Try to start by appreciating that people living with chronic disease are often living with loss—the loss of physical function, independence, or general well-being. Empathize with patients who feel angry, sad, lost, or bewildered. Ask, “Is it hard for you to live with these problems?” From there you can refer patients to community resources that may meet their needs or, when available, recommend a disease management program or case managers in the community.

Educating the Patient
Most older patients want to understand their medical conditions and are interested in learning how to manage them. Likewise, family members and other caregivers want this information. Physicians typically underestimate how much patients want to know and overestimate how long they spend giving information to patients. Devoting more attention to educating patients may seem like a luxury, but in the long run it can improve patients’ adherence to treatment, increase patients’ well-being, and save you time.

The following tips can help you inform patients and their caregivers about medical conditions and their treatment.

  • Doctors’ advice generally receives greatest credence, so the doctor should introduce treatment plans. Other medical team members have an important role, including building on the original instructions.
  • Let your patient know you welcome questions. Indicate whom on your staff he or she can call to have questions answered later.
  • Remember that some patients won’t ask questions even if they want more information. Be aware of this tendency and think about making information available even if it is not requested.
  • Provide information through more than one channel. In addition to talking to the patient, you can use fact sheets, drawings, models, videotapes, or audiotapes. In many cases, referrals to websites and support groups can be helpful.
  • Encourage the patient or caregiver to take notes. It’s helpful to offer a pad and pencil. Active involvement in recording information may promote your patient’s retention and adherence.
  • Repeat key points about the health problem and treatment at every office visit.
  • Check that the patient and his or her caregivers understand what you say. One good approach is to ask that they repeat the main message in their own words.
  • Provide encouragement. Call attention to strengths and ideas for improvement. Remember to provide continued reinforcement for new treatment or lifestyle changes.

Explaining Diagnoses
Clear explanations of diagnoses are critical. Uncertainty about a health problem can be upsetting. When patients do not understand their medical conditions, they tend not to follow the treatment plans.

In explaining diagnoses, it is helpful to begin by finding out what the patient believes is wrong, what the patient thinks will happen, and how much more he or she wants to know. Based on the patient’s responses, you can correct any misconceptions and provide appropriate types of information.

Discussing Treatment
Some older patients may refuse treatment because they do not understand what it involves or how it will improve their health. In some cases, they may be frightened about side effects or have misinformation from friends and relatives with similar health problems. They may also be concerned about the cost of the treatment.

Treatment can involve lifestyle changes (such as diet and exercise) as well as medication. Make sure you develop and communicate treatment plans with the patient’s input and consent. Tell the patient what to expect from the treatment, including recommended lifestyle change, what degree of improvement is realistic, and when he or she may start to feel better.

Keep medication plans as simple and straightforward as possible. For example, minimize the number of doses per day. Tailor the plan to the patient’s situation and lifestyle, and try to reduce disruption to the patient’s routine. Indicate the purpose of each medication. Make it clear which medications must be taken and on what schedule. It is helpful to say which drugs the patient should take only when having particular symptoms.

After proposing a treatment plan, check with the patient about its feasibility and acceptability. Work through what the patient feels may be obstacles to maintaining the plan. Try to resolve any misunderstandings. For example, make it clear that a referral to another doctor does not mean you are abandoning the patient. Provide oral and written instructions. Do not assume that all of your patients are able to read. Make sure the print is large enough for the patient to read.

Encourage your patient and his or her caregivers to take an active role in discovering how to manage chronic problems. Think in terms of joint problem solving or collaborative care. Such an approach can increase the patient’s satisfaction while decreasing demands on your time.

Understanding how different cultures view health care helps you to tailor questions and treatment plans to the patient’s needs. Although you cannot become an expert in the norms and traditions of every culture, being sensitive to general differences can strengthen your relationship with your patients.

Each culture has its own rules about body language and interpretations of hand gestures. Some cultures point with the entire hand, because pointing with a finger is extremely rude behavior. For some cultures, direct eye contact is considered disrespectful. Until you are sure about a patient’s background, you might opt for a conservative approach. And, if you aren’t certain about a patient’s preferences, ask.

The use of alternative medicines, herbal treatments, and folk remedies is common in many cultures. Be sure to ask your patient if he or she takes vitamins, herbal treatments, dietary supplements, or other alternative or complementary medicines. Also, in order to help build a trusting relationship, be respectful of native healers on whom your patient may also rely.

Older immigrants or non-native English speakers may need a medical interpreter. Almost 18 percent of the U.S. population speaks a language other than English at home, according to the Census Bureau. Among older people, 2.3 million report not speaking English or not speaking it very well. Federal policies require clinicians and health care providers who receive Federal funds, such as Medicare payments, to make interpretive services available to people with limited English.

Many clinicians rely on patients’ family members or on the ad hoc services of bilingual staff members, but experts strongly discourage this practice and recommend the use of trained medical interpreters. Family members or office staff may be unable to interpret medical terminology, may inadvertently misinterpret information, or may find it difficult to relay bad news. Although a patient may choose to have a family member translate, the patient should be offered access to a professional interpreter.

When working with non-native English-speaking patients, be sure to ask which language they prefer to speak and whether or not they read and write English (and, if not, which language they do read). Whenever possible, offer patients appropriate translations of written material or refer them to bilingual resources. If translations are not available, ask the medical interpreter to translate medical documents.

Family and informal caregivers play an important role in the lives of their loved ones. They also play an increasingly important role in how the health care system functions.

Informal caregivers may be important “informants.” They can also help to reinforce the importance of information you give or the treatment you prescribe.

To protect and honor patient privacy, be sure to check with the patient on how he or she sees the companion’s role. In many cases, the caregiver or companion can be a facilitator, helping the patient express concerns and reinforcing what you say. But it is best not to assume that a companion should be included in the medical encounter. First, check with the patient. Conducting the physical exam alone protects the patient’s privacy and allows you to raise sensitive issues. For instance, the best time to conduct a “mini-mental” test is during a private exam, so that a family member cannot answer questions or cover for the patient’s cognitive lapses.

When a companion is present, be aware of communication issues that arise in three-party interactions. Whenever possible, try to sit so that you form a triangle and can address both the patient and companion face-to-face. Be careful not to direct your remarks to the companion. By not falling into this trap, you can prevent the encounter from feeling like a “two against one” match.

Families may want to make decisions for a loved one. Adult children especially may want to step in for a parent who has cognitive impairments. If a family member has been named the health care agent or proxy, under some circumstances, he or she has the legal authority to make care decisions. However, without this authority, the patient is responsible for making his or her own choices. Try to set clear boundaries with family members, and encourage others to respect them.

Family caregivers face many emotional, financial, and physical challenges. They often provide help with household chores, transportation, and personal care. More than one-third also give medications, injections, and medical treatments to the person for whom they care. It makes sense to view informal caregivers as “hidden patients” and be alert for signs of illness and stress. Caregivers may find it hard to make time for themselves. Encourage them to seek respite care so that they can recharge and take a break from the loved one. And remember, your encouragement and praise can help to sustain a caregiver.

Cognitive Impairment


Aging itself can cause deficits in cognition that vary from person to person. While some older people show little or no decrease in cognitive function, others may be very worried about their memory and may fear dementing disorders such as Alzheimer’s disease (AD). But, not all cognitive problems are caused by AD. Various illnesses, both physical and mental, can cause temporary, reversible cognitive impairment. Certain drug combinations can also cause a problem.

Identifying and working with older adults who have cognitive impairment are important for their safety and for the safety of others. Older patients with cognitive impairment can develop difficulties in remembering and correctly adhering to instructions about medications for their other health problems. In addition, activities such as cooking and driving can become dangerous.

Many patients with cognitive impairments experience behavioral changes. For instance, they may withdraw from or lose interest in activities, grow irritable or uncharacteristically angry when frustrated or tired, or become insensitive to other people’s feelings. During more advanced stages of cognitive impairment, people may behave inappropriately—kicking, hitting, screaming, or cursing. Depending on the stage of the disease, you can suggest activities that your patient might still enjoy—for example, listening to music and perhaps dancing, playing games, gardening, or spending time with pets.

Some of your older patients may have a specific condition called mild cognitive impairment (MCI). People with MCI have ongoing memory problems but do not have other losses associated with AD such as confusion, attention problems, or difficulty with language. Some people’s cognitive problems may not get worse for many years. Some people with MCI may convert to AD over time. Research is ongoing to determine better which people with MCI will develop AD.

The suggestions in this section of the booklet pertain specifically to effective communication with patients with cognitive impairments.

Diagnosis
Accurate diagnosis of AD or other cognitive problems can help your older patient and his or her family to plan for the future. Early diagnosis offers the best chance to treat the symptoms of the disease, when possible, and to discuss ways of positively coping with the condition, including discussing care options. A relatively early diagnosis allows patients to make financial plans, prepare advance directives, and express informed consent for research. Yet data suggest that only a small fraction of people with AD are ever diagnosed.

When patients are only mildly impaired, they can be adept at covering up what is happening to them. However, giving a few straightforward tests, using a medical history, and taking a family history from another family member can often tell you if there are persistent or worsening problems. It is best to conduct tests or interviews with the patient alone so that family members or companions cannot prompt the patient. Information can also be gleaned from the patient’s behavior on arrival in your office or from telephone interactions with staff. Family members who may contact you in advance or following the visit are also a source of information, but keep in mind patient privacy concerns.

Although assessing an older person’s cognitive function is important, formal testing of mental status tends to provoke anxiety. If you are concerned about a patient’s cognition, it might be best to leave any formal testing of mental status until the latter part of the appointment—either between the history and the physical examination or after the examination—or to refer the patient to a neuropsychologist for more detailed assessment of cognition. If you administer a cognitive status test, try to present it in the context of concerns the patient has expressed. Providing support and encouragement during the testing can decrease stress.

There are limitations to any mental status test—for example, the test results can reflect level of education, or the results may appear normal early in the disease. The most commonly used screen is the Mini-Mental State Examination. This test can be used to screen patients for cognitive impairment and can be administered in the primary care setting in about 10 minutes. A positive finding suggests the need for referral to a neurologist or neuropsychologist for a more detailed diagnosis.

Cognitive impairment may reflect a variety of conditions, some reversible. In particular, it is important to review your patient’s medications to check for anticholinergic or other potentially inappropriate medications. However, since patients or caregivers may assume that the cause is Alzheimer’s disease, you may need to explain the need for a careful history, laboratory tests, and physical examination to search for other conditions or issues.

If your patient does have mild to moderate cognitive impairment, you might ask if there is someone who helps when he or she has trouble remembering. If your patient says yes, you could also ask if it would be a good idea for you to discuss the patient’s treatment plans with the helper and keep his or her name in your notes for future reference. Make these arrangements early, and check that the patient has given you formal authorization to include the helper in the conversation about your patient’s care.

Communicating With a Confused Patient

  • Try to address the patient directly, even if his or her cognitive capacity is diminished.
  • Gain the person’s attention. Sit in front of him or her and maintain eye contact.
  • Speak distinctly and at a natural rate of speed. Resist the temptation to speak loudly.
  • Help orient the patient. Explain (or re-explain) who you are and what you will be doing.
  • If possible, meet in surroundings familiar to the patient. Consider having a family member or other familiar person present at first.
  • Support and reassure the patient. Acknowledge when responses are correct.
  • If the patient gropes for a word, gently provide assistance.
  • Make it clear that the encounter is not a “test,” but rather a search for information to help the patient.
  • Use simple, direct wording. Present one question, instruction, or statement at a time.
  • If the patient hears you but does not understand you, rephrase your statement.
  • Although open-ended questions are advisable in most interview situations, patients with cognitive impairments often have difficulty coping with them. Consider using a yes-or-no or multiple-choice format.
  • Remember that many older people have hearing or vision problems, which can add to their confusion.
  • Consider having someone call the patient to follow up on instructions after outpatient visits.
  • If the patient can read, provide written instructions and other background information about the problem and options for solutions.

Conveying Findings
Some patients may prefer a cautious, reserved explanation. You might consider saying something like, “You have a memory disorder, and I believe it will get worse as time goes on. It’s not your fault. It may not help for you to try harder. Now is probably a good time for you to start making financial and legal plans before your memory and thinking get worse.” Some patients may prefer more precise language and appreciate it when a doctor uses specific words like Alzheimer’s disease. If possible, schedule additional time for the appointment so that you can listen and respond to the patient’s or caregiver’s concerns. Also, if possible, offer to have a follow-up appointment to further discuss what to expect from the diagnosis.

Regardless of how you present the diagnosis, providing written materials can make a big difference in helping your patient and his or her family know what to expect. The NIA’s Alzheimer’s Disease Education and Referral (ADEAR) Center has free publications you can include in a patient/caregiver information packet. You might want to refer your patient to a neurologist or neuropsychologist for testing. The Alzheimer’s Association or other supportive organizations can provide assistance in planning, social services, and care.

Informing family members or others that the patient may have Alzheimer’s disease or any cognitive impairment may be done in a family conference or group meeting, which should be arranged with the consent of the patient. In some situations, a series of short visits may be more suitable. You should make clear you will continue to be available for care, information, guidance, and support. If you are unable to provide all of these services, it would make a tremendous difference if you could refer the patient and family to a service organization.

Working With Family Caregivers
All family caregivers face challenges, but these challenges are compounded for people caring for patients with Alzheimer’s disease and other dementias. The patient usually declines slowly, over the course of several years. This is an exhausting and disturbing experience for everyone. The following suggestions are especially useful for family caregivers in these situations:

  • Persuade caregivers to get regular respite, especially when patients require constant attention. Ask if the caregiver, who is at considerable risk for stress-related disorders, is receiving adequate health care.
  • Explain that much can be done to improve the patient’s quality of life. Measures, such as modifications in daily routine and medications for anxiety, depression, or sleep, may help control symptoms.
  • Let the caregivers know there is time to adapt. Decline is rarely rapid. Provide information about the consumer resources and support services available from groups.
  • Help caregivers plan for the possibility that they eventually may need more help at home or may have to look into residential care.

Aging Hearts and Arteries: A Scientific Quest 

Introduction
Age is the major risk factor for cardiovascular disease. Heart disease and stroke incidence rises steeply after age 65, accounting for more than 40 percent of all deaths among people age 65 to 74 and almost 60 percent at age 85 and above. People age 65 and older are much more likely than younger people to suffer a heart attack, to have a stroke, or to develop coronary heart disease and high blood pressure leading to heart failure. Cardiovascular disease is also a major cause of disability, limiting the activity and eroding the quality of life of millions of older people each year. The cost of these diseases to the Nation is in the billions of dollars.

To understand why aging is so closely linked to cardiovascular disease, and ultimately to understand the causes and develop cures for this group of diseases, it is essential to understand what is happening in the heart and arteries during normal aging—aging in the absence of disease. This understanding has moved forward dramatically in the past 30 years. The purpose of this booklet is to tell the story of this progress, describe some of the most important findings, and give a sense of what may lie ahead.

While we know a great deal about cardiovascular disease and its risk factors, new areas of research are beginning to shed further light on the link between aging and the development and course of the disease. For instance, scientists at the National Institute on Aging (NIA) are paying special attention to certain age-related changes that occur in the arteries and their influence on cardiac function.Many of these changes, once considered a normal part of aging, may put people at increased risk for cardiovascular disease.

This and other compelling research on the aging heart and blood vessels takes place at many different research centers. A great deal of the work is being done by researchers in the Laboratory of Cardiovascular Science at the NIA or by NIA-funded scientists at other institutions. Others have worked at or been funded by the National Heart, Lung, and Blood Institute (NHLBI). NIA and NHLBI are two of 27 research institutes and centers at the National Institutes of Health, and their work is complementary. NIA research focuses on the effects of aging on the heart, blood vessels, and other parts of the body, while NHLBI works to understand the diseases and risk factors that affect the heart and blood vessels.

Both perspectives are bringing us closer to the possibility that heart disease and stroke will someday be defeated. Research on the basic biology of the aging cardiovascular system nurtures hope that we as a Nation need not accept the high rates of death and disability and the enormous health care costs imposed by cardiovascular disease among older people in our society.

It is scarcely as big as the palm of your hand yet it sustains life, pumping up to 5 quarts or more ofblood per minute to the body’s organs, tissues, and cells. In a typical day, it beats 100,000 times. And in a lifetime, it beats more than 2.5 billion times. Even as you rest, your heart is working twice as hard as your leg muscles would if you were running at full speed.

Little wonder then that from earliest mythology to modern medicine, the heart has fascinated and perplexed us. Fortunately, today we know farmore about the heart and the blood vessels than was known even a decade ago. Yet for all scientists have learned, there is still much more to unravel. Investigators, for instance, now know that the cardiovascular system undergoes significant changes as we age, and the heart and arteries that we are born with are surprisingly different in later life.

But how and why do these changes occur? What influence do these changes have on our risk of developing heart disease and other cardiovascular disorders as we get older? Are there any underlying signs—even in people who appear to have healthy hearts—that precede and predict who will develop severe cardiovascular disease and who won’t?

Scientists called gerontologists, who study aging, are seeking to answer these and other questions. As a result of this probing, some old ideas about the aging cardiovascular system are giving way to new theories. In other cases, gerontologists are just beginning to explore some questions, and the heart and arteries are yielding their secrets grudgingly.

But to truly understand what is emerging and what remains mysterious, we’ll need to start where these gerontologists began: in the normal, healthy heart.

The Intricate Pump
The heart is a marvel of coordination and timing. Almost completely composed of muscle called myocardium, it is well-equipped for its life-long marathon of ceaseless beating. It is essentially two pumps in one. The right side pumps blood to the lungs to load up on oxygen and dispose of carbon dioxide. The left side pumps oxygen-rich blood to the body.

 

To accomplish these tasks, the heart depends on a precise sequence of contractions involving its two upper chambers—the right and left atria—and its two lower ones, the right and left ventricles. Between these chambers are two valves, each with two or three flaps, also known as cusps. The tricuspid valve separates the right atrium and the right ventricle. Its counterpart, separating the left atrium and the left ventricle, is called the mitral valve. The pulmonic valve controls blood flow out of the right ventricle to the lungs where it picks up oxygen. The aortic valve controls the flow of oxygenated blood out of the left ventricle into the body. Normally these valves let blood flow in just one direction.

The heart beats in two synchronized stages. First, the right and left atria contract at the same time pumping blood into the right and left ventricles. Then the mitral and tricuspid valves close. A split second later, the ventricles contract (beat) simultaneously to pump blood out of the heart. Together, these coordinated contractions produce the familiar “lub-dub” sound of a heart beat—slightly faster than once a second.After contracting, the heart muscles momentarily relax, allowing blood to refill the heart.

To picture how this all works, imagine that as the heart relaxes dark red blood returning from the body flows into the right atrium. This blood carries little oxygen and is laden with carbon dioxide, which is produced by body tissues. When the right atrium contracts, it propels oxygen-poor blood through the tricuspid valve into the right ventricle. In turn, the right ventricle pumps blood into the pulmonary artery. From there, it flows into the lungs where it picks up oxygen and returns to the left atrium. When it contracts, the left atrium pumps the now bright red oxygenated blood through the mitral valve into the left ventricle, which pumps it into the aorta, from which it is distributed to other arteries to nourish your cells, tissues, and organs. Then the cycle begins again.

This cardiac cycle is regulated by nerve impulses, generated by the heart’s internal pacemaker called the sinoatrial node (SA node), a small bundle of specialized cells located in the right atrium. These impulses cause the heart to beat.Once generated by the SA node, the impulses spread in a coordinated fashion across the heart muscle in less than a quarter of a second. As they travel, the impulses are relayed through switching stations at precise intervals, eventually causing millions of interlocked cells to contract in near unison.

Age, Change, and Adaptation
The major sequences in this ever-moving picture of the heart beat have been known for nearly 400 years. But gerontologists are uncovering another influence on this chain of events—age—and the picture appears to be even more complex. Aging, it turns out, brings not a simple slowing down of heart function, as one might expect, but a set of intricate alterations: a slowing here, an enhancement there, a minor adjustment elsewhere. The result of these numerous small alterations is adaptation. In various ingenious, important ways, the heart at age 65 has adapted to meet the needs of the 65-year-old body.

However, these refinements have a downside. In recent years, gerontologists have learned that some changes in the structure and function of the aging cardiovascular system, even in a healthy older person without any diagnosed medical condition, can actually greatly increase the risk of developing cardiovascular diseases, including high blood pressure, atherosclerosis, and heart failure. In fact, these changes can create the nearly perfect setting for the onset of severe cardiovascular disease in some healthy older people.

Gerontologists seeking to reconcile these two conflicting pictures of cardiovascular aging are intensely studying the fundamental underpinnings of the age-associated changes in the heartand arteries in hopes of discovering new ways to effectively prevent and treat cardiovascular disease in older people. This quest—from the impact of the smallest molecule to the influence of diet and exercise—is radically changing how scientists think about the cardiovascular system.

The notion, for instance, that heart cells can’t replicate themselves is being reconsidered. Gerontologists now know far more about how aging affects blood vessels and how this process influences the development of atherosclerosis. They are learning much more about how physical activity, diet, and other lifestyle factors influence the “rate of aging” in the healthy older heart and arteries.

In the Beginning
Untangling the effects of age from those of disease and lifestyle is a theme that appears again and again in modern studies of aging. It wasn’t always so. In the 1940s and 50s, clinical gerontologists had to conduct most of their studies in chronic care hospitals or nursing homes. The people they studied lived sedentary lives, and many may have had undetected heart disease or other illnesses. From this perspective, it appeared as if virtually all bodily functions, including the cardiovascular system, deteriorated markedly with age.

Then, in 1958, the National Institutes of Health (NIH) launched the Baltimore Longitudinal Study of Aging (BLSA). This ongoing investigation, now part of the National Institute on Aging (NIA), has tracked the lives of more than 3,000 people from age 20 to 90 and older in an effort to document the normal or usual physiological changes that occur in a stable population of people who live in the community rather than institutions. BLSA data have been valuable to scientists searching for different ways in which aging, lifestyle, and disease affect the heart and blood vessels.

The modern era of heart research has also depended heavily on the development of powerful, non-invasive technologies, such as echocardiography, magnetic resonance imaging, and radionuclide imaging, which have allowed investigators to easily see valves, walls, and chambers of the heart and the flow of blood through these chambers. Two techniques, thallium scintigraphy, a highly sensitive radionuclide stress test that can detect hidden coronary artery disease, and stress electrocardiogram (ECG), a measurement of the electrical activity of the heart, are particularly useful. In combination, these two tests allow researchers to differentiate between the effects of age and the effects of coronary disease that is so prevalent among older people—effects that were once entangled and indistinguishable.

For 92-year-old John Bicknell, this is the best of times. A long-retired English professor, he remains mentally and physically active. In addition to singing in community choirs and performing in local musical theater productions, he continues to mow his own large yard and often walks up to a mile or two a day around his island home in Maine.

As he walks around his property, Bicknell sometimes gathers small twigs and branches for kindling, and makes a mental note of larger deadfall so he and his son-in-law can return later to cut it up and haul it back to the house in a truck. An avid boater, he frequently motors between the island and the mainland. In the summer, he enjoys swimming with his grandchildren in the brisk, but invigorating waters of a nearby cove.

After a recent trip to England and France, he returned home to a brewing winter storm. The next morning, he shoveled 9-inches of snow off his deck and front porch.

He looks healthy; his muscles are strong; he has no excess fat. And while gerontologists now know that John Bicknell’s 92-year-old heart is not quite the same as it was when he was 22, it continues to serve him extraordinarily well.

On one level, it’s not surprising that an older person who exercises regularly is more physically fit and better able to care for himself than most other people his age. But below the surface of that assumption lie intriguing questions that scientists are just beginning to answer. “We know that older people who exercise regularly can do more aerobic work, meaning they are more physically fit,” says Edward Lakatta, MD, who is chief of the Laboratory of Cardiovascular Science at the NIA. “But for decades gerontologists have wanted to know what changes in the aging heart and arteries allow this to happen. Fortunately, in the past few years, we have uncovered some remarkable new clues that have clarified how and why these changes occur. At the same time, however, we have detected some intriguing evidence that transforms much of what we once thought of as normal cardiovascular aging.”

Many of these adjustments are remarkably efficient, helping the older heart work as well as possible. But some ultimately may be detrimental. In particular, some gerontologists suspect several of these age-related changes may lower the heart’s resistance to disease and compromise its ability to respond to increased demands for blood and oxygen during stress.

The Effects of Normal Aging
The emerging methods of studying the heart have led to the growing realization that the many factors influencing the aging heart and blood vessels are interdependent. At least six major factors affect how the heart fills with blood and pumps it out. When scientists first discovered these factors, they thought they operated independently. But as investigators more closely examined these factors, they discovered that these six factors influence each other in various direct and indirect ways.

The diagram on the facing page illustrating their interdependence is deceptively simple. It shows only the six broad categories, but each of these terms encompasses a host of related factors. Many of these factors are the focus of rigorous research, including structural changes in the normal aging heart.

Structural Changes
The NIA’s studies of normal aging have revealed a series of fine-tuned adjustments that allow the heart to meet the needs of the aging body. This picture is radically different from the one that prevailed several decades ago when marked declines in overall heart function were thought to be the norm. The revolution in perspective began in the 1970s when researchers came upon their first surprise: The walls of the left ventricle, as it ages, grow thicker.

Up until then, gerontologists thought that the heart shrank with age. One reason was that early researchers knew about the older heart mainly through chest x-rays and autopsy studies of people who were institutionalized, often with chronic illnesses. These people’s hearts, which were affected by disease or extremely sedentary lives, often were smaller than those of younger, healthier people.

Then, in the late 1950s, gerontologists began to study healthy volunteers, such as those who participate in the BLSA. Soon afterward, scientists devised new technologies like echocardiography and radionuclide imaging.While x-rays provide a static, shadowy silhouette, echocardiography and other imaging techniques clearly show thickness, diameter, volume, and in some cases, shape of the heart and how these change with time during a given heart beat. Recently, gerontologists have begun using magnetic resonance imaging (MRI) to get a better look at the aging heart. MRI is a type of body scan that uses magnets and computers to provide high-quality images based on varying characteristics of the body’s tissues. The technology allows physicians to noninvasively study the beating heart’s overall structure and function continuously in three dimensions.

The thicker left ventricular walls supplied the first clue that the heart might be adjusting rather than simply declining with age. Scientists think that the increased thickness allows the walls to compensate for the extra stress they bear with age (stress imposed by pumping blood into stiffer blood vessels, for instance). When walls thicken, stress is spread out over a larger area of heart muscle.

Heart Filling
Other findings about the left side of the heart soon followed. While at the NIA, Gary Gerstenblith, MD, and his colleagues studied the left ventricle and the left atrium, the receiving chamber into which blood flows from the lungs before passing into the ventricle. Their echocardiograms with BLSA volunteers showed that in addition to the left ventricular wall growing thicker, the cavity of the left atrium increased.

This study also yielded one other finding, a curious one: The mitral valve—the gateway between the left atrium and ventricle—appeared to close more slowly in older people. As the ventricle fills, the two flaps of the mitral valve—like a trap door with two separate panels—float up on the rising pool of blood and come together to close the passage. If this valve were closing more slowly in older people, as the echocardiograms indicated, then perhaps the ventricle was filling more slowly.

To figure out why this occurs and if it makes any difference, investigators turned their attention to the fraction of a second between heart beats. During this momentary lull, called the diastole, the heart relaxes, fills with blood, and readies for the next contraction or systole.

Heart researchers divide the moments of diastole into even shorter periods. There is the early filling phase when blood from the left atrium pushes the mitral valve open, flows rapidly into the left ventricle, and floats the valve shut. This early diastolic filling is the phase that takes longer as people grow older, according to the Gerstenblith study. Then comes the late filling phase, when the left atrium contracts, forces open the mitral valve a second time, and delivers a last surge of blood to the ventricle, just before it too contracts.

Why should early diastolic filling slow down as people age? Could it be because the ventricle wall was not relaxing between heart beats as quickly as it once had?

This possibility intrigued NIA investigators because it fit neatly with another stray piece to the puzzle. In animal studies several years earlier, Dr. Lakatta had learned that rat hearts studied in the laboratory took longer to relax after a contraction when they were from older rats.

Later imaging studies in humans confirmed the animal studies: Between beats, the aging ventricle fills with blood more slowly because it is relaxing more slowly than it did when young.

But now another piece of the diastolic puzzle needed to be fit into place. If the older left ventricle fills more slowly with blood, does this mean it has less blood pooled at the end of diastole and thus less to send out to the body during the next contraction? The answer is no, and the reason was found in another of the adjustments that the heart makes with age. NIA investigators found that the heart compensates for the slower early filling rate by filling more quickly in the late diastolic period.

It happens like this: As the mitral valve slowly closes, incoming blood from the lungs pools in the left atrium, which is now larger and holds more blood than when young. In the last moments of the diastole, the SA node—the heart’s pacemaker—triggers the first electrical impulse (the action potential), which will lead to contraction. The impulse spreads across the cells of the two atria.

The left atrium, stretched with a greater volume of blood in older hearts, contracts harder, pushing open the valves and propelling the blood into the ventricle. The late diastolic surge of blood into the left ventricle from the atrium’s contraction occurs at all ages but is stronger in older hearts and delivers a greater volume of blood to the left ventricle. As a result, at the end of diastole, the volume of blood in older hearts is about the same (in women) or slightly greater (in men) than in younger hearts. In younger people, about twice as much blood flows into the ventricle during the early filling period than during late filling. But as we age, this ratio changes so blood flow during early and late filling is about equal.

The next step in this chain of events is contraction or systole, and here the puzzle becomes more complex.

Picture the left ventricle at the end of diastole filled with a volume of blood that is equal to or slightly greater than the volume in younger hearts; this is called end diastolic volume. When the contraction occurs, it forces out a certain amount of blood—the stroke volume. However, not all of the blood in the heart is pumped out at once. A portion remains in the ventricle, and this is called the end systolic volume. The proportion of blood that is pumped out during each beat compared to the amount that remains in the heart at the beginning of the next beat is called the ejection fraction. Doctors frequently use the ejection fraction to estimate how well the heart is pumping.

These measurements are important because the links between end diastolic volume, stroke volume, end systolic volume, and ejection fraction make up a complex set of dynamics that researchers had to sort out as they attempted to understand what differences aging makes in the heart’s pumping ability. The various cardiac volumes differ according to age, gender, body size and composition, and degree of physical activity. However, keep in mind that the various changes discussed in this section are what occur, on average, in older hearts. As we age, the differences in these measures between one individual and another will vary much more than in younger people. So, for instance, among 65 to 70-year-old women the range of end diastolic volumes and stroke volumes can be quite vast.

Pumping at Rest
When you are sitting in a chair reading a book or watching television, your heart—regardless of age—usually works well below its full capacity. Instead, the heart saves or reserves most of its capacity for times when it is really needed, such as playing tennis or shoveling snow.

In fact, at first glance, healthy young and old hearts don’t seem very different—at least when resting. For instance, cardiac output—the amount of blood pumped through the heart each minute—averages 4 to 6 quarts per minute at rest depending on body size and doesn’t change much with age. Similarly,while resting, both young and old hearts eject about two-thirds of the blood in the left ventricle during each heart beat.

But on closer examination, there is at least one important difference between a healthy resting young heart and an older one: heart rate. When we’re lying down, the rates of young and old hearts remain about the same. But when we’re sitting, heart rate is less in older people compared to younger men and women, in part, because of age-associated changes in the sympathetic nervous system’s signals to the heart’s pacemaker. As we age, some of the pathways in this system may develop fibrous tissue and fat deposits. The SA node, the heart’s natural pacemaker, loses some of its cells.

In men, the heart compensates partly for this decline in two ways. First, the increase in end diastolic volume that comes with age, means there is more blood to pump; and second, the greater volume stretches the ventricular walls and brings into play a peculiar property of muscle cells—the more they are stretched, the more they contract. This phenomenon is called the Frank-Starling mechanism and together with the greater volume of blood to be pumped, it helps to make up for the lower heart rate.

In women, end diastolic volume while sitting does not increase with age, so stroke volume does not increase. The difference between the sexes probably reflects their different needs rather than a difference in their hearts’ pumping abilities.

But while the resting older heart can keep pace with its younger counterpart, the older heart—even if in peak condition—is no match for a younger one during exercise or stress.

Pumping During Exercise
It’s no secret that the ability to run, swim, and exert ourselves in other ways diminishes as we get older. In fact, the body’s capacity to perform vigorous exercise declines by about 50 percent between the ages of 20 and 80. About half of this decline can be attributed to changes in the typical aging heart.

During any kind of activity—even moving from a sitting to a standing position—the heart must pump more blood to the working muscles. In younger people it does this by increasing the heart rate and squeezing harder during contractions, sending more blood with each beat. But age brings changes. Heart rate still rises, but it can no longer rise as high. In your 20s, for instance, your maximum heart rate is typically about 190 to 200 beats per minute; by age 80, this rate has diminished to about 145 beats per minute. A reduced response of heart cells to signals from the brain result in a substantial decline in the peak rate at which the older heart can beat. In addition, force of contraction during vigorous exercise increases, but not as much in older people as in younger ones.

As a result, the heart’s cardiovascular reserve diminishes. Put another way, a typical 20-year-old can increase cardiac output during exercise to 31/2-4 times over resting levels. In comparison, by age 80, a person can only muster about two times as much cardiac output as at rest.

Yet the aging heart still must respond to many of the same demands as the younger heart. To do so, it takes advantage of its natural flexibility. The heart, which is composed of elastic-like material, can readily alter shape and size depending on the amount of blood within its chambers.

At rest, only a small portion of the body’s blood supply is flowing into the heart at any given moment. But with exertion, your body sends out signals that increase blood flow from the veins back to the heart initially stretching and swelling it. This triggers the Frank-Starling mechanism. In response, the young heart pumps harder. Then the brain kicks in, releasing neurotransmitters that elevate heart rate, increase contraction strength, and boost ejection fraction. In addition, the young heart returns to its small, resting size at the start of each beat. All of these reactions help the young heart work more efficiently. (See When the Brain Talks to the Heart, page 18)

But the older heart doesn’t respond in the same way. Although the brain still releases neurotransmitters that stimulate the heart to work harder during vigorous exercise, the older heart is less responsive to these signals than the younger heart. And unlike the young heart, it can’t squeeze down to a small size at the end of a heart beat. So its ejection fraction increases only slightly from its resting level of about 65 percent during vigorous exercise. In addition, you might recall that the older heart can’t increase its rate as much as the younger heart during exertion. So if it can’t beat as fast or squeeze down as hard, then how does the older heart respond to the demands of exercise? The answer is: it adapts.

Because its pumping rate increases less during exercise, the older heart has more time than a younger heart to fill with blood between beats. This additional filling time, combined with a lower ejection fraction, causes the older heart to expand to a larger size during diastole than a young heart. As a result, during exercise the older, bigger heart has more blood in its chambers at the start of each beat than a younger heart. This extra blood volume allows the older heart to pump out just about as much blood with each beat as a younger, smaller heart, even though it has a lower ejection fraction. This represents the Frank-Starling mechanism working at its finest. However during vigorous exercise the older heart is still pumping less blood overall because it can’t beat as fast as a young heart.

While this adaptation certainly helps the heart meet the immediate needs of the exercising older body, it does so at a cost. As the older heart dilates between beats, wall tension and pressure within its cavities rises. This increases load on the heart and forces it to work harder. In the long run, persistently elevated pressure promotes thickening and stiffening of the ventricular walls. As a result, the ventricles don’t fully relax between beats, and this—combined with a greater filling volume—causes end diastolic left ventricular pressure to increase. When this happens the left atrial pressure increases and this pressure increase is transmitted to the lungs. As pressure rises, oxygenated blood has trouble getting from your lungs into the left side of your heart so it can be pumped out to the body. One outward sign of this scenario within the lungs is that you begin to feel short of breath while exerting yourself. How much exercise you can do before you experience this symptom depends, in part, on how much of the left ventricle’s pumping capacity has been eroded. Regular aerobic exercise can help diminish the impact of many of these age-related changes.

When the Brain Talks to the Heart: Does Age Matter?
The brain talks to the heart through the nervous system, using the language of biochemistry. Substances called neurotransmitters travel from nerve cell to heart cell, deliver the brain’s messages by binding with special receptors on the membranes of heart cells, and set off a chain of molecular events that ends with a faster beating heart, stronger contractions, and faster relaxation between beats. Or, depending on what neurotransmitter is used, the brain can tell the heart to reverse all of these effects.

This heart-brain dialogue occurs through the autonomic nervous system without you having to think about it. This system automatically regulates all of the body’s processes like breathing or digestion that don’t require conscious control. But as we age, some of these lines of communication begin to fray, and the heart doesn’t respond to the brain’s messages as promptly or as well as it once did.

For years, scientists were puzzled by this phenomenon, but they may be getting closer to understanding how and why these messages get muffled. In particular, investigators are looking at the sympathetic nervous system, the part of the autonomic nervous system that signals the heart to speed up. This subsystem helps regulate the heart beat through a series of signals passed from neurotransmitters to receptors on the membranes of heart cells. One of these important signaling cascades starts when neurotransmitters, such as catecholamines, bind to special protein molecules, called beta adrenergic receptors, on the heart cell membrane. Once activated by a neurotransmitter, these beta adrenergic receptors set off a chain of molecular events that allows more calcium to enter heart cells. Increased calcium within these cells can lead to a stronger and more rapid heart beat.

But as we get older, something goes awry in this signaling cascade. As a result, the older heart can’t respond to these neurotransmitters, so it doesn’t react to stress as well as a younger heart. During exercise, for instance, an older heart is less able than a younger heart to increase its heart rate, augment its contraction strength or boost its cardiac output to meet the needs of the body.

At first, researchers suspected that the diminished supply of catecholamines and other neurotransmitters might be the problem. To test this theory, NIA investigators infused catecholamines into the blood streams of older and younger volunteers to simulate the effects of exercise. As expected, the heart rates of the young men increased. But the older men’s rates increased less, even though they received the same supply of catecholamines. So the problem wasn’t supply.

Could the problem then be somewhere in the aging cardiovascular system’s response to catecholamines? Studies show that this is probably the case. There is a drug called propranolol which blocks the body’s response to catecholamines by blocking the beta adrenergic receptors on heart and blood vessel cells. Propranolol and aging have the same effects, according to a number of studies. Older hearts and blood vessels, apparently, have blocked some of these beta adrenergic receptors.

Investigators soon found that with age the number of beta adrenergic receptors on heart cells did diminish. But this reduction was only modest. Instead, studies now suggest that something else about these receptors changes with age: the number of them that are capable of binding with catecholamines, i.e., those in a “high affinity state,” seems to decline with age.

The reason for the reduced response could lie anywhere in the cascade of events in heart muscle cells that occurs after catecholamine binds to the receptor. Scientists are finding a host of possible cellular mechanisms that might explain the reduced response. They hope once these mechanisms are better understood, they will be able to find a way to mend the link or prevent it from disrupting messages in the first place. Eventually such findings could lead to new ways to prevent heart failure.

Under a microscope, the true grandeur of the heart reveals itself.Magnified, a rod-shaped heart muscle cell taps out a constant beat. A closer look within the cell reveals a series of thin contractile fibers called myofilaments that are the machinery driving these contractions. In the left ventricle alone, there are nearly 5 billion of these cells beating rhythmically, as if they are all listening to the same snappy tune.

The chemical chain of events that underlies the beating of these cells and of the heart as a whole is truly remarkable. First, there’s the electrical impulse along the cell’s membrane; then channels open in the cell membrane allowing sodium to flow into the cell. After that, more channels open and calcium enters and binds to a tiny structure near the membrane; then, much more calcium explodes out of that structure into the cell’s inner fluid and combines with a myofilament protein called troponin. Troponin then changes shape to allow two other proteins, actin and myosin, to come together. The joined proteins slide past each other in such a way as to shorten the cell, pulling the ends of the cell inward—this is the actual contraction—and then the whole process reverses itself as the heart relaxes in preparation for the next beat.

During the past 30 years, scientists have made some intriguing discoveries about the process that changes an electrical impulse into a muscle contraction. These discoveries have led to novel hypotheses about aging and disease. Scientists have found that age-related changes in heart muscle cells (myocytes) help explain alterations in the heart as a whole. For instance, they’ve learned there are fewer myocytes to do the work as we age and those that remain enlarge, compromising their ability to pump blood efficiently. They’ve also discovered much about how these changes could interact with disease processes and found clues to how exercise affects the biochemistry of cells. Scientists have begun to question some of the long-held theories about the nature of the aging heart, including whether some myocytes can replicate and what role aging may have in this process. And they’ve learned a great deal more about the critical role calcium plays in the drama of the aging heart.

The Marvelous Calcium Pump
Scientists have long known that calcium—the mineral that helps keep your teeth and bones strong—also has an important job within your heart. Calcium entering the myocyte’s inner fluid or cytosol binds with other contractile proteins to bring about contraction. Calcium leaving the cytosol allows the cell to relax. It’s this constantly changing ebb and flow of calcium in and out of the cytosol of heart muscle cells that is the essence of the heart beat. (See How a Myocyte Contracts.)

At the beginning of the calcium cycle—which coincides with the heart filling with blood—calcium in the cytosol and surrounding the contractile filaments of each myocyte is at least 10,000 times lower than calcium levels in your blood and in other fluids between your cells, called the intercellular spaces. As the cycle progresses, pores (or channels) in cell membranes open and close, allowing various salts to flow in and out of the cell. This activity triggers momentary fluctuations in the positive and negative electrical charges across the cell’s membrane. When these fluctuations reach a particular threshold, an electrical discharge occurs. This discharge, called the action potential, essentially flips a switch on the myocyte’s membrane to open pores that allow a small amount of calcium to enter the cell.

This tiny bit of calcium binds to openings called calcium release channels on the sarcoplasmic reticulum, an organelle (a small cellular “organ”) that serves as a storage bin for calcium. In response, the sarcoplasmic reticulum releases a large amount of its stored calcium into the cell. The calcium released from this storage compartment binds to the cell’s myofilaments, causing them to tighten or shorten. As the myofilaments tighten, the myocyte compresses (shrinking in length and fattening in width). This process occurs almost simultaneously in every cell in the heart wall, causing them to contract and pump blood out of the heart.

In order for the heart to relax, the cycle winds down and calcium detaches from the myofilaments. A cellular mechanism kicks in and pumps most of the calcium back into the storage bins located in the sarcoplasmic reticulum. Any residual calcium is driven out of the cell through specialized exit calcium carriers located on the cell’s membrane. These carriers are proteins that swap calcium inside the cell for sodium outside of it. Then the cycle restarts in preparation for the next heart beat.

If this system fails, and calcium cycling gets out of whack, chaos can ensue. The heart, for instance, can’t relax and fill with blood properly and diastolic pressure in the heart increases. In addition, individual cells may fire off rapidly and independently, resulting in arrhythmias—variations from the normal heart beat rhythm—and fibrillation, which is a very rapid twitching of individual muscle fibers. In particular, older hearts are more susceptible to spontaneous calcium oscillations than younger hearts, and it takes fewer oscillations to bring about fibrillation. Fibrillation in the left ventricle leads quickly to acute heart failure and to death if not treated.

Heart failure occurs when the heart loses its ability to pump enough blood to meet the body’s requirements. In particular, heart failure causes the heart to gradually lose its reserve pumping capacity and work less efficiently. Blood pressure and flow to body organs drops. The kidneys sense this and send out signals prompting retention of body fluid, which contributes to swelling. This can cause a backup of fluid into the lungs and body tissues triggering shortness of breath, swelling of the legs and feet, and other symptoms. As heart failure progresses the effects can become quite severe, and patients often lose the ability to perform even modest physical activity. Eventually, the heart's reduced pumping capacity may interfere with routine tasks, and individuals may become unable to care for themselves. Heart failure rises exponentially with advancing age, and studies of the calcium cycle in heart cells suggest a number of possible reasons.

 

When a Good Pump Goes Bad


Imagine sitting calmly in a living room chair when the smoke detector goes off. As you scramble to quickly get out of the house, your heart starts beating faster. A few moments later, after you discover it was a false alarm, you return to your comfortable chair, and your heart rate slows again. As this scenario suggests, your heart beat can vary from moment to moment. And your heart’s ability to respond to these changes depends a lot on calcium. The more calcium your heart cells release from their intracellular storage bins, the greater the force of the heart’s contractions. But how well these mechanisms work depends on how much calcium can be pumped from these storage bins between heart beats. In young hearts, these calcium pumps work quite well, but in older hearts these pumps are much less efficient.

After the heart beat, if you recall, most of the calcium returns to the storage bins in the sarcoplasmic reticulum and then awaits the next signal to do its job again. Scientists began taking a closer look at this mechanism when they learned that muscle from older hearts takes longer to relax than muscle from younger hearts. One of the prime suspects for this phenomenon was calcium. To test this idea, Dr. Lakatta and his colleagues at the NIA used a protein that binds to calcium and gives off a blue light to detect how much calcium is in a cell at any one time. When they injected this calcium-sensing protein into myocytes within heart muscle in laboratory dishes, the blue light showed that calcium levels, after a contraction, fell more slowly in older myocytes. Or, putting it in biologists’ terms, the cytosolic calcium transit was longer. But why? Could the calcium be spending longer in the inner fluid because the sarcoplasmic reticulum wasn’t removing it as quickly in older cells?

The answer was yes. In experiments, NIA scientists isolated the sarcoplasmic reticulum from the rest of the heart cell, placed it in a test tube, and then added calcium. The sarcoplasmic reticulum took up the calcium more slowly in samples from older animals than those from younger ones.

Subsequent studies confirmed that the sarcoplasmic reticulum—or more precisely, a protein on this organelle—removes calcium more slowly in older hearts. Researchers have found that older cells have lower amounts of this particular protein, often called the calcium pump protein because it removes the calcium in a series of repeated movements. In essence, the sarcoplasmic reticulum removes calcium from the inner fluid more slowly in older hearts because there are fewer pumps, and those that remain don’t work as well because of communication breakdowns between the brain and the heart.

If these pumps aren’t working properly or have shut down, the sarcoplasmic reticulum won’t fill as well as it should with calcium, and there won’t be enough calcium to fulfill the heart cells’ needs, particularly during exercise or stress.

Once scientists learned about the pump protein, the next question was about that protein’s gene. Proteins make up a huge category that includes enzymes, growth factors, hormones—almost all the substances that are responsible for the day-today functioning of living organisms. Proteins are produced by genes in the nucleus of every cell. Each protein has its own gene. Cells translate gene codes into proteins through a complex, multistep process called gene expression. Any alteration in this process can lead to changes in the end product, the protein.

In the case of the pump protein, the gene that produces it is only about half as active in older hearts as in younger hearts. The end result of all of these changes is a decline with age in the maximum strength of the heart beat during strenuous activity. Reduced calcium pumping also prolongs the time it takes for heart cells—and in turn, the heart as a whole—to return to a relaxed state. As a consequence, the heart can’t fill with blood as readily as it once did and prepare for the next heart beat.

Like other changes, the longer calcium transient appears to be one way that the heart adjusts to age, or more specifically to the stiffer arteries that accompany aging. Unfortunately, like those other changes, this adjustment also has a cost.

“It makes sense from an engineering standpoint to have a longer contraction if you’re pumping blood into stiffer vessels,” Dr. Lakatta says. “The downside is that when you alter the dynamics of calcium, various stresses can more easily throw the calcium out of balance. One consequence of this is that an older person is more apt to feel short of breath during vigorous exercise.”

Age Lengthens Action Potential
In addition to calcium transit, two other clusters of events in myocytes seem to be affected by age. One is the action potential. This is a transient alteration in the amounts of positive and negative charges on either side of the myocyte membrane. As mentioned earlier, the action potential triggers the opening of sodium and then calcium channels in the membrane.

The action potential is prolonged in older hearts and may contribute to the longer calcium transient. This occurs because as the heart ages, there are coordinated declines in both the activity and number of proteins involved in the action potential as well as the proteins that respond to its signals. A longer action potential generates a longer calcium transit, which in turn, produces a longer contraction. Each of these processes is controlled by specific proteins.

The prolonged action potential helps older hearts work well in most situations. It does this in two ways. First, pores on the myocyte’s membrane stay open longer to allow more calcium to enter the cell between beats. Second, the proteins that carry calcium out of the cell and sodium back in work more slowly. The net result is that more calcium is available within the cell. These effects allow the weaker sarcoplasmic reticulum—which has fewer pumps—to load up on calcium in preparation for the next beat. But these adjustments, like so many other cardiovascular adaptations, may have a downside. For instance, in an aging heart the long action potential adaptation works well at slower heart rates. But during a rapid heart rate, the longer action potential contributes to calcium dysregulation of myocytes. As a result, the older heart doesn’t respond as dynamically to the needs of the body as a young heart. So, a prolonged action potential is yet another possible reason that an older person usually can’t do as much exercise as someone younger.

Contractile Proteins


The other mechanisms that change with age involve contractile proteins—actin, myosin, troponin, and others—that interact to shorten, or contract, the myocyte. These contractile proteins pass through a series of steps, triggered by calcium, which bring actin and myosin together into crossbridges. The crossbridges use energy released during the transaction to shorten the cell. With age, one part of the crossbridge alters—the part called the myosin heavy chain.

The myosin heavy chain can be produced in two slightly different forms, one dubbed alpha, the other beta. In experimental animals, the alpha myosin heavy chain decreases with age, while the beta increases. The same seems to be true in the human atrium. When the proportion of alpha myosin heavy chain is reduced in isolated cells, the contraction speed is slower.

Changes in the myosin heavy chain have been traced back to the genes involved—alpha is expressed less with age, beta more. The expression of these genes is regulated by proteins called transcription factors that start or regulate the first steps of cellular reproduction. One of the transcription factors for the myosin gene is the same as that for the sarcoplasmic reticulum pump, suggesting that there is a common aging link between the two cellular mechanisms. Studies in rodents suggest the activity of these factors declines with age. Because of these changes the expression of genes in the aging heart tends to go back to patterns of gene expression seen in the fetus.

These age-related changes in myosin and other contractile proteins, in conjunction with alterations in calcium transit and action potential, actually help the older heart work more efficiently. That’s because slower and longer contractions don’t use as much energy. Prolonged contractions also allow the older heart to eject blood into the arteries later in the heartbeat. This adaptation is good because it improves the blood flow through an older person’s stiffer arteries.

Free Radical Damage
Myocytes produce free radicals, unstable oxygen molecules that can disrupt a cell’s inner workings. As the heart ages, these free radicals can greatly alter how well the cellular calcium pumps on the sarcoplasmic reticulum work.

In myocytes, most free radicals are produced in tiny cellular organelles called mitochondria and by an enzyme in cell membranes called NADPH oxidase. Mitochondria convert oxygen and food into an energy-releasing molecule that powers most cellular processes. But during this process they also produce potentially harmful byproducts such as oxygen free radicals. A free radical can be produced by almost any molecule when it loses an electron from one or more of its atoms. In heart muscle cells, they are commonly created when mitochondria combine oxygen with hydrogen to form water. Free radicals can cause extensive damage to proteins,membranes, and DNA. As we age, mitochondria become less efficient, progressively generating less energy releasing molecules and more free radicals.

In the aging heart, free radicals damage proteins, membranes, and calcium pumps on the sarcoplasmic reticulum that myocytes need to produce contractions. As a result of this cellular damage, myocytes can’t process calcium as well. As calcium builds up in the cell, it can begin to contract erratically, causing an arrhythmia. If this arrhythmia spreads to other cells, it can eventually disrupt beating throughout the heart and lead to serious complications.

 

Nitric Oxide
Calcium isn’t the only factor that helps the heart respond to the body’s increased need for blood and oxygen during sustained exertion or times of stress. Nitric oxide, a potent chemical messenger that helps regulate blood flow in the arteries, also signals the heart to pump harder at critical times.

As we just learned, heart cells can increase their contraction force by releasing more calcium from the sacroplasmic reticulum. Once released from this cellular storage bin, calcium binds to troponin and other contractile proteins, which trigger the heart beat. The more calcium that binds to these contractile proteins, the greater the force of the contraction. But there’s at least one other pathway, the Frank-Starling mechanism, that can increase the force of these contractions. This mechanism kicks in when increased blood flow into the heart stretches myocytes, signaling them to contract harder and produce more force. Normally, these two pathways work independently to tap the heart’s reserve capacity. But if cell stretch is sustained for prolonged periods, the amount of calcium released into heart cells during contractions gradually increases. This suggests that some coordinating mechanism is operating to ensure that, even under duress, the heart continues to pump enough blood to the body. But what this link might be mystified scientists for many years.

Steven Sollott, MD and his colleagues at the NIA theorized that sustained cell stretch prompts an enzyme, nitric oxide synthase, to produce nitric oxide. Nitric oxide, in turn, binds to the calcium release channels in the sarcoplasmic reticulum and promotes the release of calcium into the cell.

To test this theory, the investigators conducted a series of experiments with adult rats and mice—mammals with cardiovascular systems similar to humans. Some rodents were genetically altered so they could not produce the enzyme that makes nitric oxide. Others were given drugs that blocked the production of the chemical messenger. In both cases, sustained cell stretch no longer triggered increased calcium release in heart cells. Previous studies have shown that nitric oxide levels may be diminished in heart failure and other cardiovascular diseases.

“Knowing that this nitric oxide mechanism exists and how it functions in the normal heart may help us understand what happens to it with age and disease,” Dr. Sollott says. “This discovery offers scientists an opportunity to consider whether therapies that sustain or enhance the functioning of this mechanism might help aging hearts stay healthy and continue working properly.”

New ideas are also emerging about two other phenomena that have puzzled gerontologists and cardiovascular scientists for decades. As heart cells get older, there are fewer of them to do the necessary work, and those that remain get bigger.

Bigger Heart Cells...
To efficiently pump blood, the stiffness of the heart changes as it beats. When it is filling, the heart needs to be as relaxed as possible to allow blood to freely flow into it. When it contracts, it stiffens so that the pressure it exerts is greater than that found in the arteries. When this happens, blood is forced into the arteries with a minimal amount of effort. If there is a load mismatch—meaning the force differential between the heart and arteries isn’t very good—the heart can’t empty as well as it once did. As a result, the heart has to work harder to get blood into the arteries. If this occurs on a regular basis, some heart cells die, others enlarge, and the heart walls thicken.

This problem gradually increases as we get older. In some cases, the cells that remain enlarge up to 40 percent. The enlargement of these remaining myocytes seems to be the principal mechanism for the thickening of the heart walls—the hypertrophy—that occurs with normal aging.

Much evidence suggests that myocyte enlargement and the consequent thickening of the heart walls are ways that the heart adjusts to increased loads, especially from the growing stiffness of the arteries. Extra loads also may develop as the result of disease.

One reason cardiovascular researchers are so intrigued by myocyte enlargement is because of its possible links to disease. While enlargement seems to occur in response to aging and stiffening of the arteries, it is exaggerated by disease, such as coronary artery disease and high blood pressure. (However, enlargement occurs with high blood pressure at any age).

While myocyte enlargement seems to be one way that the heart adapts to increased loads, there is also evidence that at the oldest ages, it no longer adapts as much. Older animals, for instance, have less enlargement in response to heart overloads than younger animals. This failure or slowing of the adaptive response may explain why 80-year-olds are much more likely to experience heart failure following a heart attack than 60-year-olds.

These findings are yet another clue suggesting that specific age-associated changes in healthy hearts and blood vessels compromise their ability to respond to everyday stress and strain. In turn, these changes gradually lower the heart’s resistance to certain cardiovascular conditions including left ventricular hypertrophy, atrial fibrillation, and congestive heart failure.

...But Fewer of Them
As we age, even the healthiest hearts lose cells. In a robust 70-year-old man without heart disease or high blood pressure, these age-related losses are estimated to account for up to a 30 percent reduction in the total number of myocytes in the heart. Although it’s unclear whether this loss of heart cells is good or bad for the body as a whole, evidence suggests that loss of a significant number of heart cells may contribute to the decline in cardiovascular health in older people.

Cardiovascular scientists are exploring why some myocytes die while others continue to thrive. Injury, due to a lack of oxygen or ischemia, seems to be one of the prime killers. But studies suggest that programmed cell death—apoptosis—could be a significant factor as well.

Apoptosis is a process in which a cell orders itself to stop functioning, shrink, and ultimately dissolve. It has been observed in other cells in the body, where it may be a mechanism for adjusting to development or removing unwanted or potentially dangerous cells, such as cancer cells, from the body. At least one study suggests that apoptosis in the heart becomes more common with age. And other research has found that excessive apoptosis may contribute to decline in the aging cardiovascular system.

A number of molecular processes, such as increased free radical production, can activate a cell’s apoptotic or self-destruct mechanism. In rodents, for instance, NIA grantee Christiaan Leewenburgh, PhD, of the University of Florida and his colleagues found that cytochrome c, a mitochrondial protein, becomes a signal for cell death if it “leaks” from the mitochondria. The hearts of older rats released greater amounts of that cell-death signal than did the hearts of younger rats. This difference may be partly responsible for the increase in heart cell death.

 

Cardiovascular scientists studying apoptosis are particularly interested in the role of a process called cardiac stretch. Myocytes are connected, so when one dies—for whatever reason—others must stretch to maintain the connections. As myocytes are stretched, they release chemical substances called growth factors, such as norepinephrine and angiotensin. These growth factors may not only help explain why these cells enlarge, but also why some of them die. In laboratory dishes, for instance, the same growth factors that regulate heart cell growth also trigger apoptosis in some myocytes. However, these and other growth factors may have an equally important role in a process that was once thought to be impossible: the replication and regeneration of heart cells.

The Untapped Promise of the Aging Heart
For decades it was believed that the heart had a set number of myocytes, and once one of these cells died, they couldn’t be replaced. Because these cells were thought to be unable to divide, according to this view, their numbers progressively decreased with age and ultimately impaired heart function.

While this view was widely accepted, it was never proven. And now, compelling but controversial evidence raises new questions about its validity.

One of the first challenges to this dogma came in 2001 when scientists from New York Medical College in Valhalla, New York found large scale replication of heart muscle cells in two regions of the heart, and identified several other key indicators of cell regeneration. These scientists, led by NIA-grantee Piero Anversa, MD studied myocytes from the hearts of 13 patients, 4 to 12 days after their heart attacks, and from the hearts of 10 patients who did not have cardiovascular disease. Samples were obtained from the border zone near the site of the heart attack and from a more distant site from the damaged tissue.

 

By viewing these areas of the heart with a high resolution confocal microscope, the investigators were able to measure the expression of a protein found in the nucleus of dividing heart muscle cells. This protein is expressed during all phases of a cell’s life cycle and is a strong indicator of ongoing cell division.

The scientists also obtained images of cell division and found other evidence of myocyte replication, including the formation of the mitotic spindle, and contractile ring, critical structural indicators of cell division. In comparison with normal hearts, the number of myocytes multiplying in diseased hearts was 70 times higher in the border zone and 24 times higher in the remote tissue.

But where were these new hearts cells coming from? Subsequent studies—in both animals and humans—suggested that, although most adult heart cells probably aren’t able to replicate, a small core of adult stem cells might exist in the heart or in the bone marrow that are capable of replenishing and replacing damaged or dying myocytes. However, other scientists have had difficulty duplicating these results. So for now, the notion that adult stem cells can regenerate heart muscle remains a tantalizing, but unproven, possibility.

Some cardiologists theorize that adult stem cells in young hearts might be able to produce enough new myocytes to replace those that are naturally dying. In effect, these stem cells might help keep the total number of myocytes stable in the young heart. But mounting evidence suggests that even if these stem cells exist, their numbers decline with age. As a result, some scientists suspect there are fewer new heart cells to replace older ones which are dying in greater numbers due to age, injury, and other problems. So the deterioration of the older heart could be related, in part, to the inability of aging cardiac stem cells to replace dead and dying myocytes with new ones.

Gerontologists exploring this exciting new area of research have many questions, but few answers at this point. For instance, does the number of cardiac stem cells really decline with age? What role do growth factors play in regulating the activity of these cells? How are the changes in cardiac stem cells linked to other age-related alterations in the heart and arteries? Why are scientists having so much difficulty replicating the earlier findings? Are the myocytes in the heart of an 80-year-old basically the same ones present in his or her heart at birth or have the cells been gradually replaced over the years like the skin? And perhaps most importantly, if these stem cells exist, can anything be done to stimulate them to produce new myocytes that will counteract the effects of age in the older heart?

The key to answering this final question lies in learning more about stem cells and how they work. Investigators already know that stem cells have important characteristics that distinguish them from other types of cells. Unlike most cells in the body, such as skin or brain cells, which are dedicated to performing a specific function, stem cells are not specialists. But under certain physiologic or experimental conditions, they can be induced to become cells with special functions such as the beating cells of the heart muscle or the insulinproducing cells of the pancreas. Another unique characteristic of stem cells is their ability to renew themselves for long periods through cell division.

Scientists primarily work with two kinds of stem cells from animals and humans: embryonic stem cells and adult stem cells.Most of the basic science research discoveries on embryonic and adult stem cells come from research involving animals, particularly mice. Embryonic stem cells are derived from embryos. Specifically, embryonic stem cells are derived from embryos that develop from eggs that have been fertilized in vitro.

Adult stem cells typically generate the cell types of the tissue in which they reside. A blood-forming adult stem cell in the bone marrow, for example, normally produces many types of blood cells such as red blood cells, white blood cells, and platelets. Until recently, it had been thought that a bloodforming cell in the bone marrow—which is called a hematopoietic stem cell—could not give rise to the cells of a very different tissue, such as myocytes in the heart. However, a number of experiments over the last several years have raised the possibility that stem cells from one tissue may be able to make cell types of a completely different tissue, a phenomenon known as plasticity.

Because of this flexibility, stem cells hold enormous potential for cell replacement or tissue repair in heart disease and many other age-associated disorders. Gerontologists are seeking to find out if these cells will yield any practical interventions that might promote healthy aging.

“We’ve made substantial progress, but there is a lot more to be learned,” according to Dr. Lakatta. “Finding ways to activate these cells and get them to where they are needed in the heart and ensuring that they develop into heart cells are significant challenges.”

While daunting, these and other challenges are motivating gerontologists to investigate many new interventions that in the future could help keep aging hearts and arteries healthy.

As we age, for instance, pressure increases in the arteries, and this can affect the structure and function of the left ventricle. In fact, a growing number of scientists suspect that age-related changes in the blood vessels may actually instigate many of the transformations that occur in the older heart.

Stretched end-to-end, the arteries, veins, and other vessels of the human circulatory system would measure about 60,000 miles. On any given day, the heart pumps about 1,800 gallons of blood through this vast network. In an average lifetime, the heart pumps approximately one million barrels of blood—enough to fill more than 3 supertankers—through the circulatory system.

No doubt about it, the heart and arteries are remarkable. But as we age, the cardiovascular system becomes more susceptible to diseases including high blood pressure and atherosclerosis. Nearly 40 percent of all deaths among those 65 and older can be attributed to heart problems. By age 80, men are nine times more likely to die of chronic heart failure than they were at age 50. Among women, this risk increases 11-fold over the same time period.

Certainly, poor lifestyle—smoking, little or no regular exercise, a diet laden with fat, cholesterol, and sodium—contribute to the development of these cardiovascular disorders. But it is becoming more apparent that like the heart, blood vessels undergo changes with advancing age, and these changes, including arterial stiffening and thickening, are major risk factors for these diseases.

This relationship is complex. In fact, studies—in both animals and humans—have found that many of the factors that underlie the age-related changes in the arteries are also implicated in the development of cardiovascular disease. This suggests that there are some common links between these two distinct, but intertwined processes. Based on these and other findings, some investigators theorize that aging is the driving force in a cycle that begins with age-related changes in the blood vessels. These changes create an environment that promotes arterial stiffening, which contributes to development of hypertension (high blood pressure). At the same time, age-related changes also make it easier for fatty deposits to build up on the inside of arteries. This accumulation, part of a process known as atherosclerosis, can accelerate the aging of the arteries, which, in turn, leads to further fatty build up and narrowing of the vessel.

 

In essence, aging arteries form an alliance with risk factors for atherosclerosis, hypertension, and other precursors of heart disease and stroke to profoundly elevate the risk of developing these conditions. However, as scientists learn more about the changes that occur in aging blood vessels, they are making some key discoveries. For instance, in some people these changes occur at an accelerated rate; in others, they occur much more slowly than average. This suggests that how well your arteries perform as you get older depends on a series of complex interactions among age, disease, lifestyle, and genetics, Dr. Lakatta says. In any case, epidemiological studies have consistently shown that people with the greatest amount of arterial stiffening and thickening are at the highest risk for developing stroke, heart attack, and other cardiovascular events.

But investigators also now know that several of these changes, such as arterial stiffening and thickening, don’t occur to the same extent in all people. In fact, studies strongly suggest that exercise, good nutrition, and emerging drug therapies can slow the aging of the blood vessels, even among people who are genetically at risk. These interventions could delay or prevent the onset of cardiovascular diseases in many older people.

“We’re moving into an era when it will be imperative to find out what your blood vessels are like before clinical disease sets in so that, if necessary, appropriate measures can be taken to keep your cardiovascular system as healthy as possible,” Dr. Lakatta says.

In Search of a Connection
So, what made scientists think there might be a connection between stiffening and thickening of arteries and heart function? It goes back to what they have learned in the past few decades, partly through NIA’s Baltimore Longitudinal Study of Aging. By comparing younger and older volunteers, scientists have been able to put together a picture of what happens both in the heart and in the blood vessels as people age.

The heart, they have learned, adjusts in many subtle and interconnecting ways: It develops thicker walls, and it fills with blood and pumps the blood out in a different pattern and even by somewhat different mechanisms than when young. But it is also becoming clear that many of these adjustments are made in response to changes in the structure of the aging blood vessels, particularly the arteries. For instance, NIA studies show that among those with the stiffest arteries, heart walls are thicker.

To picture how these and other changes influence cardiovascular health, imagine an animated computer graphic of the arteries at, say, age 25, when the walls are still fairly smooth, slick, and compliant. As the heart contracts, the aortic valve opens and blood is pumped into the aorta, the largest artery in the body, and flows up toward the neck, where the carotid artery branches off to take blood to the head and brain, and then down toward the rest of the body. When the aorta receives the rushing pulse of blood from the heart, it also receives pressure spreading from the walls of the heart to its own walls. This pressure travels along the aorta’s walls in wave after wave until it reaches the walls of the smaller branching arteries that take the blood to the rest of the body. There, the speed of these pressure waves—known as pulse wave velocity—slows, and some are sent back through the aorta walls, becoming what are called wave reflections.

What Happens During Atherosclerosis?


Atherosclerosis (ath-er-o-skle-RO-sis) is the build-up of fatty deposits called plaque on the inside walls of arteries. Plaque is a combination of cholesterol, other fatty materials, calcium, and blood components that stick to the artery wall lining. A hard shell or scar covers the plaque. As plaque builds up in an artery, the artery gradually narrows and can become clogged. As an artery becomes more and more narrowed, less blood can flow through. The artery may also become less elastic.

Most plaque buildup occurs in medium to large arteries and many investigators suspect that this buildup begins with changes in the endothelium, the innermost layer of the artery. These changes cause white blood cells to stick to the endothelial cells, weakening the barrier between the endothelium and the other layers of the artery. This allows fats, cholesterol, calcium, platelets, and cellular debris to accumulate in artery walls. In turn, this accumulation can stimulate other arterial wall changes that lead to the additional thickening of the endothelium and the formation of plaques.

Plaques have various sizes and shapes. Some plaques are unstable and can rupture or burst. When this happens, it causes blood clotting inside the artery. If a blood clot totally blocks the artery, it stops blood flow completely. This is what happens in most heart attacks and strokes. There are usually no symptoms, such as pain, until one or more artery is so clogged with plaque that blood flow is severely reduced.

All of this takes time. In fact, atherosclerosis is a slow, progressive condition that often starts in childhood. But by age 65 it affects one out of every two adults. Scientists at the National Heart, Lung, and Blood Institute are studying why and how the arteries become damaged with age, how plaques develops and changes over time, and why plaques can break open and lead to blood clots. In particular, they have identified the age-related changes in the arteries discussed in this booklet as the major catalyst for the development of atherosclerosis. Research is underway to find drugs that might delay or prevent these age-related vascular changes and, in turn, reduce the risk of atherosclerosis.

There are a number of other risk factors, such as smoking, high blood pressure, and high blood cholesterol that can be modified with a diet, exercise, and other lifestyle changes. The more risk factors you have, the more likely it is that you have atherosclerosis. Talk with your health care provider about your risks for atherosclerosis and cardiovascular disease and what you can do to reduce them.

Now, add 50 years to this picture. The arteries, including the aorta, grow stiffer and dilate; their walls become thicker, their diameter larger. As a result, the stiffer vessels no longer expand and contract as much as they once did with each heart beat.Eventually, the opposition to the flow of blood by the stiffer aorta walls increases significantly.

Along the walls of the stiffer aorta, the pressure waves move more rapidly, and as a result, the wave reflections occur sooner than they did before. The timing of the wave reflection, in fact, is one of the effects of arterial stiffness that can be measured noninvasively. Epidemiological studies using these measures have determined that high aortic pulse wave velocity (aPWV) is an independent predictor of arterial stiffness and cardiovascular disease and death.

As the walls of the large arteries become stiffer, diastolic blood pressure tends to drop and systolic blood pressure rises. The difference between these two numbers is called pulse pressure. High pulse pressure—greater than 60 millimeters of mercury—is associated with greater thickening and stiffening of arterial walls. In turn, arterial stiffening and thickening contribute to increased pulse pressure. Many studies have found that elevated pulse pressure is also an important risk factor for stroke and heart attack.

Next, picture the effects of movement—when a person sits up, stands up, or begins to walk or run—the heart rate increases and blood pressure changes. A group of pressure sensitive nerves in the base of the carotid artery respond by sending a message to the brain. The brain in turn sends a message back to the heart, which changes its rate and strength of contraction. This arterial/brain/heart message system is called the baroreceptor response. Blood vessels also dilate to allow for the extra blood flow. In addition, blood is turned away temporarily from those organs that don’t need it (for instance, the stomach), so that more can be delivered to the working muscles.

In the older picture, the baroreceptor response is blunted with age, perhaps as a result of stiffer arteries. Also, at maximum exercise, the large arteries do not dilate as much as in the younger picture. In essence, this age-related stiffening impedes pulsing blood flow from the heart and places an increased workload on the heart.

 

As the blood moves into the smaller arteries, the hydraulics change. The pulse smoothes out, the flow becomes more steady. The opposition to this steady flow is known as peripheral vascular resistance or PVR; so far studies show that among men, resting PVR does not change with normal aging, but that it does rise somewhat in women. PVR is actually elevated in people who have high diastolic blood pressure, but is also elevated, to a lesser extent, in people who have high systolic and nearly normal diastolic blood pressure. This condition, called systolic hypertension, is so common that a person age 55 or older has about a 65 percent chance of developing it. However, PVR is not usually directly measured outside of a research laboratory setting because of the complexities involved. Instead, physicians monitor diastolic blood pressure. If it remains steady or increases rather than dropping in the presence of aortic stiffening, it’s a sign of elevated PVR. (See The Nitty Gritty of High Blood Pressure.)

 

Inside Every Artery...


Scientists are still sorting out why these aging changes in blood pressure and PVR occur and what can be done to prevent them.But one key focal point of research is the inner workings of the arterial wall.

At first glance a large artery resembles a simple rubber tube. But like many first impressions, this is a bit deceiving. The arterial wall is actually comprised of three intricate layers of tissue. The innermost layer, closest to the blood, is called the intima. The part of the intima nearest to the blood is a single layer of specialized cells, called endothelial cells, which sits atop the sub-endothelial space and a wall called the basement membrane. These endothelial cells act as a barrier to prevent certain substances from entering the vessel wall through the intima. Endothelial cells sense mechanical signals, such as blood pressure and flow, and chemical signals, such as oxygen tension, and temperature. In reaction to these signals, they secrete proteins called cytokines and chemokines as well as growth factors and other substances that help regulate the structure and function of the arteries.

The smooth muscle cells in the media, the middle layer of the artery, are surrounded by a network of fibers primarily made of two proteins, collagen and elastin. The elastin forms concentric rings within the vessel wall. The outermost layer, the aventitia, is composed of connective tissue and small blood vessels that feed the walls of large arteries. Together, these three layers of artery wall surround the lumen, the opening that blood flows through on its journey throughout the body. With age, each of these layers change in complex ways.

...Time Takes its Toll
Aging, for instance, triggers thickening of the intima and stiffening of the arterial walls. This occurs, in part, because of a fierce molecular struggle.

Healthy endothelial cells produce nitric oxide, an important signaling molecule that helps keep arteries supple. When nitric oxide enters a cell, it stimulates a biochemical process that relaxes and dilates blood vessels. Nitric oxide also helps keep atherosclerosis in check by preventing platelets and white blood cells from sticking to the blood vessel walls. The molecule also can curb the abnormal growth of vascular muscle, which can thicken blood vessel walls.

But unhealthy endothelial cells are a different story. In these cells, nitric oxide regulation is impaired. To make nitric oxide, endothelial cells need L-arginine, an amino acid that is one of the basic building blocks of proteins, and an enzyme called nitric oxide synthase (NOS). Normally, endothelial cells have plenty of L-arginine and NOS. But NOS is often in short supply in aging blood vessels. In addition, people who have heart disease or who are at high risk of developing it produce a modified amino acid called asymmetric dimethylarginine (ADMA). ADMA blocks the production of nitric oxide from L-arginine. Even if sufficient amounts of nitric oxide are produced, it can be inactivated by oxygen free radicals, unstable molecules that injure vascular tissue. In any case,without adequate levels of biologically available nitric oxide, endothelial cells in the intima can’t function properly. In fact, some researchers consider decreased availability of nitric oxide in the endothelium as one of the earliest signs of arterial aging and a pathological sign of atherosclerosis and high blood pressure. However, much of this complex process remains a mystery and scientists continue to explore precisely how nitric oxide production and bioavailability affect blood vessels.

The Nitty Gritty of High Blood Pressure
By age 60, high blood pressure affects one in every two Americans. Hypertension, as doctors call it, was once thought to be a normal part of aging. But researchers now know that high blood pressure is dangerous at any age.

When we talk about blood pressure, what we’re actually referring to is the pressure within the aorta and the large arteries that connect to it. Blood pressure is measured in millimeters of mercury (mmHg) and recorded as two numbers. Systolic blood pressure (the top number in a blood pressure reading) is the maximum pressure that occurs in the blood vessels when the heart contracts. As the heart relaxes between beats, the pressure dissipates. This low pressure is measured as diastolic (the bottom number) blood pressure.

Systolic blood pressure is largely determined by the stiffness of the arteries and the amount of blood pumped through them during a heart beat. Many doctors once believed that as we got older our bodies needed increased systolic blood pressure to push blood through stiffened arteries. But researchers now know that this increase is not normal, and that high blood pressure at any age significantly increases the risk of heart attack, strokes, and kidney failure.

Today, most experts recommend that blood pressure not exceed 120/80 mmHg. Smoking, high cholesterol, and diabetes can elevate the risk of developing high blood pressure. Check your blood pressure regularly. If it is elevated, talk with your doctor. Exercise, dietary changes and, in some cases, medication can make a difference.

But they do know that endothelial cells depend on nitric oxide to help subdue the production of oxygen free radicals. Nitric oxide molecules can eradicate some of these free radicals, but in the process they also destroy themselves. This leaves less nitric oxide available to help endothelial cells keep arteries in tiptop shape.

Angiotensin II, a growth factor involved in this process, is more prevalent in aging arteries. In addition to increasing free radical production, angiotensin II decreases nitric oxide production and stimulates blood vessel inflammation. It also can cause vessels to tighten and raise blood pressure, forcing the heart to work harder.

 

Much of angiotensin II’s damage is done in partnership with an enzyme called NADPH oxidase, the primary source of free radicals in the arteries. After angiotensin II activates it, NADPH oxidase causes an increase in production of superoxide, a free radical. Superoxide binds with nitric oxide to create an even more potent free radical called peroxynitrite. Peroxynitrite then binds to proteins and nitrites, harming them. Like other free radical processes, this chain of events steals bioavailable nitric oxide away from endothelial cells, leaving them more vulnerable to damage. But the impact of angiotensin II isn’t limited to the intima. It also has an important role in age-associated alterations of the media, the middle layer of the arterial wall.

In addition to depleting nitric oxide, free radicals can damage the membranes and DNA of endothelial cells in the intima and smooth muscle cells in the media. Free radical damage is one of many things that can induce some of these cells to stop functioning, shrink, and ultimately die in a process known as apoptosis. Apoptosis may contribute to the decline in cardiovascular health as we age. Free radicals also can oxidize proteins, altering their structure and function. As a result, these proteins can’t work properly, and this can trigger a cascade of cellular alterations that promote stiffening and thickening of arterial walls and contribute to atherosclerotic plaque build up.

Stuck in the Middle with You
With age, some smooth muscle cells in the media die causing the remaining ones to work harder and grow larger.Over time, other alterations cause some smooth muscle cells to stop contracting as usual. Instead, these cells begin producing excessive amounts of proteins and other matrix substances, creating an imbalance of elastin and collagen in the media. As the amount of collagen increases in the blood vessel wall, it tends to bind to glucose molecules, forming crosslinks known as advanced glycation end products (AGES). This process, which has been compared to what happens as turkey is roasted in an oven, is slow and complex. But as more AGES form, the collagen strands in the media turn brown, become crosslinked, and become less supple. Age takes its toll on elastin, too. It becomes overloaded with calcium, stretches out, and eventually ruptures, further eroding an artery’s flexibility.

Scientists studying this process are particularly intrigued by matrix metalloprotease-2 (MMP2), an enzyme activated by angiotensin II as well as many other signals. Although many of its functions are unclear, studies in rodents, monkeys, and humans suggest MMP2 helps break down key components of the basement membrane, the barrier that separates the intima from the media in artery walls. MMP2, in conjunction with angiotensin II, also activates other growth factors, such as transforming growth factor, which might stimulate collagen and cell growth, the development of fibrous tissue, and contribute to thickening of the intima. In addition, this combination of MMP2 and angiotensin II activates PDGF-B, a growth factor, which acts as an attractant that lures smooth muscle cells to migrate from the media to the intima.

But in smaller blood vessels, the activity of PDGFB and other growth factors, such as vascular endothelial growth factor (VEGF), tend to decline with age. These growth factors play an important role in a process called angiogenesis that leads to the development of new small blood vessels. In some cases, angiogenesis can stimulate the growth of new collateral small vessels around narrow spots or blockages in the arteries that threaten to reduce blood flow to the heart. As we age, however, this process switches off. Enzymes that break down collagen also seem to be involved in this process and are less active as we get older. Scientists are still unraveling why this happens, but as ageassociated changes and damage accumulate in endothelial cells, they secrete less of the critical growth factors needed for angiogenesis. Angiogenesis also depends, in part, on the availability of nitric oxide, which declines with age. In addition, there appears to be an age-associated decrease in the number of endothelial progenitor cells. These adult stem cells are produced in the bone marrow and circulate in the bloodstream.

Under certain circumstances, endothelial progenitor cells can differentiate into endothelial cells, which are needed to form new blood vessels or repair damaged ones. In essence, progenitor cells are the “mothers” of “daughter” endothelial cells. As the number of progenitor cells declines, angiogenesis is less likely to occur. Researchers are investigating ways, such as gene and cell therapy, to reactivate angiogenesis in older people who have cardiovascular disease. But scientists have much to learn about the safety and efficacy of these techniques.

From Balloon to Bicycle Tire
Scientists are still piecing together how, or even if, many of these various processes interact. But they do know that, as the result of these and other age associated changes in large arteries, the endothelial barrier in the intima becomes more porous. Some of the signals these cells transmit to the smooth muscle cells in the media become garbled. In turn, these smooth muscle cells can mistakenly perceive that an injury has occurred. They move into the intima, multiply, and produce collagen and other molecules. In reaction, the endothelial cells produce substances that send signals to circulating blood cells to help out in the repair process. Unfortunately, in their effort to help, blood cells stick to endothelial cells instead of flowing smoothly through the blood vessel. The net impact of these interactions is that the intimal-media layer thickens, contributes to arterial stiffness, and creates a fertile environment for the development of atherosclerosis in aging arteries.

Can Gene Therapy be Used to Treat Heart Problems?

In the future an experimental technique, called gene therapy, may allow doctors to treat heart disease and other cardiovascular disorders by inserting a gene into a patient’s cells instead of using drugs or surgery. Investigators are testing several approaches to gene therapy including:

• Replacing a mutated gene that causes disease with a healthy copy of the gene
• Inactivating or “knocking out” a mutated gene that is functioning improperly, or
• Introducing a new gene into the body to help fight a disease.

The NIH has been on the cutting edge of this research. More than a decade ago, for instance, cardiovascular investigators began experimenting with ways to increase the supply of certain growth factors through gene therapy. If more growth factors could be produced, scientists theorized they might stimulate angiogenesis—the growth of new small blood vessels called capillaries.

Knowing the genes that code for the growth factors, the investigators found ways to add copies of these genes to heart muscle. To get genes to the myocytes, they engineered molecular delivery trucks called vectors for the genes. These vectors, made from inactivated adenoviruses—the same viral culprits that cause the common cold—were injected into rats. Scientists hoped the vectors would unload their DNA cargo, which then would begin producing the proteins needed to induce capillary growth. And in this experiment, that’s exactly what happened. One of the vectors worked.

More recently, scientists successfully used gene therapy in older rats to increase the activity of the gene that produces calcium pump proteins on sarcoplasmic reticulum, the cellular storage bin for calcium. This therapy significantly improved heart muscle contraction in these rodents. In another animal study, researchers at The Johns Hopkins School of Medicine in Baltimore used gene therapy to convert a small region of guinea pig heart muscle tissue into specialized pace making cells. Potentially, this technique could one day lead to the development of genetically engineered, biological pacemakers to replace implantable electronic devices. However, scientists must overcome many technical challenges before gene therapy will be a practical approach to treating disease.

The NIH has been on the cutting edge of this research. More than a decade ago, for instance, cardiovascular investigators began experimenting with ways to increase the supply of certain growth factors through gene therapy.

New Blood Test May Help Doctors Detect Emerging Heart Disease

Blood often tells the story of our lives. Tests that measure blood cholesterol levels and other cardiovascular risk factors have become a routine part of health screenings. And in the future, doctors may check yet another blood test—one that measures inflammation—that may help them better assess the risk of disease in the aging heart and arteries.

The test measures levels of C-reactive protein (CRP), a substance produced in the liver, which is often elevated in people who have rheumatoid arthritis and other diseases that cause chronic inflammation. Several studies have indicated that increased blood levels of CRP in otherwise healthy people are associated with an increased risk of heart attack, stroke, and other cardiovascular problems.

Scientists are still investigating whether CRP is merely an indicator of inflammation or if it has an active role in this process. In any case, cardiovascular risk factors such as excessive weight, diabetes, and a sedentary lifestyle are associated with high CRP blood levels. Healthy people with CRP levels less than 1 milligram per liter of blood are considered at the lowest risk of a cardiovascular event in the next 10 years. Depending on medical history and other factors, a person at intermediate risk—1 to 3 milligrams of CRP per liter of blood—could have up to a 20 percent risk of having a heart attack in the next decade. Those with CRP levels of 3 milligrams or more per liter have the highest risk.

However, researchers stress that inflammation is just one of many factors that could increase your risk of cardiovascular disease as you get older. To date no evidence has emerged to suggest that treating people for elevated CRP alone improves survival or reduces cardiovascular complications. For now, detection and treatment of more well-established risk factors, such as high blood pressure and high blood cholesterol, remains a greater priority.

But some treatments for these other risk factors could help lower CRP. The same lifestyle changes, for instance, that help lower cholesterol—regular exercise, a healthy diet, weight loss, and quitting smoking—can also help reduce inflammation. Aspirin and other drugs, including cholesterol-lowering medications such as statins, can decrease CRP levels as well.

...some treatments for these other risk factors could help lower CRP. The same lifestyle changes, for instance, that help lower cholesterol—regular exercise, a healthy diet, weight loss, and quitting smoking—can also help reduce inflammation.

The cumulative effect of all these age-related changes can be boiled down to this: the ability of larger blood vessels to expand and contract diminishes, the lumen enlarges, and the arterial walls thicken. The result is “hardened”or stiffened arteries that set the stage for the onset of high blood pressure, elevated pulse wave velocity, atherosclerosis, and other precursors of cardiovascular disease. The more severe the effects of aging are on the blood vessels, the easier it is for atherosclerosis, hypertension, and other processes to do damage and, in turn, have an effect on the rate of aging in the vessels. Smoking, lack of exercise, a poor diet, and obesity also can exacerbate these effects.

It’s this cycle, with age as the principal instigator, which gradually helps change youthful and healthy blood vessels into old and potentially diseased ones. In a sense, this progression transforms a young person’s arteries, which are like soft latex balloons, into the equivalent of rigid, bulky bicycle tires in later life.

However, arterial stiffness and intimal-medial thickening occur at varying rates in different people. Studies suggest that the rate of both of these agerelated changes predict stroke, heart disease, and other cardiovascular problems. For example, in one large study that followed healthy volunteers who had no previous symptoms of heart disease, those who had the greatest amount of intimal-media thickening were four times more likely to develop cardiovascular conditions over the next 7 years compared to those with the least arterial thickening. Similarly, studies have shown that healthy people with the stiffest blood vessels were three times more apt to develop high blood pressure over a 5-year span than those with more pliable vessels. In yet another large-scale study, involving 3,075 healthy older people, those who had the highest pulse wave velocity (PWV)—a measure of arterial stiffness—were three times more likely to die of cardiovascular disease than those who had the lowest PWVs.

“Clearly, many people of middle and advanced age whom we once thought of as healthy actually aren’t,” Dr. Lakatta says. “It is becoming more apparent that changes in the aging circulatory system, even among those who don’t have outward symptoms, precede and predict a higher risk of developing cardiovascular diseases. The greater these changes are, the greater is the risk for getting these diseases.”

Keeping Your Arteries Healthy
The well-being of your arteries depends on a healthy endothelium, the inner lining of your blood vessels.

“Endothelial cells are the prima donnas within the blood vessels. They control almost every activity that occurs in the vessels, and they’re fundamentally altered with age,” Dr. Lakatta says. “People who maintain a healthy endothelium as they get older and those who make an effort to do things that promote the repair of injured endothelium can reduce the risk of heart attacks and strokes caused by atherosclerosis or hypertension.”

Although scientists still have much to learn about the endothelium and what can be done to keep it healthy, a number of studies suggest that certain modifiable risk factors can have an important impact on the cardiovascular system. For instance, regular moderate exercise, such as running, walking, or swimming can reduce body fat, increase lean muscle mass, decrease blood pressure, increase HDL cholesterol (the “good” cholesterol) levels, and lessen the extent of arterial stiffening. All of these exercise-induced changes can have a positive influence on endothelial cells.

 

In addition, scientists have long known that tobacco smoke contains numerous toxic compounds, such as carbon monoxide, that promote endothelial cell damage. Smoking also increases blood pressure and heart rate. Free radicals in smoke slash the amount of nitric oxide available in the blood stream.Nitric oxide, as you may recall, is a signaling molecule that helps keep arteries pliable. Because nicotine causes narrowing of blood vessels, less oxygen is transported to the heart. If you smoke, blood platelets become stickier and are more apt to form clots in your arteries.

As we mentioned earlier, high blood pressure—hypertension—causes blood vessels to thicken, diminishes production of nitric oxide, promotes blood clotting, and contributes to the development of atherosclerotic plaques in the arteries. Blood pressure is considered high when systolic pressure exceeds 140 mmHg and when diastolic blood pressure is higher than 90mmHg.

Excessive weight increases the risk of high blood pressure and can increase the likelihood that you’ll have high blood triglycerides and low HDL cholesterol, Dr. Lakatta says. Being overweight can also increase the probability you’ll develop insulin resistance, a precursor of diabetes. (See Metabolic Syndrome Accelerates Aging of Arteries, page 48)

Diabetes, a disease in which the body does not produce or properly use insulin, becomes more common as we age. In fact, nearly half of all cases are diagnosed after age 55.Atherosclerosis develops earlier and is more aggressive in people who have diabetes. In part, this occurs because diabetes causes the endothelium to produce excessive amounts of superoxide anion, a free radical that destroys nitric oxide. People age 65 and older who have diabetes are nearly four times more likely than those who don’t to develop peripheral vascular disease, a condition that clogs the arteries that carry blood to the legs or arms.And, cardiovascular diseases and stroke are leading causes of diabetesrelated deaths. If you suspect you have or are at risk for diabetes, check with your doctor. Symptoms include increased thirst, increased hunger, fatigue, increased urination—especially at night, unexplained weight loss, blurred vision, and slow healing of wounds and sores.

Exercise: Your Heart’s Best Friend
In one of her better-known gags, comic Ellen DeGeneres quips, “My grandmother started walking five miles a day when she was 60. Now she’s 97 years old and we don’t know where the heck she is.”

Funny, yes. But regular physical exercise is no joke. In fact, it may be the most important thing a person can do to fend off heart disease, stroke, and other age-associated diseases. Emerging scientific evidence suggests that people who exercise regularly not only live longer, they live better.

Scientists have long known that regular exercise causes certain changes in the hearts of younger people: Resting heart rate is lower, heart mass is higher, and stroke volume is higher than in their sedentary counterparts. These differences make the heart a better pump. Evidence now suggests these changes occur even when exercise training begins later in life, at age 60 or 70, for instance. In other words, you don’t lose the ability to become better physically conditioned. In addition, several studies have shown that exercise not only helps reduce debilitating symptoms such as breathlessness and fatigue in people who have heart failure, it also prolongs life.

Exercise training may be effective because it appears to improve the function of virtually every cell in the cardiovascular system. Animal studies, for instance, suggest that regular aerobic workouts help heart muscle cells remove calcium from their inner fluid at a faster rate after a contraction. This improved calcium cycling allows the heart to relax more and fill with more blood between beats.

Exercise also improves blood vessel elasticity and endothelial function, in part, by blocking the production of damaging free radicals and maintaining the production of nitric oxide, an important signaling molecule that helps protect the inner layer of the arteries. Together, these changes can slow the progression of atherosclerosis and other age-related cardiovascular conditions.

Endurance exercises such as brisk walking increase your stamina and improve the health of your heart, lungs, and circulatory system. But other exercises are equally important to maintaining health and self-reliance as you get older. Strength exercises, for instance, build muscles and reduce your risk of osteoporosis. Balance exercises help prevent a major cause of disability in older adults: falls. Flexibility or stretching exercises help keep your body limber. As part of a daily routine, these exercises and other physical activities you enjoy can make a difference in your life as you get older.

Researchers have also found that stress reduction techniques, such as taking a walk, practicing yoga, or deep breathing are important to cardiovascular health. Emotional stress triggers the release of adrenaline from the adrenal gland and noradrenaline from the nerve endings in your heart and blood vessels. These hormones make the heart beat faster and adversely affect blood vessels. Under stress, an older person’s blood pressure rises more rapidly and stays higher longer than a younger person’s because the older person’s blood vessels are stiffer and have lost much of their elasticity.

Healthy Foods, Healthy Arteries: Is There a Connection?
What you eat can help keep your heart and arteries healthy—or lead to excessive weight, high blood pressure, and high blood cholesterol—three key factors that increase the risk of developing cardiovascular disease, according to the National Heart, Lung, and Blood Institute. Based on the best available scientific evidence, the American Heart Association (AHA) recommends a diet that includes a variety of fruits, vegetables, and grains, while limiting consumption of saturated fat and sodium.

 

Fruits and vegetables have lots of antioxidants such as vitamin C and vitamin A that neutralize free radicals and may prevent oxidation in the arteries, dietary experts say. Fruits and vegetables also contain plenty of soluble fiber, a substance that has been shown to reduce blood cholesterol levels, which is healthy for the endothelium.

Breads, cereals, and other grain foods, which provide complex carbohydrates, vitamins, minerals, and fiber, are associated with a decreased risk of cardiovascular disease, according to the AHA Dietary Guidelines.However, some studies suggest eating less sugar, breads, and other simple and complex carbohydrates can lower blood insulin levels and decrease body fat and weight—three factors that are linked to an increased risk of heart disease and stroke. In recent years, a number of dietary recommendations based on these findings have become popular and are currently catching the public’s awareness. While contentious, these are important issues and long-term studies are required to determine the risks and benefits of such diets, Dr. Lakatta says.

Saturated fats are usually solid at room temperature. These fats are primarily found in animal foods like meat, poultry, and dairy products like butter. Saturated fats tend to raise levels of “bad” low-density lipoprotein (LDL) and increase the risk of atherosclerosis. In fact, within 2 hours of eating a high saturated fat meal, endothelial cells don’t work as well. Such meals can cause a temporary 50 percent dip in endothelial function, even in healthy young people who have no risk factors for atherosclerosis, Dr. Lakatta says.

 

In addition to saturated fats, some scientists are concerned about trans-fatty acids—unsaturated fats that have been artificially solidified by food manufacturers in a process called hydrogenation to make products like margarine and vegetable shortenings. These scientists suspect that trans-fatty acids, which are often described as hydrogenated or partially hydrogenated fats on many food labels, are more damaging to the heart and arteries than saturated fats.

But researchers have found other types of fats may be beneficial. Monounsaturated fats, found mainly in plant foods such as peanuts and olives, help lower LDL cholesterol. Like polyunsaturated fats, monounsaturated fats are usually liquid at room temperature. Polyunsaturated fats, found in fish, nuts, and dark leafy vegetables, have been getting a lot of attention from scientists in the past few years. They’ve concluded that one type of polyunsaturated fat—omega-3 fatty acid—found in fish may promote several things that improve endothelial function, including increasing nitric oxide production, slashing the production of free radicals and other substances that cause inflammation, and boosting HDL cholesterol levels. Fish such as salmon, herring, and mackerel are good sources of omega-3s.

 

Control over the condition of our arteries may also lie in how much salt we consume. In cultures where little sodium (in the form of salt) is consumed, blood pressures do not rise with age. Cultural differences have also been found in arterial stiffness. One study compared rural and urban populations in China. The urban population consumed much higher levels of sodium than the rural groups. And they had stiffer arteries. Other researchers found that sodium appears to accelerate age-associated stiffening of arteries. In particular, sodium promotes thickening of aging arterial walls, reduces the amount of nitric oxide available to endothelial cells, and promotes the formation of oxygen free radicals. But shifting to a low sodium diet, research suggests, can begin to diminish arterial stiffness in as little as 2 weeks.

Most of the sodium in your diet comes from processed foods. The remaining is added at the table and while cooking. Scientists who study this issue suggest limiting the amount of sodium that you consume from all these sources to no more than 1,500 milligrams (mg) each day (an average American adult consumes about 3,300 milligrams daily). They recommend reading food labels carefully and buying foods that say “reduced sodium,” “low in sodium,” “sodium free,” or “no salt added.” Some dietitians suggest seasoning foods with herbs and spices like oregano, onion powder, or garlic instead of sodium.

Depression among Older Adults

―I didn’t know anything about depression, so I didn’t know I was depressed. … The questionnaire was essential to getting me in for treatment. It was sent to me three times before I sent it back. I took medication and went to a class that helped me learn skills to work on the depression. … I now have two friends getting treatment for depression since I told them about my situation.‖ — Participant in a depression care management program (CDC, 2009a)

An estimated 7 million of the nation’s 39 million adults aged 65 years and older are affected by depression, which is a persistent sad, anxious, or empty feeling, or a feeling of hopelessness and pessimism. Depression in older adults is often not recognized or treated. Yet, it is fairly easy to detect, highly treatable, and a candidate for prevention efforts—making it an excellent focus for public health activities.

Depression is not a normal part of aging. While older adults may face widowhood, loss of function, or loss of independence, persistent bereavement or serious depression is not ―normal‖ and should be treated (U.S. Surgeon General, 1999). Living with untreated depression presents a serious public health problem. Depression complicates chronic conditions such as heart disease, diabetes, and stroke; increases health care costs; and often accompanies functional 2 impairment and disability (Frederick, 2007; Katon, 2003; Snowden, 2008; Unützer, 1997). Depression is also linked to higher health care costs (Unützer, 1997) and tied to higher mortality from suicide and cardiac disease (Frederick, 2007; Snowden, 2009).

Effective treatment reduces depressive symptoms and secondary symptoms such as pain, and improves functioning and quality of life (Frederick, 2007; Snowden, 2008). That means depression among older adults can be addressed through better community-based approaches to identifying and treating depression and through more public awareness. This issue brief will examine community-based approaches to depression and the role of public health and the aging services network.

PUBLIC HEALTH ROLE

―The nation is now poised to take the next step toward realizing the vision of integrating mental health and public health described a decade ago in the Surgeon General’s report. Spiraling health care costs and the rising number of uninsured Americans have built momentum for health care reform, and it is clear that a population-based, public health approach—one that encompasses mental health—will be needed as a foundation for that reform.— David Satcher, M.D., Ph.D., Morehouse School of Medicine and former U.S. surgeon general

As the lead government agency for the nation’s public health, the Centers for Disease Control and Prevention (CDC) plays a central role in the efforts to integrate mental health and public health (Satcher, 2010). CDC’s Healthy Aging Program also has been working to link public health departments with the aging services network on mental health issues. CDC’s role in mental health of the aging includes collecting data to monitor the effect of depression on older adults, helping states assess their state and local data, gathering evidence for effective community-based programs, and promoting evidence-based interventions that can help adults maintain a healthy outlook.

The public health community can monitor depression in the population; develop, test, and start programs that address depression in older adults; and incorporate mental health promotion into chronic disease prevention efforts. In addition, the public health community can work with aging services and mental health providers to more readily reach older adults who may be depressed. ―Routine, systematic screening can successfully identify adults who are depressed and direct them to appropriate treatment,‖ CDC concludes in its report Promoting Preventive Services for Adults 50–64: Community and Clinical Partnerships (CDC, 2009c). 3

CDC collects data on depression, anxiety, psychological distress, and mental illness stigma through supplemental mental illness symptom modules to the state Behavioral Risk Factor Surveillance System (BRFSS) questionnaire. The BRFSS is the world’s largest, ongoing telephone health survey system, tracking health conditions and risk behaviors in the United States annually. In 2006, 38 states and three territories used a depression and anxiety module, according to CDC. The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) has funded the following number of states to add either the mental illness and stigma module or the depression and anxiety module to their BRFSS: 36 states in 2006; 35 states in 2007; 19 states in 2008; and 19 states in 2009 (Freeman, 2010).

In addition, since 1993 the BRFSS has included a question about number of mentally unhealthy days experienced. Mentally unhealthy days are those ―when mental health was not good because of stress, depression, or emotional problems.‖ Interestingly, a trend toward more mentally unhealthy days has been occurring for people in the 55–64 age group. This preretirement age group reported 2.7 mentally unhealthy days a month in 2000, rising to 3.4 days in 2008, the last year for which data is available (CDC, 2009b; Zack, 2004). ―That is a significant trend,‖ said Rosemarie Kobau, M.P.H., public health advisor in the Arthritis, Epilepsy, and Quality of Life Branch. Comparable numbers for ages 64–74 and 75+ were around 2.0 mentally unhealthy days a month in those same years.

CDC also collects information through the National Health Interview Survey, National Health and Nutrition Examination Surveys, and Medicare Health Outcomes Survey. In addition to CDC, the U.S. Surgeon General, the Task Force on Community Preventive Services, Healthy People 2010, the White House Conference on Aging, and other experts have recognized depression as a significant public health problem among older adults.


The U.S. Surgeon General identified older adults as a priority concern in its first report on mental health (U.S. Surgeon General, 1999). It concluded there are effective interventions for most mental disorders, such as depression and anxiety, experienced by older persons and for many mental health problems, such as bereavement. The Task Force on Community Preventive Services reviewed depression treatments and recognized several broad categories as appropriate for adults aged 60 years and older (TFCPS, 2007). It strongly recommended home-based depression care management and clinic-based depression care management.      SAMHSA’s Transforming Mental Health Care in America initiative included older adults among its target groups for a seamless system designed to help people achieve their maximum potential in all spheres of life and at all points in their development (SAMHSA, 2005). The initiative called for SAMHSA, CDC, and the Health Resources and Services Administration to collaborate in helping to serve older adults.                                                                                                            

As a result of this attention to the mental health problems of older adults, the once-separate public health and mental health systems are starting to work more closely together to address depression among older adults. In the past, public health focused on surveillance for health behaviors and chronic disease in order to plan public health programs, while the mental health field used a separate data collection system that emphasized measurement of disease prevalence and health care use (Freeman, 2010). Recent efforts to integrate these systems have included adding chronic disease measures to the Collaborative Psychiatric Epidemiology Surveys and incorporating depression measures in the BRFSS and other data collection systems (Freeman, 2010).   WHAT IS DEPRESSION? ―Everyone feels sad or blue sometimes. It is a natural part of life. But when the sadness persists and interferes with everyday life, it may be depression. Depression is not a normal part of growing older. It is a treatable medical illness, much like heart disease or diabetes.— Geriatric Mental Health Foundation


The Surgeon General in 1999 identified mental health as a state of ―successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity.‖ Mental disorders, on the other hand, are characterized by ―alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning.


Research indicates depressive illnesses are disorders of the brain (NIMH, 2007). Depression has no known cause, but is believed to result from several genetic, biochemical, environmental, or psychological factors. Depression is treatable in 80 percent of cases (NIMH, 2007).


However, depression may be overlooked in older adults, because they may show different or less obvious symptoms than younger people, and may be less inclined to experience or acknowledge feelings of sadness or grief (Gallo, 1999). Depression in older adults must also 5
be distinguished from the effects of medical conditions or prescription medications that may cause depressive symptoms.
Older adults are less likely than younger adults to have major depression, but have higher rates of minor depression and dysthymia (Ciechanowski, 2004)—both conditions contribution to significant disability (Wells, 1989; Beekman, 1997).

Types of Depression

Major depression is defined as depressed mood most of the day or loss of interest or pleasure over a two-week period accompanied by at least four of the following symptoms: significant weight loss or gain, insomnia or sleeping too much nearly every day, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, inability to think or concentrate, or recurrent thoughts of death. In elderly adults, cognitive symptoms (e.g., disorientation, memory loss, and distractibility) may be particularly prominent.
Minor depression is one or more periods of depressive symptoms that have lasted for two weeks or longer, but with fewer symptoms and less impairment than major depression. An episode involves either a sad or depressed mood or loss of interest or pleasure in nearly all activities.

Dysthymic disorder, or dysthymia, is a long-term (two years or longer) depressed mood for most of the day, for more days than not, accompanied by two or more of the following: poor appetite or overeating, insomnia or sleeping too much, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness. The symptoms are less severe than depression.

HOW MANY OLDER ADULTS HAVE DEPRESSION?

Estimates of the prevalence of depression among older adults range from 15–20 percent of adults older than 65 (Ciechanowski, 2004; GMHF, 2008; Koenig, 1996; Lebowitz, 1996). The levels are lower among community-dwelling older adults and higher among those in nursing homes (Lebowitz, 1996).

Another study, which looked at clients aged 60 years and older receiving in-home case management services through 13 area agencies on aging in Washington State, found an estimated 20–30 percent of older adults have minor depression, and 25 percent have major depression, according to Dr. Mark Snowden, M.D., M.P.H., Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine. 6

On the BRFSS, 7.7 percent of adults age 50 or older reported current depression, and 15.7 percent reported a lifetime diagnosis of depression. However, certain groups reported different levels of depression at age 50 or older (CDC, 2008):
Hispanic, 11.4 percent
Other non-Hispanic, 11.0 percent
Black, non-Hispanic, 9.0 percent
White, non-Hispanic, 6.8 percent

Women aged 50 years and older also reported more current depression (8.9 percent of women are currently depressed, compared with 6.2 percent of men) and lifetime depression (19.1 percent of women compared with 11.7 percent of men) (CDC, 2008).
Interestingly, adults aged 50–64 years reported more current depression (9.4 percent of those aged 50–64, compared with 5 percent of those aged 65 or older) and lifetime diagnosis of depression (19.3 percent of those aged 50–64, compared with 10.5 percent of those 65+) (CDC, 2008). Some experts suggest this may be due to the stress of the preretirement years.

COST OF UNTREATED DEPRESSION

Depressed older adults have higher health care expenses because they are more likely to visit the Emergency Department, have more frequent hospitalizations and doctor visits, and take more medications than adults without depression, according to the U.S. Surgeon General’s report (1999).
 
For example, Medicare participants who have diabetes or congestive heart failure as well as depression have significantly higher health care costs than their counterparts who do not have co-existing depression, according to a study funded by the National Institute of Mental Health. Jürgen Unützer, M.D., M.P.H., of the University of Washington, and colleagues analyzed Medicare claims of 14,903 participants enrolled in a pilot Medicare disease management program, Medicare Health Support, operated by Green Ribbon Health in Florida (Unützer, 2009). The researchers found those with depression and chronic disease had significantly higher total health care costs than those with chronic disease but no depression ($22,960 vs. $11,956) (Unützer, 2009). Only a small proportion of the increased costs are from mental health specialty care.

There are other costs of untreated depression besides monetary costs, including poor quality of life and possible suicide. People aged 65 years and older accounted for 16 percent of suicides in 2004 (CDC, 2007). 7

SCREENING GUIDELINES

Screening for depression allows professionals to look for the condition in patients who do not report symptoms, according to the U.S. Preventive Services Task Force (USPSTF). Screening should only be offered when there are services or systems in place to immediately refer the patient for further assessment, treatment, and follow-up (USPSTF, 2002). Screening by itself, without treatment and follow-up, is not effective, USPSTF concluded after a research review completed in 2009 (USPSTF, 2009; O’Conner, 2009). Operated by the U.S. Agency for Healthcare Research and Quality, USPSTF is a group of health experts who review published research and make recommendations about preventive health care.

Screening should be done in an appropriate setting, using a depression screening instrument appropriate for an older adult population, Dr. Snowden said. Examples of depression screening tools include the Geriatric Depression Scale, the Center for Epidemiologic Studies Depression Scale, and the Patient Health Questionnaire. While screening identifies the likelihood someone may have depression, it is not in itself a diagnosis, Dr. Snowden added. Diagnosis and treatment should be offered by someone trained in evaluating depression symptoms and other medical problems associated with depression (Snowden, 2009).

TREATING DEPRESSION

―CDC research revealed several important studies that identified depression care programs that work, that communities can engage in, that we know are going to have the desired outcomes and effect on depression—Lynda Anderson, Ph.D., director of CDC’s Healthy Aging Program

For older adults (age 60+), the top recommended treatment is home- or clinic-based depression care management (DCM), according to the nonfederal Task Force on Community Preventive Services, whose members are appointed by CDC. The recommendations are contained in the Guide to Community Preventive Services (commonly known as the Community Guide) (TFCPS, 2007). The panel also endorsed cognitive behavior therapy for treating late-life depression, although not as strongly as DCM. The ratings are based on the evidence of effectiveness in improving short-term depression outcomes.

The task force concluded that these recommended programs—DCM and cognitive behavior therapy (CBT)—―should be disseminated throughout public health and aging networks while acknowledging the challenges and obstacles involved‖ (Snowden, 2007).
DCM, sometimes called collaborative care management, uses a team approach. A trained social worker, nurse, or other practitioner (sometimes called a depression care manager)


oversees patient education, outcomes tracking, and support/delivery of the evidence-based treatments that a primary care provider prescribes in consultation with a psychiatrist (Snowden, 2007). DCM was supported by eight randomized clinical trials with more than 3,000 subjects, who reported a greater reduction in depression symptoms, higher remission rates, and more improvements in health-related quality of life than people in the control group (Snowden, 2008).

Home-based DCM is designed for older adults living in their own homes, public housing, or residential facilities. It involves home visits by a trained depression care manager, who work with other team members (case manager and supervising psychiatrist) outside the home. In studies examined by the Task Force, the response rate to home-based DCM ranged from 27–43 percent for the intervention group compared with 15 percent for the control group. ―Response‖ was defined as a 50 percent reduction in depression measure scores. The remission rate, which refers to absence of symptoms of depression, was 36 percent for the intervention group versus 12 percent for the control group (TFCPS, 2007). The total mean cost for the one program that reported costs was $630 per patient for six visits.

In clinic-based DCM, a trained depression care manager works with the patient’s primary care provider, psychiatrist, or other health care personnel, employing patient education, antidepressant treatment and/or psychotherapy, and supervision by a psychiatrist. One research study of clinic-based DCM reported a 45 percent response rate and a 25 percent remission rate for subjects with major depression or dysthymia (TFCPS, 2007). Another study found a 55 percent response rate and a 36 percent remission for subjects with major depression after a similar time period; no statistically significant improvement was found for subjects with minor depression (Bruce, 2002). Costs for the depression care had a mean cost of $580 per patient (Unützer, 2002).

CBT is psychotherapy focusing on clients’ patterns of thought and behaviors that induce a depressed mood (Snowden, 2008). The therapist educates the client on how to identify and change these thoughts and behaviors to relieve the depression symptoms. Generally the therapist has a master’s degree and is supervised by someone with an M.D. or Ph.D. (Steinman, 2007). CBT was determined to be an effective intervention, regardless of whether delivered in the home or clinic, according to Dr. Snowden. 9

Dr. Snowden, with support from the CDC Healthy Aging Program and Community Guide Staff, made several presentations to the Task Force on Community Preventive Services that resulted in the task force’s independent recommendations about depression interventions for older adults. ―As a result, the task force came out with Community Guide recommendations for the first time on preventive services for older adults about mental health,‖ Dr. Anderson said.


However, ―Just because the Community Guide recommends something, doesn’t guarantee things are likely to change,‖ Dr. Snowden explained. ―It is not enough to just fund studies that prove an intervention is effective if those interventions never get out into everyday use. So CDC funded a dissemination and implementation study to find out what needed to be done to put the interventions into practice. The study by the University of Washington found that once research was completed, the community-based agency was often able to continue the project on its own; however, case managers were not referring patients to the program. The researchers decided to re-establish the research-phase partnership with the community-based agency that participated in the study in order to figure out ways for the agency to continue to use the program. One DCM program was modified to lower the eligibility age from 60 to 50, allow the intervention to be used for major depression as well as minor depression, hire a recruiter/coordinator to help facilitate the evidence-based programs and take the burden off the case manager, allow a language interpreter to go into a patient’s home, and improve monitoring so the agency could assess progress. Those changes help ensure more patients can access the program, according to Dr. Snowden.

In addition, Washington State and others are experimenting with ways to provide sustainable funding for DCM programs. For example, a King County, Washington, tax levy for homeless veterans was expanded to include older adults. This provided funds for a DCM known as the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) to begin to reach older veterans and underserved minorities. A SAMHSA grant was used for intervention training and to create a PEARLS toolkit for community-based providers.

MODEL PROGRAMS FOR TREATING DEPRESSION IN OLDER ADULTS

Below are descriptions of three model DCMs used with older adults.
Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors), developed by Baylor College of Medicine and others, focuses on underserved, frail, community-dwelling adults age 60 and older who are receiving case management services. The program provides depression care in the participant’s home. Participants and their caregivers receive education about depression and self-care and assistance in contacting primary care and mental health


providers. The program provides coaching and support as the client engages in behavioral changes to manage depression and pursue meaningful activities. It generally involves three in-person visits and three to six telephone calls over three to six months (CDC, 2009).
The interventionist does not have to have professional licensure and receives on-site training. Other resources include a manual, worksheets, client handouts, and forms to document client outcomes.

Researchers found that participants in the program lowered their levels of depression and pain, learned where to get help for depression, and engaged in more activities.


The program cost is $3,000 for training and set-up. Per-patient costs have not been determined.
Care for Elders in Houston and Baylor College of Medicine manage the dissemination of Healthy IDEAS to potential adopters. Contact: Nancy Wilson, nwilson@bcm.edu, 713-798-3850; http://careforelders.org/default.aspx/MenuItemID/290/MenuGroup/Initiatives.htm.
The U.S. Administration on Aging has awarded a grant to Sheltering Arms Senior Services in Houston, Texas, to build on the Healthy IDEAS program, with a focus on under-served and minority older adults. The goal is to improve partnerships between community aging service providers, health care organizations, academic researchers, and consumers.

IMPACT (Improving Mood—Promoting Access to Collaborative Treatment) is a clinic-based depression care management program developed at the University of Washington for older adults with major depression or dysthymic disorder. It employs a trained nurse, social worker, or psychologist, who teaches clients problem-solving techniques, in coordination with a primary care physician who may prescribe antidepressant medications. A psychiatrist provides consultation and supervision as needed. IMPACT was designed for a clinical setting, but has also been implemented in home health care and chronic disease management programs.
Participants receive an assessment and education about depression, and are urged to engage in physical activity or schedule pleasurable events. Clients who are taking antidepressant medications and continue to be depressed are offered a six- to eight-session trial of problem-solving treatment. The DCM follows up about every two weeks during the intensive phase and then monthly thereafter for several months (CDC, 2009).

IMPACT participants were twice as likely as usual-care patients to have a 50 percent or higher reduction in their symptoms (CDC, 2009). The program also reduces total health care costs by about $3,300 per person over a four-year period, compared with usual care (Unützer, 2008).


The yearly cost of the program is about $750 per participant. Free program materials are available online; however, there is an in-person training cost of about $250.


PEARLS (Program to Encourage Active, Rewarding Lives for Seniors) is a home-based depression care management program for minor depression and dysthymia in adults aged 60 years and older who are receiving home-based social services from community services agencies. PEARLS offers eight in-home counseling sessions and three to six maintenance followup telephone calls. A trained depression care manager, usually a social worker or mental health counselor, uses problem-solving treatment, social and physical activity planning, and pleasant-event planning (CDC, 2009). The depression care manager works closely with a supervising psychiatrist. 11

PEARLS significantly reduced depressive symptoms and improved health status in chronically medically ill older adults (Ciechanowski, 2006). Participants were three times more likely than those receiving usual care to significantly reduce their symptoms of depression (43 percent vs. 15 percent) or completely eliminate depression (36 percent vs. 12 percent) (CDC, 2009). Participants were also more likely to report greater health-related quality of life improvements (functional as well as emotional well-being) and reduce their use of health care services, such as hospitalization. The University of Washington developed PEARLS in the late 1990s.
The cost of the program is about $630 per patient. Resources include a DCM manual, implementation toolkit, and $500 training program in Seattle twice a year.

BARRIERS TO CARE

Because effective programs for treating depression in older adults exist and are recommended, why don’t more older adults access them? There are various barriers that keep effective treatment programs, known as evidence-based programs or EBPs, from being used.
One barrier is that many older adults and society itself tends to have a stigma against mental illness, viewing depression as a personal weakness or character flaw (Kobau, 2010). Many older adults are reluctant to go to a mental health specialist (Snowden, 2008). ―Some older persons believe that mental health disorders and treatment are shameful, represent personal failure, or will lead to a loss of autonomy. As a result, they may deny having problems or refuse to seek treatment,‖ attendees at the 2005 White House Conference on Aging concluded.

CDC collects data on mental health stigma through two questions on the BRFSS. It asks the respondent if he or she agrees: 1) ―treatment can help people with mental illness lead normal lives‖ and 2) ―people are generally caring and sympathetic to people with mental illness.


In addition to stigma, ageism and erroneous assumptions that depression is a normal part of aging may cause practitioners to miss a potential depression diagnosis. A significant step toward addressing stigma would be for the public and practitioners to better understand that depression is common and treatable (Steinman, 2007). Another problem is many primary care clinics do not usually screen for depression (Snowden, 2008).

Another obstacle to accessing treatment is many EBPs for depression have not been tested among all population cohorts, especially non-English-speaking populations, lower-income people, people of color, people older than age 85 and those with cognitive impairments (Steinman, 2007).

A significant hurdle to accessing care is that Medicare and other insurers do not cover depression care unless it is provided by physicians, psychologists, licensed clinical social workers, or advanced RN practitioners (Steinman, 2007). In some cases Medicare and Medicaid will not reimburse for a registered nurse serving as a case manager or for a supervising psychiatrist (Snowden, 2008). Yet many of the EBPs developed for addressing depression in older adults can be administered by a well-trained person with a bachelor’s degree.
Without payment, however, it is difficult to provide properly trained and supervised staff to deliver the EBP.

Another common problem with EBPs is that once the initial research is completed, they often ―sit on the shelf without being disseminated and used. One solution is the University of Washington’s previously described approach to revise the original program to better match a community’s unique needs.

In addition, public health and agencies on aging do not traditionally work together in the area of mental health.

FUTURE DIRECTIONS

―Because the condition is highly treatable and currently undertreated among community-based older adults, late-life depression is an appropriate focus for disease prevention programs.


Policymakers clearly need to understand that EBP for depression can improve treatment outcomes and lower health care costs (Steinman, 2007). Treating depression effectively also can help improve arthritis, diabetes, cancer, and other disease outcomes (Steinman, 2007).
The public health, mental health, and aging services networks need to work together more closely to reach and treat older adults with depression. Public health and agencies on aging can do this by creating partnerships and collaborative care programs to identify, reach, and treat older adults with depression. Such a collaborative approach would allow consistent information to be disseminated to each of these sectors, instead of the current model under which CDC reaches out to state and local public health departments, SAMHSA communicates with state mental health programs and mental health providers with treatment information, and the Administration on Aging reaches the network on aging with service information. Better packaging of information about depression in older adults could produce a useful toolkit for professionals who work with them.

―The public health community needs to understand the seriousness of depression among older adults, understand the need to work with the mental health communities in state health departments and in local areas, and understand that there are effective services out there 13
for older adults,‖ Dr. Anderson said. ―Whereas the aging services network, which is more services oriented, can begin by looking at how to implement those kinds of programs and work with the public health community to help organize and connect to these programs.‖
Public health professionals can help the aging services network with the collection and analysis of data on depression among older adults and with tracking, evaluation, and identification of programs that are effective, Dr. Anderson said.

In addition, public health disease prevention programs for older adults should include a depression screening and treatment component, according to Dr. Snowden (Snowden, 2008).
On the financing side, Medicare and other insurers could cover evidence-based programs for depression, giving more older adults access to depression treatment.

At the same time, more research is needed to understand how well depression care programs will work with nontraditional populations outside the academic setting, in places such as senior centers and area agencies on aging. Another area requiring more research is the effect of physical activity on depression.

Efforts also need to focus on pre-Medicare-age adults. In Promoting Preventive Services for Adults 50–64: Community and Clinical Partnerships (CDC, 2009c), CDC, AARP and American Medical Association, lay out a plan to promote clinical preventive services for adults aged 50 to 64 years. ―Widespread agreement exists on a recommended array of preventive services and effective ways to increase their use, the document states. The report recommends using preventive services for this age group, including depression screening and management.

States can also use existing data to identify older adults enrolled in case management who have a depression score showing they are at risk and might benefit from services like PEARLS. That data can also help the aging services network look at how local communities can finance and deliver services.

In the future, public health surveillance systems will focus more on psychological well-being by measuring positive psychological function as both a protective factor against poor health outcomes and as a mental health indicator in its own right (Freeman, 2010). Well-being looks at the degree to which people feel positive and enthusiastic about themselves and life (Manderscheid, 2010).

 

STORY IDEAS FOR JOURNALISTS

1) Help your readers overcome the stigma about mental health and depression issues. Address people’s reluctance to admit having depression. Interview older adults who were reluctant to seek treatment due to stigma, but got over the stigma, received treatment, and report that their life is better and they can now solve their problems.

2) Write a story about the need for public health departments to focus more on mental health issues among older adults.

3) When writing about a new intervention or treatment for depression in older adults, ask how many people are receiving this intervention. Is it something that will ―sit on the shelf, or is there a mechanism in place to ensure its widespread use?

4) Investigate why Medicare and other insurers will only pay for mental health services provided by certain levels of professionals, when many evidence-based programs can effectively be provided by a properly trained professional with a bachelor’s degree.

 

The word "arthritis" makes many people think of painful, stiff joints. But, there are many kinds of arthritis, each with different symptoms and treatments. Most types of arthritis are chronic. That means they can go on for a long period of time.
Arthritis can attack joints in almost any part of the body. Some types of arthritis cause changes you can see and feel—swelling, warmth, and redness in your joints. In some kinds of arthritis, the pain and swelling last only a short time, but are very uncomfortable. Other types of arthritis might be less painful, but still slowly cause damage to your joints.

Common Kinds of Arthritis
Arthritis is one of the most common diseases in the United States. Older people most often have osteoarthritis, rheumatoid arthritis, or gout.


Osteoarthritis (OA) is the most common type of arthritis in older people. OA starts when tissue, called cartilage, that pads bones in a joint begins to wear away. When the cartilage has worn away, your bones rub against each other. OA most often happens in your hands, neck, lower back, or the large weight-bearing joints of your body, such as knees and hips.


OA symptoms range from stiffness and mild pain that comes and goes to pain that doesn't stop, even when you are resting or sleeping. Sometimes OA causes your joints to feel stiff after you haven't moved them for a while, like after riding in the car. The stiffness goes away when you move the joint. Over time, OA can make it hard to move your joints. It can cause a disability if your back, knees, or hips are affected.


Why do you get OA? Growing older is what most often puts you at risk for OA, possibly because your joints and the cartilage around them become less able to recover from stress and damage. Also, OA in the hands may run in families. Or, OA in the knees can be linked with being overweight. Injuries or overuse may cause OA in joints such as knees, hips, or hands.


Rheumatoid arthritis (RA) is an autoimmune disease, a type of illness that makes your body attack itself. RA causes pain, swelling, and stiffness that lasts for hours. RA can happen in many different joints at the same time. People with RA often feel tired or run a fever. RA is more common in women than men.


RA can damage almost any joint. It often happens in the same joint on both sides of your body. RA can also cause problems with your heart, muscles, blood vessels, nervous system, and eyes.


Gout is one of the most painful kinds of arthritis. It most often happens in the big toe, but other joints can also be affected. Swelling may cause the skinto pull tightly around the joint and make the area red or purple and very tender.
Eating foods rich in purines like liver, dried beans, peas, anchovies, or gravy can lead to a gout attack in people with the disease. Using alcohol being overweight, and taking certain medication may make gout worse. In older people, someblood pressure medicines can also increase the chance of a gout attack. To decide if you have gout, your doctor might do blood tests and x-rays.


Warning Signs
You might have some type of arthritis if you have:

  • Ongoing joint pain
  • Joint swelling
  • Joint stiffness
  • Tenderness or pain when touching a joint
  • Problems using or moving a joint normally
  • Warmth and redness in a joint

If any one of these symptoms lasts more than 2 weeks, see your regular doctor or one who specializes in treating arthritis, called a rheumatologist. If you have a fever, feel physically ill, suddenly have a swollen joint, or have problems using your joint, see your doctor right away.


Treating Arthritis


Getting enough rest doing the right exercise, eating a healthy diet and learning the right way to use and protect your joints are keys to living with any kind of arthritis. The right shoes and a cane can help with pain in the feet, knees, and hips when walking. But make sure the cane is fitted by a professional. Don’t borrow one from a friend or neighbor. There are also gadgets to help you open jars and bottles or to turn the doorknobs in your house.


Some medicines can help with pain and swelling. Acetaminophen might ease arthritis pain. Some people find NSAIDs (nonsteroidal anti-inflammatory drugs), like ibuprofen, naproxen, and ketoprofen, helpful. Some NSAIDs are sold without a prescription, while others must be prescribed by a doctor. Be very careful about possible side effects of some NSAIDs, whether sold with or without a prescription. Read the warnings on the package or insert that comes with the drug. Talk to a doctor about if and how you should use acetaminophen or NSAIDs for your arthritis pain. The U.S. Food and Drug Administration has more information about drugs such as those mentioned here.
Osteoarthritis (OA). Medicines can help you control the pain. Rest and exercise may make it easier to move your joints. Keeping your weight down is a good idea. If pain from OA is very bad, there are shots your doctor can give you.


Rheumatoid arthritis (RA). Treatment can help the pain and swelling. This might slow down or stop joint damage. You may feel better and find it easier to move around. Your doctor might also suggest anti-rheumatic drugs called DMARDs (disease-modifying antirheumatic drugs). These can slow damage from the disease. Other medicines known as corticosteroids (like prednisone) can ease swelling. These are strong medicine and should only be taken with a doctor’s prescription. Another kind of drug, called a biologic response modifier, blocks the damage done by the immune system. These may help people with mild-to-moderate RA when other treatments have not worked.
Gout. The most common treatment for an acute attack of gout is NSAIDs or corticosteroids. They can bring down the swelling, so you may start to feel better within a few hours after treatment. The pain usually goes away within a few days. If you have had an attack of gout, talk to your doctor to learn why you had the attack and how to prevent future attacks. If you have had several attacks, your doctor might prescribe medicines to prevent future ones.


Exercise Can Help


Along with taking the right medicine and properly resting your joints, exercise might help with arthritis symptoms. Daily exercise, such as walking or swimming, helps keep joints moving, lessens pain, and makes muscles around the joints stronger.
Three types of exercise are best if you have arthritis:

  • Range-of-motion exercises, like dancing, might relieve stiffness and help you keep moving your joints.
  • exercises, such as weight training, will keep or add to muscle strength. Strong muscles support and protect your joints.
  • Aerobic exercises, like bicycle riding, make your heart and arteries healthier, help prevent weight gain, and also may lessen swelling in some joints.

The National Institute on Aging (NIA) has created the to help you start and stick with a safe exercise program. . tip sheets, personal more! You can even keep track in your exercise program.

Other Things To Do
Along with exercise and weight control, there are other ways to ease the pain around joints. You might find comfort by using a heating pad or a cold pack, soaking in a warm bath, or swimming in a heated pool.
Your doctor may suggest  when damage to your joints becomes disabling or when other treatments do not help with pain. Surgeons can repair or replace some joints with artificial (man-made) ones.
Other Remedies
Recent studies suggest that acupuncture may ease OA pain for some people. Research also shows that two glucosamine and chondroitin, may help lessen moderate to severe OA pain, but they seem to have no effect on changes to cartilage in the knee. Scientists continue to study these kinds of alternative treatments. Always check with your doctor before trying any new treatment for arthritis.
Many people with arthritis try remedies that have not been tested or proven helpful. Some of these, such as snake venom, are harmful. Others, such as copper bracelets, are harmless, but also unproven.
How can you tell that a remedy may be unproven?

  • The remedy claims that a treatment, like a lotion or cream, works for all types of arthritis and other diseases.
  • Scientific support comes from only one research study.
  • The label has no directions for use or warning about side effects.
  • The person recommending the treatment profits directly from your purchase of the medicine.
  • People who are now completely well are presented to you as having the same problems you have (this is called anecdotal evidence).

End of Life: Helping With Comfort and Care

Introduction

At the end of life, each story is different. Death comes suddenly, or a person lingers, gradually failing. For some older people, the body weakens while the mind stays alert. Others remain physically strong, and cognitive losses take a huge toll. But for everyone, death is inevitable, and each loss is personally felt by those close to the one who has died.


End-of-life care is the term used to describe the support and medical care given during the time surrounding death. Such care does not happen just in the moments before breathing finally stops and a heart ceases to beat. An older person is often living, and dying, with one or more chronic illnesses and needs a lot of care for days, weeks, and sometimes even months.


End of Life: Helping With Comfort and Care hopes to make the unfamiliar territory of death slightly more comfortable for everyone involved. This publication is based on research, such as that supported by the part of the National Institutes of Health. This research base is augmented with suggestions from practitioners with expertise in helping individuals and families through this difficult time. Throughout the booklet, the terms supportive care, and are used to describe individualized care that can provide a dying person the best quality of life until the end. Most of the stories in this booklet are fictitious, but they depict situations that reflect common experiences at the end of life.
When a doctor says something like, “I’m afraid the news is not good. There are no other treatments for us to try. I’m sorry,” it may close the door to the possibility of a cure, but it does not end the need for medical support. Nor does it end the involvement of family and friends. There are many places and a variety of ways to provide care for an older person who is dying. Such care often involves a team. If you are reading this, then you might be part of such a team.


Helping With Comfort and Care provides an overview of issues commonly facing people caring for someone nearing the end of life. It can help you to work with health care providers to complement their medical and caregiving efforts. The booklet does not replace the personal and specific advice of the doctor, but it can help you make sense of what is happening and give you a framework for making care decisions.

Providing Comfort at the End of Life

Comfort care is an essential part of medical care at the end of life. It is care that helps or soothes a person who is dying. The goal is to prevent or relieve suffering as much as possible while respecting the dying person’s wishes.


You are probably reading this because someone close to you is dying. Is it a parent or grandparent, your husband or wife, a favorite aunt or uncle, your best friend? You wonder what will happen. You want to know how to give comfort, what to say, what to do. At the same time, you’re possibly unsure about what is needed, worried about doing the wrong thing, or afraid of being there—or not being there—at the moment of death.


You might be giving day-to-day care to the dying person, chosen to make health care decisions, or a close family member or friend who wants to help. You would like to know how to make dying easier—how to help ensure a “good death,” with treatment consistent with the dying person’s wishes.

Comfort needs near the end of life:

  • Physical Comfort
  • Mental and Emotional Needs
  • Spiritual Issues
  • Practical Tasks

A “good death” might mean something different to you than to someone else. Your sister might want to know when death is near so she can have a few last words with the people she loves and take care of personal matters. Your husband might want to die quickly and not linger. Perhaps your mother has said she would like to be at home when she dies, while your father wants to be in a hospital where he can receive treatment for his illness until the very end. Some people want to be surrounded by family and friends; others want to be alone. Of course, often one doesn’t get to choose, but having your end-of-life wishes followed, whatever they are, and being treated with respect while dying are common hopes.


Generally speaking, people who are dying need care in four areas—physical comfort, mental and emotional needs, spiritual issues, and practical tasks. In this chapter you will find a number of ways you can be of help to someone who is dying. Always remember to check with the health care team to make sure these suggestions are appropriate.

Physical Comfort

There are ways to make a person who is dying more comfortable. Discomfort can come from a variety of problems. For each there are things you or a health care provider can do, depending on the cause. For example, a dying person can be uncomfortable because of:

  • Pain
  • Breathing problems
  • Skin irritation
  • Digestive problems
  • Temperature sensitivity
  • Fatigue

What about morphine?

Morphine is an opiate, a strong drug used to treat serious pain. Sometimes, morphine is also given to ease the feeling of shortness of breath. You might have heard that giving morphine leads to a quicker death. Is that true? Most experts think this is unlikely, especially if increasing the dose is done carefully. Successfully reducing pain and/or concerns about breathing can provide needed comfort to someone who is close to dying.

Pain. Watching someone you love die is hard enough, but thinking that person is also in pain makes it worse. Not everyone who is dying experiences pain, but there are things you can do to help someone who does. Experts believe that care for someone who is dying should focus on without worrying about possible long-term problems of drug dependence or abuse. Don’t be afraid of giving as much pain medicine as is prescribed by the doctor. Pain is easier to prevent than to relieve, and overwhelming pain is hard to manage. Try to make sure that the level of pain does not “get ahead” of pain-relieving medicines. If the pain is not controlled, ask the doctor or nurse to arrange for consultation with a pain management specialist.


Struggling with severe pain can be draining. It can make it hard for families to be together in a meaningful way. Pain can affect mood—being in pain can make someone seem angry or short-tempered. Although understandable, irritability resulting from pain might make it hard to talk, hard to share thoughts and feelings.


Breathing problems. Shortness of breath or the feeling that breathing is difficult is a common experience at the end of life. The doctor might call this dyspnea (disp-NEE-uh). Worrying about the next breath can make it hard for important conversations or connections. Try raising the head of the bed, opening a window, using a vaporizer, or having a fan circulating air in the room. Sometimes, the doctor suggests extra oxygen, given directly through the nose, to help with this problem.


People very near death might have noisy breathing called a death rattle. This is caused by fluids collecting in the throat or by the throat muscles relaxing. It might help to try turning the person to rest on one side. There is also medicine that can be prescribed to help clear this up. But not all noisy breathing is a death rattle. And, it may help to know that this noisy breathing is usually not upsetting to the person dying, even if it is to family and friends.


Skin irritation. Skin problems can be very uncomfortable. With age, skin becomes drier and more fragile naturally, so it is important to take extra care. Gently applying alcohol-free lotion can relieve dry skin as well as be soothing.


Dryness on parts of the face, such as the lips and eyes, can be a common cause of discomfort near death. A lip balm could keep this from getting worse. A damp cloth placed over closed eyes might relieve dryness. If the inside of the mouth seems dry, giving ice chips, if the person is conscious, or wiping the inside of the mouth with a damp cloth, cotton ball, or a specially-treated swab might help.
Sitting or lying in one position puts constant pressure on sensitive skin, which can lead to painful bed sores (sometimes called pressure ulcers). When a bed sore first forms, the skin gets discolored or darker. Watch carefully for these discolored spots, especially on the heels, hips, lower back, and back of the head. Turning the person from side to back and to the other side every few hours may help prevent bed sores. Or try putting a foam pad under an area like a heel or elbow to raise it off the bed and reduce pressure. A special mattress or chair cushion might also help. Keeping the skin clean and moisturized is always important. A bed sore that won’t heal probably needs treatment by a wound specialist.


Digestive problems. Nausea, vomiting, constipation, and loss of appetite are common end-of-life complaints. The causes and treatments for these symptoms are varied, so talk to a doctor or nurse right away. There are medicines that can control nausea or vomiting or relieve constipation.


If someone near death wants to eat, but is too tired or weak, you can help with feeding. If loss of appetite is a problem, encourage eating by gently offering favorite foods in small amounts. Or try serving frequent, smaller meals rather than three big ones. But, don’t force a person to eat. Going without food and/or water is generally not painful, and eating can add to discomfort. Losing one’s appetite is a common and normal part of dying. A conscious decision to give up food can be part of a person’s acceptance that death is near.
Temperature sensitivity. People who are dying may not be able to tell you that they are too hot or too cold, so watch for clues. For example, someone who is too warm might repeatedly try to remove a blanket. You can take off the blanket and try a cool cloth on his or her head. If a person is hunching his or her shoulders, pulling the covers up, or even shivering—those could be signs of cold. Make sure there is no draft, raise the heat, and add another blanket, but avoid electric blankets because they can get too hot.


Fatigue. It is common for people nearing the end of life to feel tired and have little or no energy. Keep activities simple. For example, a bedside commode can be used instead of walking to the bathroom. A shower stool can save a person’s energy, as can switching to sponging off in bed.


Medical tests and treatments can be uncomfortable and can drain the strength of a person who is dying. Some may no longer be necessary and can be stopped, as one woman’s family learned. At eighty, Catherine had already been in a nursing home for two years since her stroke. Her health began to fail quickly, and she was no longer able to communicate her wishes. Her physician, Dr. Jones, told her family she was dying. He said that medical tests, physical therapy, and IVs (intravenous tubes inserted into a vein with a needle to give medicine or fluids) were no longer really needed and should be stopped since they might be causing Catherine discomfort. Dr. Jones also said that checking vital signs (pulse, blood pressure, temperature, and breathing rate) was interrupting her rest and would no longer be done regularly.


Then Catherine developed pneumonia. Her family asked about moving her to the hospital. The doctor explained that Catherine could get the same treatment—antibiotics, if chosen, and oxygen—in the familiar surroundings of her nursing home. Besides, he said a move could disturb and confuse her. The family agreed to leave Catherine in the nursing home, and she died two days later surrounded by those close to her. Experts suggest that moving someone to a different place, like a hospital, close to the time of death, should be avoided if possible.

Mental and Emotional Needs

Complete end-of-life care also includes helping the dying person manage any mental and emotional distress. Someone nearing the end of life who is alert might understandably feel depressed or anxious. Encouraging conversations about feelings might be beneficial. You might want to contact a counselor, possibly one familiar with end-of-life issues. If the anxiety is severe, medicine might provide relief.
A dying person might also have some specific fears and concerns. He or she may fear the unknown or worry about those left behind. Some people are afraid of being alone at the very end. This feeling can be made worse by the understandable reactions of family, friends, and even the medical team. For example, when family and friends do not know how to help or what to say, sometimes they stop visiting. Or, someone who is already beginning to grieve may withdraw. Doctors may become discouraged because they can’t cure their patient and feel helpless. Some seem to avoid a dying patient. This can add to a dying person’s sense of isolation. If this appears to be happening, try to discuss your concerns with the family, friends, or the doctor.


The simple act of physical contact—holding hands, a touch, or a gentle massage—can make a person feel connected to those he or she loves. It can be very soothing. Warm your hands by rubbing them together or running them under warm water.


Try to set the kind of mood that is most comforting for the dying person. What has he or she always enjoyed? For example, Bill loved a party, so it was natural for him to want to be surrounded by family and friends when he was dying. Ellen always preferred spending quiet moments with one or two people at a time, so she was most comfortable with just a few visitors. Some experts suggest that when death is very near, music at low volume and soft lighting are soothing. In fact, near the end of life, music therapy might improve mood, help with relaxation, and lessen pain. Listening to music might also evoke memories those present can share. For some people, keeping distracting noises like televisions and radios to a minimum is important.

Spiritual Issues

People nearing the end of life may have spiritual needs as compelling as their physical concerns. Spiritual needs involve finding meaning in one’s life and ending disagreements with others, if possible. The dying person might find peace by resolving unsettled issues with friends or family. Visits from a social worker or a counselor may also help. Many people find solace in their faith. Praying, talking with someone from one’s religious community (such as a minister, priest, rabbi, or Muslim cleric), reading religious text, or listening to religious music may bring comfort.


Family and friends can talk to the dying person about the importance of their relationship. For example, adult children can share how their father has influenced the course of their lives. Grandchildren can let their grandfather know how much he has meant to them. Friends can relate how they value years of support and companionship. Family and friends who can’t be present could send a recording of what they would like to say or a letter to be read out loud.


Sharing memories of good times is another way some people find peace near death. This can be comforting for everyone. Some doctors think it is possible that even if a patient is unconscious, he or she might still be able to hear; it is probably never too late to say how you feel or to talk about fond memories.


Always talk to, not about, the person who is dying. When you come into the room, it is a good idea to identify yourself, saying something like “Hi, Bob. It’s Mary, and I’ve come to see you.” Another good idea is to have someone write down some of the things said at this time—both by and to the one dying. In time, these words might serve as a source of comfort to family and friends. People who are looking for ways to help may welcome the chance to aid the family by writing down what is said.


There may come a time when a dying person who has been confused suddenly seems clear-thinking. Take advantage of these moments, but understand that they might be only temporary, not necessarily a sign he or she is getting better.

Practical Tasks

There are many practical jobs that need to be done at the end of life—both to relieve the dying person and to support the caregiver. Everyday tasks can be a source of worry for someone who is dying, and they can overwhelm a caregiver. Taking over small daily chores around the house—such as answering the door, picking up the mail or newspaper, writing down phone messages, doing a load of laundry, feeding the family pet, taking children to soccer practice, picking medicine up from the pharmacy—can provide a much needed break for caregivers.


A dying person might be worried about who will take care of things when he or she is gone. Offering reassurance—“I’ll make sure your African violets are watered,” “Jessica has promised to take care of Bandit,” “Dad, we want Mom to live with us from now on”—might provide a measure of peace. Reminding the dying person that his or her personal affairs are in good hands can also bring comfort.
Everyone may be asking the family “What can I do for you?” It helps to make a specific offer. Say to the family “Let me help with ...” and suggest something like bringing meals for the caregivers, paying bills, walking the dog, or babysitting. If you’re not sure what to offer, talk to someone who has been through a similar situation. Find out what kind of help was useful. If you want to help, but can’t get away from your own home, you could schedule other friends or family to help with small jobs or to bring in meals. This can allow the immediate family to give their full attention to the dying person.


If you are the primary caregiver, try to ask for help when you need it. Don’t hesitate to suggest a specific task to someone who offers to help. Friends and family are probably anxious to do something for you and/or the person who is dying, but they may be reluctant to repeatedly offer when you are so busy.


Setting up a phone tree or computer listserv for the family to contact friends and other relatives can reduce the number of calls to the house. A listserv is a way to send the same message to a large group of people through email. Some families set up a website where they can share news, thoughts, and wishes. These can all save close family members from the emotional burden of answering frequent questions about how their loved one is doing.

Questions to Ask

This section has described what family and friends can do to provide comfort and ease to someone nearing the end of life. Here are some questions to help you learn more about what you might do.
Ask the doctor in charge:

  • Since there is no cure, what will happen next?
  • Why are you suggesting this test or treatment?
  • Will the treatment bring physical comfort?
  • Will the treatment speed up or slow down the dying process?
  • What can we expect to happen in the coming days or weeks?

Ask the caregiver:

  • How are you doing? Do you need someone to talk with?
  • Would you like to go out for an hour or two? I could stay here while you are away.
  • Who has offered to help you? Do you want me to work with them to coordinate our efforts?
  • Can I help, maybe … walk the dog, answer the phone, go to the drug store or the grocery store, or watch the children (for example)…for you?

Finding Care At the End of Life

Decades ago, most people died at home, but medical advances have changed that. Today, most Americans are in hospitals or nursing homes at the end of their lives. Some people enter the hospital to get treated for an illness. Increasingly, people are choosing hospice care at the end of life.
There is no "right" place to die. And, of course, where we die is not usually something we get to decide. But, if given the choice, each person and/or his or her family should consider which type of care makes the most sense, where that kind of care can be provided, whether family and friends are available to help, and, of course, how they will manage the cost.

HOSPITALS AND NURSING HOMES

George is sixty-four and has a history of congestive heart failure. One night he is taken to the hospital with chest pain. George and those closest to him had previously decided that, no matter what, the doctor should try to do everything medically possible to extend George's life. So, when George needed care, he went to a hospital, where doctors and nurses are available around-the-clock. Hospitals offer a full range of treatment choices, tests, and other medical care. If George's heart continues to fail, the hospital intensive care unit (ICU) or coronary care unit (CCU) is right there. Although hospitals have rules, they can sometimes be flexible. If George's doctor thinks he is not responding to treatment and is dying, the family can ask for relaxed visiting hours. If George's family wants to bring personal items from home, they can ask the staff if there are space limitations or if disinfection is needed. Whether George is in the ICU, CCU, or a two-bed room, his family can ask for more privacy.


In a hospital setting, there is always medical staff available who know what needs to be done for someone who is dying. This can be very reassuring for that person, as well as for family and friends.

Who pays for care at the end of life?

How to pay for care at the end of life depends on the type and place of care and the kind of insurance. Medicare, Medicaid, private medical insurance, long-term care insurance, Veterans Health Administration (if VA-eligible), or the patient and his or her family are common sources of payment.

More and more people are in nursing homes at the end of life. In a nursing home, nursing staff is also always present. A nursing home, sometimes called a skilled nursing facility, has advantages and disadvantages for end-of-life care. Unlike a hospital, a doctor is not in the nursing home all the time. But, plans for end-of-life care can be arranged ahead of time, so that when the time comes, care can be provided as needed without first consulting a doctor. If the dying person has lived in the facility for a while, the staff and family have probably already established a relationship. This can make the care feel more personalized than in a hospital. As in a hospital, privacy may be an issue. You can ask if arrangements can be made to give your family more time alone when needed.

The doctor wants to move my relative to the ICU. What can we expect?

The ICU (intensive care unit) and CCU (coronary care unit) are types of critical care units; that is, they are parts of a hospital where more seriously ill patients can benefit from specially-trained staff that have quick access to advanced equipment. The medical staff in ICUs and CCUs closely monitor and care for a small number of patients. Doctors who work in these units are called intensivists.


Patients in the ICU or CCU are often connected to monitors that check breathing, heart rate, pulse, blood pressure, and oxygen levels. An IV (intravenous) tube may supply medicines, fluids, and/or nutrition. Another tube called a Foley catheter may take urine out of the body; a tube through the nose or stomach area may provide nutrition and remove unwanted fluids. A breathing tube through the mouth or trachea (windpipe) may be attached to a ventilator or respirator to help with breathing. Often these external supports—designed to be used for a short time—will maintain vital functions while the body heals.


But sometimes, even with intensive care, the body can't heal, and organs start to fail. When this happens, survival is unlikely. In this case, the health care team might talk to the family—and the patient if he or she is conscious—about considering whether or not to continue intensive treatment.

HOME

Home is likely the most familiar setting for someone who needs end-of-life care. Family and friends can come and go freely.can be a big job for family and friends—physically, emotionally, and financially. But, there are benefits too, and it is often a job they are willing to take on. Hiring a home nurse is an option for people who need additional help.


In order to make comfort care available at home, you will have to arrange for services (such as visiting nurses) and special equipment (like a hospital bed or bedside commode). Health insurance might only cover these services or equipment if they have been ordered by a doctor. Work with the doctor to decide what is needed to support comfort care at home. If the dying person is returning home from the hospital, sometimes a hospital discharge planner, often a social worker, can help with the planning. Your local Area Agency on Aging might be able to recommend other sources of help .


A doctor has to be available to oversee the patient's care at home—he or she will arrange for new services, adjust treatment, and order medicines as needed. It is important to follow the doctor's plan in order to make the dying person as comfortable as possible. Talk with the doctor if you think a treatment is no longer helping.

PALLIATIVE CARE AND HOSPICE

Doctors can provide treatment to seriously ill patients in the hopes of a cure for as long as possible. These patients also receive symptom care or palliative care. For example, in time George developed anemia along with his heart failure. Managing the anemia can improve some of the symptoms troubling George. It might also make it easier for him to do things like get dressed or bathe on his own. Treating his anemia is part of palliative care.


Recently, the term palliative care has come to mean more than just treating symptoms. In the United States, palliative care now often refers to a comprehensive approach to improving the quality of life for people who are living with potentially fatal diseases. It provides support for family members, very similar to the more familiar concept of hospice care.


In a palliative care program, a multidisciplinary health care team works with both the patient and family to provide any support—medical, social, and emotional—needed to live with a possibly fatal illness. The health care team may be made up of doctors, nurses, therapists, counselors, social workers, and others as needed.


Palliative care can be provided in hospitals, nursing homes, outpatient palliative care clinics, certain other specialized clinics, or at home. Medicare covers some of the treatments and medicine. Veterans may be eligible for palliative care through the Department of Veterans Affairs. Private health insurance might pay for some services. Health insurance providers can answer questions about what they will cover.

Who can benefit from palliative care?

Palliative care is not just for people who might die soon. It is a resource for anyone with a long-term disease that will, in time, probably cause their death. These include heart failure, chronic obstructive pulmonary disease, or Parkinson's disease. The organized services available through palliative care could also be helpful to any older person having a lot of general discomfort and disability very late in life.

In palliative care, you aren't asked to make a choice between treatment that might cure a terminal disease and comfort care. In time, if the doctor believes the patient is not responding to treatment and is likely to die within 6 months, there are two possibilities. Palliative care could transition to hospice care. Or, the palliative care could continue, with increasing emphasis on comfort care and less focus on medical treatment aimed at a cure.
That is what happened with Jack, retired from the U.S. Air Force, who was diagnosed with disease at age seventy. As the disease progressed and breathing became more difficult, Jack wanted to explore experimental treatments to slow the disease. Through the palliative care provided by the Veterans Health Administration, while receiving treatment for his pulmonary disease, Jack was also able to receive the comfort care and emotional support he needed to cope with his health problems. The palliative care program also provided help around the house and other support for Jack's wife, making it easier for her to care for Jack at home.


At some point, curative medical treatment may no longer make sense—it might not help or may actually make the patient more uncomfortable. Hospice is designed for this situation. The patient beginning hospice care understands that his or her illness is not responding to medical attempts to cure it or to slow the disease's progress. The hospice approach to end-of-life care is similar to palliative care, in that it provides comprehensive comfort care to the dying person as well as support to his or her family, but, in hospice, attempts to cure the person's illness are stopped.


Hospice is an approach to care, and so it is not tied to a specific place. It can be offered in two types of settings—at home or in a facility such as a nursing home, hospital, or even in a separate hospice center. Hospice care brings together a team of people with special skills—among them nurses, doctors, social workers, spiritual advisors, and trained volunteers. Everyone works together with the person who is dying, the caregiver, and/or the family to provide the medical, emotional, and spiritual support needed. A member of the hospice team visits regularly and is always available by phone—24 hours a day, 7 days a week.


It is important to remember that stopping treatment specifically aimed at curing an illness does not mean discontinuing all treatment. A good example is cancer. If the doctor determines that the cancer is not responding to chemotherapy and the patient chooses to enter into hospice care, then the chemotherapy will stop, but other medical care may continue. For example, if the person has, he or she will still get medicine for that.
Choosing hospice does not have to be a permanent decision. For example, Delores was eighty-two when she learned that her kidneys fail. She thought that she had lived a long, good life and didn't want to go through dialysis, so Delores began hospice care. A week later she learned that her granddaughter was pregnant. Delores changed her mind about using hospice care and left to begin dialysis in the hopes of one day holding her first great-grandchild.


Similar to Delores, real-life humorist and Washington Post columnist Art Buchwald, age eighty-one, decided against the kidney dialysis suggested by his doctor. Buchwald entered hospice in February 2006, expecting to die of kidney disease within a few weeks. It was big news when his condition stabilized. When it became clear death was not imminent, Buchwald left hospice. He spent the summer in Martha's Vineyard and died in January 2007.


Some Differences Between Palliative Care and Hospice

 

Palliative Care

Hospice

Who can be treated?

Anyone with a serious illness

Anyone with a serious illness whom doctors think has only a short time to live, often less than 6 months

Will my symptoms be relieved?

Yes, as much as possible

Yes, as much as possible

Can I continue to receive treatments to cure my illness?

Yes, if you wish

No, only symptom relief will be provided

Will Medicare pay?

It depends on your benefits and treatment plan

Yes, it pays all hospice charges

Does private insurance pay?

It depends on the plan

It depends on the plan

How long will I be cared for?

This depends on what care you need and your insurance plan

As long as you meet the hospice's criteria of an illness with a life expectancy of months, not years

Where will I receive this care?

  • Home
  • Assisted living facility
  • Nursing home
  • Hospital
  • Home
  • Assisted living facility
  • Nursing home
  • Hospice facility
  • Hospital

Copyright © National Hospice and Palliative Care Organization. All rights reserved. Reproduction and distribution by an organization or organized group without the written permission of the National Hospice and Palliative Care Organization are expressly forbidden.

Art Buchwald on leaving the hospice:

  • I maintained everyone has to die—I still do. The hospice gives a person the opportunity to die with dignity. It provides care, help, and as much comfort as possible.
  • In spite of the fact that I've been staying in a hospice, I'm not going to heaven immediately. My doctor informs me that I can stop over on Martha's Vineyard on the way there.

Art Buchwald, Too Soon to Say Goodbye (New York:  Random House, 2006).

Eighty-year-old Annie had advanced cancer and asked for help through a hospice program, so she could stay in the home she had lived in for more than 40 years. A hospice team helped her family and friends with caregiving and everyday activities. Annie's family arranged respite care—once she went into a facility for a few days to give her husband a break. Respite care can be for as short as a few hours or for as long as several weeks. After Annie died, hospice continued to support her family offering bereavement counseling for a year.
Hospice care was a relief for Annie who didn't want to be a burden to her relatives in her last days. Hospice services also greatly reduced the stress of caregiving for Annie's family. In fact, a widow or widower is less likely to die within 18 months after if that spouse received hospice services. This was true for Annie's husband who weathered the sadness of her loss without having his health decline. Families of people who received care through a hospice program are also more satisfied with end-of-life care than are those of people who did not have hospice services. Hospice recipients are more likely to have their pain controlled and less likely to undergo tests or be given medicines they don't need than people who don't use hospice care.


Before Annie died, she chose to receive hospice care and agreed to give up treatment, such as chemotherapy and radiation, to try to cure her lung cancer. But she continued to receive comfort care and counseling. If Annie had changed her mind, she could have left hospice care and received treatment for her cancer.

What does the hospice "6-month requirement" mean?

Some people misinterpret their doctor's suggestion to consider hospice. They think it means death is very near. But that's not always the case. Sometimes people don't begin hospice care soon enough to take full advantage of the help it offers. Perhaps they wait too long to begin hospice; they are too close to death. Or, some people are not eligible for hospice care soon enough to receive its full benefit. In the United States, older people can receive hospice care through Medicare if their health care provider thinks they have less than 6 months to live. Doctors have a hard time predicting how long an older, frail person will live. Health often declines slowly, and some people might need a lot of help with daily living for more than 6 months before they die. Talk to the doctor if you think a hospice program might be helpful. If he or she agrees, but thinks it is too soon for Medicare to cover the services, then you can investigate how to pay for the services that are needed.
What happens if someone under hospice care lives longer than 6 months? If the doctor continues to certify that that person is still close to dying, Medicare can continue to pay for hospice services. It is also possible to leave hospice care for a while and then later return if the health care provider still believes that the patient has less than 6 months to live.

Questions to Ask

Choosing among the different options for care at the end of life can be difficult. Here are some questions that might help you determine what is best for you and your family.

  • How long is this person expected to live?
  • What kind of end-of-life care is needed?
  • Is the most likely caregiver able to give that kind of care?
  • Where would the person who is dying want to have this end-of-life care—a facility or at home, for example?
  • What is the best place to get the type of care he or she wants?
  • Who will pay for this care?
  • Can we get help paying for respite care?
  • Can children, grandchildren, friends, pet, etc., visit whenever they want?
  • Is there a good chance that treatment in an intensive care unit will reverse the dying process, or instead draw it out?

Dementia At the End of Life


As they reach the end of life, people suffering from conditions like (AD) or Parkinson's disease can present special problems for caregivers. People live with these diseases for years, becoming increasingly disabled. Because they do not die soon after they are diagnosed, it can be hard to think of these as terminal diseases. But they do contribute to death.
Illnesses like Alzheimer's disease make it difficult for those who want to provide supportive care at the end of life to know what is needed. Because people with advanced  can no longer communicate, they cannot share their concerns. Is Uncle Bert refusing food because he is not hungry or because he's confused? Why does Grandma Ruth seem agitated? Is she in pain and needs medication to relieve it, but can't tell you?


As these conditions progress, they also obstruct efforts to provide emotional or spiritual comfort. How can you let Grandpa know how much his life has meant to you? How do you make peace with your mother if she no longer knows who you are? Someone who has might not take spiritual comfort from sharing family memories or understand when others express what an important part of their life this person has been. Palliative care or hospice can be helpful in many ways to families of people with dementia.
Sensory connections—targeting someone's senses, like hearing, touch, or sight—can bring comfort to people with Alzheimer's disease. Being touched or massaged and listening to music, "white" noise, or sounds from nature seem to soothe some people and lessen their agitation.


When an illness like Alzheimer's disease is first diagnosed, if everyone understands that there is no cure, then can be made before thinking and speaking abilities fail and people can no longer legally complete documents like . That didn't happen in Ethel's family. She had been forgetful for years, but even after her family knew that AD was the cause of her forgetfulness, they never talked about what the future would bring. As time passed and the disease eroded Ethel's memory and her ability to think and speak, she became less and less able to share her concerns and desires with those close to her. This made it hard for her daughter Barbara to know what Ethel needed or wanted. Barbara's decisions, therefore, had to be based on what she knew about her mom's values and priorities, rather than on what Ethel actually said she would like.


Quality of life is an important issue when making health care decisions for people with Alzheimer's disease. For example, there are that might slow the progression of this devastating disease for a short time in some patients, generally early in the illness. However, in more advanced AD, some caregivers might not want these drugs prescribed. They may believe that the quality of life is already so diminished and that the medicine is unlikely to make a difference. If the drug has serious side effects, they are even more likely to decide against it.
End-of-life care decisions are more complicated for caregivers if the dying person has not expressed the kind of end-of-life care he or she would prefer. Someone might not be able to imagine the later stages of the disease. Ethel was like that. She and Barbara never talked about things like feeding tubes, machines that help with breathing, antibiotics for pneumonia, or transfers to the hospital. So when doctors raised some of these questions, Barbara didn't know how to best reflect her mother's wishes. When making care decisions for someone else near the end of life, it is important to consider how a treatment will benefit the person and what the side effects and risks might be. Sometimes you might decide to try the health care team's suggestion for a short time. Other times you might decide that the best choice is to do nothing.
Alzheimer's disease and similar conditions often progress slowly and unpredictably. Experts suggest that signs of the final stage of Alzheimer's disease include some of the following:

  • Being unable to move around on one's own
  • Being unable to speak or make oneself understood
  • Needing help with most, if not all, daily activities
  • Eating problems such as difficulty swallowing or no appetite

Because of their unique experience with what happens at the end of life, hospice and palliative care experts might also be of help identifying when someone in the final stage of Alzheimer's disease is beginning to die.


Caring for people with Alzheimer's disease at home can be demanding and stressful for the family caregiver. Depression is a problem for some family caregivers, as is fatigue, because many feel they are always "on call." More than half of one group of family caregivers reported cutting back on work hours or giving up their jobs because of the demands of caregiving. Most of those family members taking care of dying Alzheimer's disease patients at home expressed relief when death happened—for themselves and for the person who died. It is important to realize such feelings are normal. Hospice—whether used at home or in a facility—gives family caregivers needed support near the end of life, as well as help with their grief, both before and after their family member dies.
Questions to Ask
You will want to understand how the available medical options presented by the health care team fit into your family's particular needs. You might want to ask questions such as:

  • How will the approach the doctor is suggesting affect your relative's quality of life? Will it make a difference?
  • If considering hospice for your relative with Alzheimer's disease, does the facility have special experience with people with dementia?

Understanding Health Care Decisions
It can be overwhelming to be asked to make health care decisions for someone who is dying and no longer able to make his or her own decisions. It is even more difficult if you do not have written or even verbal guidance. How do you decide what type of care is right for someone? Even when you have written documents, some decisions still might not be clear.


Two approaches might be useful. One is to put yourself in the place of the person who is dying and try to choose as he or she would. That is called substituted judgment. Sheila's ninety-year-old mother. The doctor said damage to Esther's brain was widespread and she needed to be put on a breathing machine (ventilator) or she would probably die. The doctor asked Sheila if she wanted that to be done. Sheila remembered how her mother disapproved when an elderly neighbor was put on a similar machine after a stroke. She decided to say no, and her mother died peacefully a few hours later. Some experts believe that decisions should be based on substituted judgment whenever possible, but decision-makers sometimes combine that with another method.


The other approach, known as best interests, is to decide what would be best for the dying person. Jim's father, Sam, is eighty and has lung cancer, as well as advanced Parkinson's disease. He is in a nursing facility and doesn't seem to recognize Jim when he visits. Sam's doctor suggested that surgery to remove part of a lung might slow down the course of the cancer and give Sam more time. But, Jim thought, "What kind of time? What would that time do for Dad?" Jim decided that putting his dad through surgery and recovery was not in Sam's best interests.


If you are making decisions for someone at the end of life and trying to use one of these approaches, it may be helpful to think about the following:

  • Has the dying person ever talked about what he or she would want at the end of life?
  • Has he or she expressed an opinion about how someone else was being treated?
  • What were his or her values in life? What gave meaning to life? Maybe it was being close to family—watching them grow and making memories together. Perhaps just being alive was the most important thing.

As a decision-maker without specific guidance from the dying person, you need as much information as possible on which to base your actions. You might ask the doctor:

  • What can we expect to happen in the next few hours, days, or weeks?
  • Why is this new test being suggested?
  • Will it change the current treatment plan?
  • Will a new treatment help my relative get better?
  • How would the new treatment change his or her quality of life?
  • Will it give more quality time with family and friends?
  • How long will this treatment take to make a difference?
  • If we choose to try this treatment, can we stop it at any time? For any reason?
  • What are the side effects of the approach you are suggesting?
  • If we try this new treatment and it doesn't work, what then?
  • If we don't try this treatment, what will happen?
  • Is the improvement we saw today an overall positive sign or just something temporary?

It is a good idea to have someone with you when with medical staff. Having someone take notes or remember details can be very useful during this emotional time. If you are unclear about something you are told, don't be afraid to ask the doctor or nurse to repeat it or to say it another way that does make sense to you. Do not be reluctant to keep asking questions until you have all the information you need to make decisions. Make sure you know how to contact a member of the medical team if you have a question or if the dying person needs something. You may want to get pager numbers, email, or cell phone numbers.


Sometimes the whole family wants to be involved in every decision. Maybe that is the family's cultural tradition. Or, maybe the person dying did not pick one person to make health care choices before becoming unable to do so. That is not unusual, but it is probably a good idea to choose one person to be the spokesperson and the contact person when dealing with medical staff. The doctor and nurses will appreciate answering questions from only one person. Even if one family member is named as the decision-maker, it is a good idea, as much as possible, to have family agreement about the care plan. If you can't agree on a care plan, a decision-maker, or even a spokesperson, the family might need to hire a mediator, someone trained to bring people with different opinions to a common decision. In any case, as soon as possible after the doctor says the patient is dying, the family should try to discuss with the medical team what approach to end-of-life care they want for their family member. That way, decision making for crucial situations can be planned and does not have to be done quickly.


ISSUES YOU MAY FACE


Maybe you are now faced with making end-of-life choices for someone close to you. You've thought about that person's values and opinions, and you've asked the health care team to explain the treatment plan and what you can expect to happen. But there are other issues that you need to understand in case they arise. What if the dying person starts to have trouble breathing and a doctor says a ventilator might be needed? Maybe one family member wants the health care team to "do everything" to keep this relative alive. What does that involve? Or, what if family members can't agree on end-of-life care, or they disagree with the doctor? What happens then?
Here are some common end-of-life issues like those—they will give you a general understanding and may help in your conversations with the doctors.


If we say "do everything," what does that mean? This means that if someone is dying, all measures that might keep vital organs working will be tried—for example, using a machine to help with breathing (ventilator) or starting dialysis for failing kidneys. Such life support can sometimes be a temporary measure that allows the body to heal itself and begin to work normally again. It is not intended to be used indefinitely in someone who is dying. "Doing everything" does not include medical treatments intended to cure a medical condition, such as surgery or chemotherapy.


What can be done if someone's heart stops beating (cardiac arrest)? CPR (cardiopulmonary resuscitation) can sometimes restart a stopped heart. It is most effective in people who were generally healthy before their heart stopped. In CPR, the doctor repeatedly pushes on the chest with great force and periodically puts air into the lungs. Electric shocks (called defibrillation) may also be used to restart the heart, and some medicines might also be given. Although not usually shown on television, the force required for CPR can cause broken ribs or a collapsed lung. Often, CPR does not succeed, especially in an elderly person who is already failing.


What if someone needs help breathing or completely stops breathing (respiratory arrest)? Sometimes doctors suggest using a ventilator (a respirator or breathing machine)—the machine forces the lungs to work. Initially, this involves intubation, putting a tube attached to a ventilator down the throat into the trachea or windpipe. Because this tube can be quite uncomfortable, people are often sedated. If the person needs ventilator support for more than a few days, the doctor will probably suggest a tracheotomy, sometimes called a "trach" (rhymes with "make"). This tube is then attached to the ventilator. This is more comfortable than a tube down the throat and may not require sedation. Inserting the tube into the trachea is a bedside surgery. A tracheotomy can carry risks, including collapsed lung, plugged tracheotomy tube, or bleeding.


How can I be sure the medical staff knows that we don't want efforts to restore a heart beat or breathing? As soon as the decision that medical staff should not do CPR or other life-support procedures is made by the patient or the person making health care decisions, the doctor-in-charge should be told of this choice. The doctor will then write this on the patient's chart using terms such as DNR (Do Not Resuscitate), DNAR (Do Not Attempt to Resuscitate), or DNI (Do Not Intubate). If end-of-life care is given at home, a special "non-hospital DNR," signed by a doctor, is needed. This ensures that if emergency medical technicians (EMTs) are called to the house, they will respect your wishes. Without a non-hospital DNR, in many places EMTs are required to perform CPR and similar techniques when called to a home. Hospice staff can help determine whether a medical condition is part of the normal dying process or something that needs the attention of EMTs. DNR orders do not stop all treatment. They only mean that CPR and a ventilator will not be used. These orders are not permanent—they can be changed if the situation changes.


What about pacemakers (or similar devices)—should they be turned off? A pacemaker is a device implanted under the skin on the chest that keeps a heartbeat regular. It will not keep a dying person alive. Some people have an implantable cardioverter defibrillator (ICD) under the skin. This is a pacemaker that also shocks the heart back into regular beats when needed. The ICD should be turned off at the point when life support is no longer wanted. This can be done without surgery.


What if the doctor suggests a feeding tube? If a patient can't or won't eat or drink, even when spoon fed, the doctor might suggest a feeding tube. While recovering from an illness, a feeding tube can be helpful. But at the end of life, a feeding tube might cause more discomfort than not eating. As death approaches, loss of appetite is common. Body systems start shutting down, and fluids and food are not needed as before. Some experts believe that at this point few nutrients are absorbed from any type of nutrition, including that received through a feeding tube.


If tube feeding is going to be tried, there are two methods that can be used. In the first, a feeding tube, known as a nasogastric or NG tube, is threaded through the nose down to the stomach to give nutrition for a short time. Sometimes the tube is uncomfortable. If so, the doctor might try a smaller, child-sized tube. Someone with an NG tube might try to remove it. This usually means the person has to be restrained, which could mean binding his or her hands to the bed. If tube feeding is required for an extended time, then a gastric or G tube is put directly into the stomach through an opening made in the side or abdomen. This second method is also called a PEG tube for percutaneous endoscopic gastrostomy tube. These carry risks of infection, pneumonia, and nausea.

Some people try tube feeding for a short time to see if it makes a difference, while keeping open the option of removing the tube if there is no improvement. Talk to the doctor about how the feeding tube could help and how long it makes sense to try it.


Refusing food might be a conscious decision—a part of the dying person's understanding that death is near. The decision-maker should think carefully about doing something that might be against the dying person's wishes.


Should someone dying be sedated? Sometimes very near the end of life, the doctor might suggest sedation to manage symptoms that are not responding to treatment and still make the patient uncomfortable. This means using medicines to put the patient in a sleep-like state. Sedation doesn't cause a person to die more quickly. Many doctors suggest continuing to use comfort care measures like pain medicine even if the dying person is sedated. Sedatives can be stopped at any time. A person who is sedated may still be able to hear what you are saying—so try to keep speaking directly to, not about, him or her. Do not say things you would not want the patient to hear.
What about antibiotics? Antibiotics are medicines that fight infections caused by bacteria. Lower respiratory infections, such as , are often caused by bacteria and are common in older people who are dying. If someone is already dying when the infection began, giving antibiotics is probably not going to prevent death but might make the person feel more comfortable. Tom was eighty-three and had lived in a nursing home for several years with advanced Parkinson's disease when he choked on some food causing him to inhale a small amount into his lungs. As a result, Tom developed aspiration pneumonia. The doctors assured his wife that they could keep Tom comfortable without antibiotics, but she wanted them to try treating his pneumonia. He died a few days later despite their efforts.
Is refusing treatment legal? Choosing to stop treatment that is not curing or controlling an illness or deciding not to start a new treatment is completely legal—whether the choice is made by someone who is dying or by the one making health care decisions. Some people think this is like allowing death to happen. The law does not consider refusing such treatment to be either suicide or euthanasia, sometimes called "mercy killing."


What happens if the doctor and I have different opinions about care for someone who is dying? Sometimes medical staff, the patient, and family members disagree about a medical care decision. This can especially be a problem when the dying person can't tell the doctors what kind of end-of-life care he or she wants. For example, the family might want more active treatment, like chemotherapy, than the doctors think will be helpful. If there is an advance directive explaining the patient's preferences, those guidelines should determine care. Without the guidance of an advance directive, if there is disagreement about medical care, it may be necessary to get a second opinion from a different doctor or to consult the ethics committee or patient representative, also known as an ombudsman, of the hospital or facility. An arbitrator (mediator) can sometimes assist people with different views to agree on a plan.


The doctor does not seem familiar with our family's views about dying. What should we do? America is a rich melting pot of religions, races, and cultures. Ingrained in each tradition are expectations about what should happen as a life nears its end. It is important for everyone involved in a patient's care to understand how each family background may alter expectations, needs, and choices. You may come from a different background than the doctor you are working with. You might be used to a different approach to talking about what is happening or making health care decisions at the end of life than the medical staff is. For example, many health care providers look to a single person—the dying person or his or her chosen representative—for important health care decisions at the end of life. But, in some cultures the entire immediate family takes on that role, something American doctors might not expect. It is helpful to discuss your personal and family traditions with your doctors and nurses. Don't be reluctant to say what you want. Each person—each family—is entitled to the end-of-life care that best matches their beliefs and rituals. Make sure you understand how the available medical options presented by the health care team fit into your family's desires for end-of-life care.


If there are religious or cultural customs surrounding death that are important to you, tell the health care providers with whom you are working. Knowing that these practices will be honored could ease the dying person. Telling the medical staff ahead of time may also help avoid confusion and misunderstanding when death occurs.


Questions to Ask


Here are some examples of the kinds of questions you might want to ask the medical staff caring for the dying person:

  • What is the care plan?
  • If we try using the ventilator to help with breathing and decide to stop, how will that be done?
  • If we try the treatment plan you are suggesting and then decide to stop, what will happen?
  • If my family member is dying, why does he or she have to be connected to all those tubes and machines? Why do we need more tests?
  • What is the best way for our family to work with the care staff?
  • How can I make sure I get a daily update on my family member's condition?
  • Will you call me if there is a change in his or her condition?

Things to Share
Make sure the health care team knows what is important to your family surrounding the end of life. You might say:

  • In my religion, we … (then describe your religious traditions regarding death).
  • Where we come from … (tell what customs are important to you at the time of death).
  • In our family when someone is dying, we prefer … (describe what you hope to have happen).

What Happens When Someone Dies

When death comes suddenly, there is little time to prepare. On the other hand, watching an older person become increasingly frail may mean that it's hard to know when the end of life begins because changes can happen so slowly. But if you do know death is approaching and understand what will happen, then you do have a chance to plan. Listen carefully to what doctors and nurses are saying. They may be suggesting that death could be soon.

Should there always be someone in the room with a dying person?

Staying close to someone who is dying is often called "keeping a vigil." It can be comforting for the caregiver to always be there, but it can also be tiring and stressful. Unless your cultural or religious traditions require it, do not feel that you must stay with the person all the time. You need to eat and rest. If there are other family members or friends around, try taking turns sitting in the room. Some people almost seem to "prefer" to die alone. They appear to slip away just when visitors leave. Of course, experts have no way to prove that's what happened.

Just as each life is unique, so is each death. But, there are some common experiences very near the end:

  • Shortness of breath, known as dyspnea
  • Depression
  • Anxiety
  • Tiredness and sleepiness
  • Mental confusion
  • Constipation or incontinence
  • Nausea
  • Refusal to eat or drink

Each of these symptoms, taken alone, is not a sign that someone is dying. But, for someone with a serious illness or declining health, these might suggest that that person is nearing the end of life.


In addition, closer to death, the hands, arms, feet, or legs may be cool to the touch. Some parts of the body may become darker or blue-colored. Breathing and heart rates may slow. In fact, there may be times when the person doesn't breathe for many seconds, known as Cheyne-Stokes breathing. Some people hear a death rattle. That is noisy breathing that makes a gurgling or rattling sound. Finally, the chest stops moving, no air comes out of the nose, and there is no pulse. Eyes that are open can seem glassy.


After death, there may still be a few shudders or movements of the arms or legs. There could even be an uncontrolled cry because of muscle movement in the voice box. Sometimes there will be a release of urine or stool, but usually only a small amount since so little has probably been eaten in the last days of life.

Calling 911 or not?

When there is a medical emergency, such as a heart attack, stroke, or serious accident, we know to call 911. But if a person is dying at home and does not want CPR, calling 911 is not necessary. In fact, a call to 911 could cause confusion. Many places require EMTs (emergency medical technicians) who respond to 911 calls to perform CPR if someone's heart has stopped. Consider having a "non-hospital DNR".

Things to Do After Someone Dies

Immediately following death, nothing has to be done. Take the time you need to start the grieving process. Some people want to stay in the room with the body; others prefer to leave. You might want to have someone make sure the body is lying flat before the joints become stiff and cannot be moved. This rigor mortis begins sometime during the first hours after death.


After the death, how long you can stay with the body may depend on where death happens. If it is at home, there is no need to move the body right away. If your religious, ethnic, or cultural background requires any special customs soon after death, there should be time for that now. If the death is likely to happen in a facility, such as a hospital or nursing home, discuss any important customs or rituals with the staff early on, if possible. That will allow them to plan so that you can have the appropriate time with the body.


Some families want time to sit quietly with the body, console each other, and maybe share memories. You could ask a member of your religious community or a spiritual counselor to come. If you have a list of people to notify, this is the time to call those who might want to come and see the body before it is moved.


As soon as possible, the death must be "pronounced" by someone in authority like a doctor in a hospital or nursing facility or a hospice nurse. This person also fills out the forms certifying the cause, time, and place of death. These steps will make it possible for an official death certificate to be prepared. This legal form is necessary for many reasons, including life insurance and financial and property issues. If hospice is helping, a plan for what happens after death is already in place. If death happens at home without hospice, try to talk with the doctor, local medical examiner (coroner), your local health department, or a funeral home representative in advance about how to proceed.
Arrangements should be made to pick up the body as soon as the family is ready. Usually this is done by a funeral home. The hospital or nursing facility, if that is where death takes place, may call the funeral home for you. If at home, you will need to contact the funeral home directly or ask a friend or family member to do that for you.


The doctor may ask if you want an autopsy. This is a medical procedure conducted by a specially-trained physician to learn more about what caused death. For example, if the person who died was believed to have Alzheimer's disease, a brain autopsy will allow for a definitive diagnosis. If your religion or culture objects to autopsies, talk to the doctor. Some people planning a funeral with a viewing worry about having an autopsy, but the physical signs of an autopsy are usually hidden by clothing.

What about organ donation?

At some time before death or right after it, the doctor may ask about donating organs such as the heart, lungs, pancreas, kidneys, cornea, liver, and skin. Organ donation allows healthy organs from someone who dies to be transplanted into living people who need them. People of any age can be an organ donor. The person who is dying may have already indicated they would like to be an organ donor. Some states include it on the driver's license. If not, the decision has to be made quickly. There is no cost to the donor's family for this "gift of life." If the person has requested a do-not-resuscitate (DNR) order, but wants to donate organs, he or she might have to indicate that the desire to donate supersedes the DNR. That is because it might be necessary to use machines to keep the heart beating until the medical staff is ready to use the donated organs.

Getting Help For Your Grief

Losing someone close to you can make you feel sad, lost, alone, and maybe even angry. You greatly miss the person who has died—you want them back. You might have also been so busy with caregiving that it now seems you have nothing to do. This can add to your feelings of loss. This is all part of grieving, a normal reaction to the loss of someone you love.


There are many ways to grieve and to learn to accept this loss. Try not to ignore your grief. Support may be available until you can manage your grief on your own. It is especially important to get help with your loss if you feel overwhelmed, consumed, or very depressed by it.
Family and friends can be a great support. They are grieving too, and some people find that sharing memories is one way you can help each other. Feel free to talk about the one who is gone. Sometimes people hesitate to bring up the loss or mention the dead person's name as they worry this can be hurtful. But everyone may find it helpful to talk directly about their loss. Shortly after Carol's husband Doug died, her friends started coming over with dinners as well as memories to share. They would sit around Carol's dining table for hours remembering Doug's humor and kindness. Soon Doug's friends were joining them with their own recollections. It was so like old times that it almost seemed Doug had just stepped out of the room. Those evenings together helped Carol, as well as the others, start to heal after their loss.


Sometimes people find grief counseling makes it easier to work through their sorrow. There are grief counselors who will talk with you one-on-one. Regular talk therapy can help people learn to accept a death and, in time, create a new life. There are also support groups where grieving people help each other. These groups can be specialized—parents who have lost children or for example—or they can be just generally for anyone learning to manage grief. Check with religious groups, a local hospital, hospice groups, or your doctor to find support groups in your area.
An essential part of hospice is providing grief counseling to the family of someone who was under their care. Even if hospice was not used before the death, you can ask hospice workers for bereavement support at this time. If the death happened at a nursing home or hospital, there is often a social worker you can ask for resources that can help. The funeral home might also be able to suggest where you can find counseling.
Remember to take good care of yourself. You might know that grief affects how you feel emotionally, but you may not realize that it can also have physical effects. The stress of the death and your grief could even make you sick. Eat well, get enough sleep, and get back to doing things you used to enjoy, like going to the movies, walking, or reading. Accept offers of help or companionship from friends and family. It's good for you and for them.

Let major decisions wait, if possible.

Try to delay major life decisions until you are feeling better. You don't want to decide to make a big change like selling your home or leaving your job when you are grieving and perhaps not thinking clearly.

Planning for End-of-Life Care Decisions

Because of advances in medicine, each of us, as well as our families and friends, may face many decisions about the dying process. As hard as it might be to face the idea of your own death, you might take time to consider how your individual values relate to your idea of a good death. By deciding what end-of-life care best suits your needs when you are healthy, you can help those close to you make the right choices when the time comes. This not only respects your values, but also allows those closest to you the comfort of feeling as though they can be helpful.


There are several ways to make sure others know the kind of care you want when dying.

TALKING ABOUT END-OF-LIFE WISHES

The simplest, but not always the easiest, way is to talk about end-of-life care before an illness. Discussing your thoughts, values, and desires will help people who are close to you to know what end-of-life care you want. For example, you could discuss how you feel about using life-prolonging measures or where you would like to be cared for. For some people, it makes sense to bring this up at a small family gathering. Others may find that telling their family they have made a will (or updated an existing one) provides an opportunity to bring up this subject with other family members. Doctors should be told about these wishes as well. As hard as it might be to talk about your end-of-life wishes, knowing your preferences ahead of time can make decision making easier for your family. You may also have some comfort knowing that your family can choose what you want.


On the other hand, if your parents are aging and you are concerned about what they want, you might introduce the subject. You can try to explain that having this conversation will help you care for them and do what they want. You might start by talking about what you think their values are, instead of talking about specific treatments. Try saying something like, “when Uncle Walt had a stroke and died, I thought you seemed upset that his kids wanted to put him on a respirator.” Or, “I’ve always wondered why Grandpa didn’t die at home. Do you know?” Encourage your parents to share the type of care they would choose to have at the end of life, rather than what they don’t want. There is no right or wrong plan, only what they would like. If they are reluctant to have this conversation, don’t force it, but try to bring it up again at a later time.

ADVANCE DIRECTIVES AND OTHER DOCUMENTS

Written instructions letting others know the type of care you want if you are seriously ill or dying are called advance directives. These include a living will and health care power of attorney. A living will records your end-of-life care wishes in case you are no longer able to speak for yourself. You might want to talk with your doctor or other health care provider before preparing a living will. That way you will have a better understanding of what types of decisions might need to be made. Make sure your doctor and family have seen your living will and understand your instructions.


Because a living will cannot give guidance for every possible situation, you probably want to name someone to make care decisions for you if you are unable to do so for yourself. You might choose a family member, friend, lawyer, or someone in your religious community. You can do this either in the advance directives or through a durable power of attorney for health care that names a health care proxy, who is also called a representative, surrogate, agent, or attorney-in-fact. “Durable” means it remains in effect even if you are unable to make decisions. A durable power of attorney for health care is useful if you don’t want to be specific—if you would rather let the health care proxy evaluate each situation or treatment option independently. A durable power of attorney for health care is also important if your health care proxy, the person you want to make choices for you, is not a legal member of your family. Of course, you should make sure the person and alternate(s) you have named understand your views about end-of-life care. If you don’t name someone, the state you live in probably has an order of priority based on family relationships to determine who decides for you. A few states let people name a health care proxy by telling their doctor, without paperwork.


Don’t confuse a durable power of attorney for health care with a durable power of attorney. The first is limited to decisions related to health care, while the latter covers decisions regarding property or financial matters.


A lawyer can prepare these papers, or you can do them yourself. Forms are available from your local or State government, from private groups, or on the Internet. Often these forms need to be witnessed. That means that people who are not related to you watch as you sign and date the paperwork and then sign and date it themselves as proof that the signature is indeed yours. Make sure you give copies to your primary doctor and your health care proxy. Have copies in your files as well. Hospitals might ask for a copy when you are admitted, even if you are not seriously ill.


Sometimes people change their mind as they get older or after they become ill. Review the decisions in your advance directives from time to time and make changes if your views or your health needs have changed. Be sure to discuss these changes with your health care proxy and your doctor. Replace all copies of the older version with the updated ones, witnessed and signed if appropriate.


You should also give permission to your doctors and insurance companies to share your personal information with your health care proxy. This lets that person discuss your case with your doctor and handle insurance issues that may come up.


Do you live in one state, but spend a lot of time in another? Maybe you live in the north and spend winter months in a southern state. Or possibly your children and grandchildren live in a different state and you visit them often. Because states’ rules and regulations may differ, make sure your forms are legal in both your home state and the state you travel to often. If not, make an advance directive with copies for that state also. And make sure your family there has a copy.

Closing Thoughts

Many Americans have little experience with someone who is dying. But, when the time comes, unless the death is unexpected and quick, there are choices to be made. These may not be easy. But planning ahead and working with the health care team can help you provide needed comfort.


You will probably remember for a long time what you do for someone who is dying. Realize that this is a difficult time for you too. Caring for someone at the end of life can be physically and emotionally exhausting. In the end, accept that there may be no perfect death, just the best you can do for the one you love. And the pain of losing someone close to you may be softened a little because, when they needed you, you did what you could.


REFERENCES AND RESOURCES

JOURNALS AND REFERENCES CITED:

AAGP, 2008: American Association for Geriatric Psychiatry. Geriatrics and mental health—the facts, 2008. Available at www.aagponline.org/prof/facts_mh.asp.
Beekman, 1997: Beekman AT, Deeg DJ, Braam AW, et al. Consequences of major and minor depression in later life: a study of disability, well-being and service utilization. Psychol Med 1997;27:1397–1409.
CDC, 2007: Centers for Disease Control and Prevention. Web-based injury statistics query and reporting system (WISQARS), National Center for Injury Prevention and Control, 2005. Available at http://www.cdc.gov/injury/wisqars/index.html.
CDC, 2008: Centers for Disease Control and Prevention and National Association of Chronic Disease Directors. The state of mental health and aging in America Issue Brief 1: what do the data tell us?, 2008. Available at http://apps.nccd.cdc.gov/MAHA/MahaHome.aspx.
CDC, 2009a: Centers for Disease Control and Prevention and National Association of Chronic Disease Directors. The state of mental health and aging in America Issue Brief 2: addressing depression in older adults: selected evidence-based programs, 2009. Available at http://apps.nccd.cdc.gov/MAHA/MahaHome.aspx.
CDC, 2009b: Centers for Disease Control and Prevention. Mean mentally unhealthy days: age group. Available at http://apps.nccd.cdc.gov/HRQOL/TrendV.asp?State=1&Category=3&Measure=3.
CDC, 2009c: Centers for Disease Control and Prevention, AARP, American Medical Association. Promoting preventive services for adults 50–64: community and clinical partnerships. Available at www.cdc.gov/aging.
Ciechanowski, 2004: Ciechanowski P, Wagner E, et al. Community-integrated home-based depression treatment in older adults: a randomized controlled trial. JAMA 2004;291:1569–77.
Frederick, 2007: Frederick JT, Steinman LE, et al. Community-based treatment of late life depression: an expert panel–informed literature review. Am J Prev Med 2007;33(3).
Freeman, 2010: Freeman EJ, Colpe LJ, et al. Public health surveillance for mental health. Prev Chronic Dis 2010;7(1). Available at www.cdc.gov/pcd/issues/2010/jan/09_0126.htm.
Gallo, 1999: Gallo JJ, Rabins PV. Depression without sadness: alternative presentations of depression in late life. Am Fam Physician 1999;60(3):820–6.
GMHF, 2008: Geriatric Mental Health Foundation. Depression in late life: not a natural part of aging, 2008. Available at www.gmhfonline.org/gmhf/consumer/factsheets/depression_latelife.html.
HHS, 2000: U.S. Department of Health and Human Services, Healthy People 2010, Disability and Secondary Conditions, 2000. Available at http://www.healthypeople.gov/Document/HTML/Volume1/06Disability.htm.
Katon, 2003: Katon W, Lin E, Russo J, et al. Increased medical costs of a population-based sample of depressed elderly patients. Arch Gen Psychiatry 2003;60(9):897–903. 15
Kobau, 2010: Kobau, R. Attitudes about mental illness and its treatment: validation of a generic scale for public health surveillance of mental illness associated stigma. Community Ment Health J 2010; 46(2):164-76.
Koenig, 1996: Koenig HG, Blazer DG. Minor depression in late life. Am J Geriatr Psychiatry 1996;4(Suppl 1):S14-21.
Lebowitz, 1996: Lebowitz BD. Depression and treatment of depression in late life: an overview of the NIH consensus statement. Am J Geriatr Psychiatry 1996;4 Suppl 1\:S3-6.
Manderscheid , 2010: Manderscheid RW, Ryff CD, et al. Evolving definitions of mental illness and wellness, Prev Chronic Dis 2010;7(1). Available at www.cdc.gov/pcd/issues/2010/ jan/09_0124.htm.
NIMH, 2007: National Institute of Mental Health. Depression booklet, 2007. Available at www.nimh.nih.gov/health/publications/depression/index.shtml.
Parks, 2006: Parks J, Svendsen D, et al. Morbidity and mortality in people with serious mental illness, National Association of State Mental Health Program Directors Medical Directors Council, October 2006. Available at www.nasmhpd.org/general_files/publications/med_directors_pubs/Technical%20Report%20on%20Morbidity%20and%20Mortaility%20-%20Final%2011-06.pdf.
SAMHSA, 2005: Substance Abuse & Mental Health Services Administration, Transforming mental health care in America: the federal action agenda: first steps, 2005. Available at: www.samhsa.gov/Federalactionagenda/NFC_conclusion.aspx.
Satcher, 2010: Satcher D, Druss BG. Bridging mental health and public health. Prev Chronic Dis 2010;7(1). Available at www.cdc.gov/pcd/issues/2010/jan/09_0133.htm.
Snowden, 2008: Snowden M, Steinman L, et al. Treating depression in older adults: challenges to implementing the recommendations of an expert panel. Prev Chronic Dis 2008;5(1). Available at www.cdc.gov/pcd/issues/2008/jan/07_0154.htm.
Snowden, 2009: Snowden M, Steinman L, et al. Screening for depression in older adults: recommended instruments and considerations for community-based practice. Clin Geriatr 2009;17(9):26-32.
Steinman, 2007: Steinman LE, Frederick JT, et al. Recommendations for treating depression in community-based older adults. Am J Prev Med 2007;33(3):175–81. Available at www.ajpm-online.net/article/S0749-3797%2807%2900330-3/abstract.
TFCPS, 2007: Task Force on Community Preventive Services. Guide to Community Preventive Services Web site, Interventions To Reduce Depression Among Older Adults: Home-Based Depression Care Management, 2007. Available at www.thecommunityguide.org/mentalhealth/depression-home.html.
Unützer, 1997: Unützer J, Patrick DL, Simon G, et al. Depressive symptoms and the cost of health services in HMO patients aged 65 years and older: a 4-year prospective study. JAMA 1997;277(20):1618-23. Available at http://jama.ama-assn.org/cgi/content/abstract/277/20/1618.
Unützer, 2002: Unützer J, Katon W, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002;288(22):2836–45.
Unützer, 2008: Unützer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care 2008;14:95–100.
Unützer, 2009: Unützer J, Schoenbaum M, et al. Health care costs associated with depression in medically ill fee-for-service Medicare participants. Journal of the American Geriatric Society, 2009; 57:3, 375–584. U.S. Surgeon General, 1999: Older adults and mental health. In: Mental health: a report of the surgeon general, 1999.
USPSTF, 2002: U.S. Preventive Services Task Force. Screening for depression: recommendations and rationale. May 2002. Agency for Healthcare Research and Quality.
USPSTF, 2009: U.S. Preventive Services Task Force. Screening for depression in adults: U.S. preventive services task force recommendation statement.
O’Conner, 2009: O’Connor, E.A. Screening for depression in adult patients in primary care settings: a systematic evidence review. Ann Intern Med 2009;151: 784,793.
Wells, 1989: Wells K, Stewart A, Hays R, et al. The functioning and well-being of depressed patients. JAMA 1989;262:914-9.
WHCOA, 2005: 2005 White House Conference on Aging, Report to the President and the Congress: The booming dynamics of aging. Available at www.whcoa.gov/index.asp.
Zack, 2004: Zack MM, Moriarty DG, et al. Worsening trends in adult health-related quality of life and self-rated health—United States, 1993–2001, Public Health Reports 2004;119(5):493–505.