Dear Dr. K,

Any ideas on how I can relieve my mother’s anxiety about her thinking an animal got in the house? I can’t find anything and have moved the couches but she is convinced and scared.

She’s always been a worrier, plus her thinking has been deteriorating and her vision is impaired a bit. I take care of her and my Dad both 94. She gets upset if I tell her I think she just thought she was seeing something and says I think she is crazy. Last night she woke me up shaking and practically in tears because she thought she saw it again -I offered for her to come sleep with me but she wouldn’t. Any suggestions? — C.S.

Thanks so much for sending in this question. This is a very common complaint I hear from family caregivers, so I am happy to share some thoughts about what might be going on and what you can do.

Now, I can’t say for sure what is going on with your mother. That’s because she’s not my patient, and I’m not in a position to interview her and examine her.

What I can say, however, is that it’s very common for older adults to develop persisting fears, worries, and complaints that often strike their family members as irrational, paranoid, absurd, or ridiculous.

Why is this?

Among my own patients, I’ve found this is often related to underlying cognitive impairment. Meaning, a problem with memory or thinking that hasn’t yet been fully diagnosed by doctors.  In some cases, this kind of complaint ends up being one of the very earliest signs of clinical dementia.

Lewy-Body dementia, in particular, is associated with visual hallucinations. But any process causing brain deterioration (Alzheimer’s, vascular dementia, etc.) can result in anxieties spiraling out of control, or persisting strange beliefs.

That said, it’s quite possible for an aging person to express such fears and not have it be dementia. Maybe there really is an animal in the house, or a person stealing your parent’s things. It’s also possible for people to develop confusion or false beliefs due a problem other than dementia, such as mental illness or delirium.

(For more in-depth information on the most common causes of paranoia and strange beliefs in older adults, see this article: 6 Causes of Paranoia in Aging & What to Do.)

Still, given your mom’s age and the fact you’ve noticed other signs of “thinking deterioration,” there’s a good chance that her persisting fear could be related to some chronic underlying cognitive impairment.

4 Things to try to help your mother

I can’t tell you what you should do, but here are some ideas that are generally helpful for this type of situation:

1. Evaluate her underlying cognitive condition. In other words, get her evaluated for possible underlying dementia. Alzheimer’s and other dementias are not curable, but if that’s what’s going on, getting a diagnosis sooner rather than later can help you. For instance, if she gets this diagnosis, then you’ll know to look for relevant caregiver resources, including resources on communication in dementia.

For more on what can cause cognitive problems in older adults, see “Cognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check.”

There are also a number of things you can do to help her thinking be the best it can be, such as avoiding certain medications, minimizing stress, and promptly recognizing delirium.

Last but not least, if she is diagnosed with dementia, your family should address advance care planning, and prepare for further cognitive decline. (This is sad to think about, but important!)

2. Reason why, rather than reasoning with. Instead of trying to convince her that nothing is there, see if you can figure out what might be triggering her perception that an animal is in the house. Is there a flapping curtain or other object that she’s misinterpreting, given her vision problems? Would better lighting in the house at night help?

3. Prioritize reassurance, validation, and emotional connection over rational explanations. No matter what their age or mental condition, people respond to feeling heard and loved.

And once the brain starts changing, it’s even less likely that a logical explanation will relieve a person’s anxiety. So, try focusing on acknowledging her concern and helping her feel better. It does sound like you’re already trying to do this, but since it’s such an important point, I’m saying it anyway!

Interestingly, research indicates that even people with poor memories maintain a lasting impression of an emotional experience. So keep fostering those positive emotions however you can. You might find that a hug and song work better than moving all the couches, and having your mother worry that you think she’s crazy.

4. Consider getting ideas from others caring for elderly relatives. Other family caregivers are often an excellent source of advice for trouble-shooting common problems such as anxiety, or even delusions.

You can start getting ideas — and support — from other caregivers right away through an online forum. I would recommend doing this while her cognitive evaluation is pending, as you and she need practical behavior solutions sooner rather than later.

(Need more guidance on how to implement the suggestions above? I do offer a course to help families with all of this: Helping Older Parents with Early Memory Loss.)

Whom to ask for help

Of course, I always recommend families bring up their concerns with their relative’s doctors. Most concerns families have about an aging parent do track back to underlying medical problems that should be identified and addressed.

That said, many primary care doctors don’t have the time or experience to provide the optimal evaluation and support. If her doctor doesn’t seem very helpful, consider a specialty consultation with a neurologist, memory center, or geriatrician. (See this post for ideas on how to find a geriatrics consultation.) This should enable you to get a better understanding of what brain and body problems might be affecting your mother’s behavior.

For managing day-to-day challenges, you can get excellent practical advice from geriatric care managers, but this usually requires paying out of pocket.

I hope some of this advice helps. This is a tough situation to deal with, but if you’re persistent about investigating and looking into other ways to respond, you’ll hopefully hit upon an approach that brings your family some relief.

If nothing else, finding out that other people are dealing with similar problems is often a big relief to people.

You might also find my free online training for families helpful (see below), in which I teach families how to better communicate with an aging parent who may have memory loss.

Have you been told that you — or someone important to you — has heart failure?

This wouldn’t surprise me, as this is one of the most common heart conditions affecting older adults. People are sometimes alarmed by the term “heart failure”; does it mean the heart is about to stop working?  Luckily, that’s not usually the case.

Heart failure actually means that the heart is not pumping or filling as well as it should. This can affect how well blood moves through the body, and it can lead to symptoms such as shortness of breath, fatigue, swelling, and reduced ability to exercise.

Heart failure can be serious, and it is important to take it seriously. But it is also a condition that many older adults live with for years, especially when it is properly diagnosed and treated.

In this article, I’ll explain:

• What heart failure means
• The main types of heart failure
• Common causes in older adults
• Symptoms to watch for
• How heart failure is diagnosed
• How it is treated and managed
• What to know if an older person is frail
• Questions to ask the doctor

This information is based on a Better Health While Aging video podcast conversation with cardiologist Cara Pellegrini, MD,  who is a professor at UCSF.

What Is Heart Failure?

Heart failure means that the heart is experiencing some level of dysfunction in its ability to pump blood to meet the needs of the body. 

How the heart works

The heart’s job is to move blood through the body. Veins bring the blood back to the heart, into the right side, from which blood is sent to the lungs to release carbon dioxide and pick up oxygen. From the lungs, the blood returns to the left side of the heart and from there, the left ventricle — the heart’s main pumping chamber — pushes oxygen-rich blood out to the rest of the body.

With each heartbeat, the heart alternates between two states:

• Systole is when the heart squeezes to empty the ventricles and pump blood
• Diastole is when the heart relaxes to fill the ventricles with blood

When the heart is not pumping as efficiently as it should, the body may not get enough blood flow. In some people, fluid can also build up in the lungs, legs, or abdomen.

This is why heart failure used to often be called “congestive heart failure.” The word “congestive” refers to the extra fluid that can accumulate when the heart and kidneys are trying to compensate for reduced blood flow. However, not everyone with heart failure has obvious congestion, so many clinicians now simply use the term “heart failure.”

The Two Main Types of Heart Failure

Most heart failure affects the left side of the heart. There are two main types:

• Systolic heart failure: the heart has trouble generating a good squeeze to pump the blood forward.
  • This can be associated with a dilated or weakened ventricle (the lower heart chamber)

• Diastolic heart failure: the heart has difficulty relaxing and filling with enough blood between beats.
  • This often involves a thickened ventricle wall

Two newer terms for heart failure:

In recent years, cardiologists have encouraged health providers to categorize heart failure into these two types:

• Heart failure with reduced ejection fraction, often called HFrEF (pronounced “hef-ref”)
• Heart failure with preserved ejection fraction, often called HFpEF (pronounced “hef-pef”)

Ejection fraction refers to the percentage of blood in the left ventricle that gets pumped out with each beat. It’s usually assessed through an echocardiogram (an ultrasound of the heart).

A normal ejection fraction is usually about 55% or higher. It is not expected to be 100%, because the heart never pumps out all the blood in the ventricle with each beat.

Heart Failure With Reduced Ejection Fraction: HFrEF

This type is often related to systolic dysfunction.

Remember, “systole” refers to the squeezing phase of the heartbeat. In HFrEF, the left ventricle has become weaker and is not squeezing as forcefully as it should.

When the ejection fraction is reduced — for instance 40%, 30%, or lower — this suggests the heart’s squeeze function is impaired.

Heart Failure With Preserved Ejection Fraction: HFpEF

This type is often related to diastolic dysfunction.

“Diastole” refers to the relaxation phase of the heartbeat. During this phase, the heart relaxes and fills with blood.

In HFpEF, the heart may still squeeze well enough for the ejection fraction to look normal. But the heart muscle may be stiff or thickened, making it harder for the ventricle to relax and fill properly.

This is especially common in older adults. Aging itself can be associated with stiffening of the heart and blood vessels, and conditions such as high blood pressure can make this worse over time.

Left-Sided and Right-Sided Heart Failure

Most heart failure involves the left side of the heart, especially the left ventricle. This makes sense because the left ventricle has the demanding job of pumping blood to the entire body.

But some people also have right-sided heart failure, either alone or along with left-sided heart failure. The right side of the heart pumps blood to the lungs. Problems affecting the lungs, heart valves, or right ventricle can contribute to right-sided heart failure.

For most older adults, however, heart failure affects mainly the left ventricle, and the question is whether the person has reduced or preserved ejection fraction.

How Common Is Heart Failure in Older Adults?

Heart failure becomes much more common with age.

It is relatively uncommon in younger adults, but it becomes much more frequent in people over 60 and especially in people in their 70s, 80s, and beyond. The CDC estimates that nearly 6.7 million U.S. adults have heart failure, and population studies show that prevalence rises substantially in later life.

Part of the reason is that, over a lifetime, the heart may be affected by:

• High blood pressure
• Coronary artery disease
• Heart attacks
• Diabetes
• Valve disease
• Arrhythmias, such as atrial fibrillation
• Alcohol or other toxins
• Other metabolic or inflammatory stresses

Even when no single dramatic event has occurred, these cumulative effects can eventually contribute to heart dysfunction.

Common Causes of Heart Failure in Older Adults

Here are the most common causes of heart failure in older adults. Bear in mind that an older person’s heart failure might have several underlying causes.

High Blood Pressure

Longstanding high blood pressure is one of the most common contributors to heart failure in older adults.

When blood pressure is high, the heart has to pump against more resistance. Over time, this can lead to thickening and stiffness of the heart muscle, which is a common pathway to HFpEF. High blood pressure can also contribute to reduced squeeze function in some people.

Coronary Artery Disease and Heart Attacks

The heart muscle needs its own blood supply, delivered through the coronary arteries.

If those arteries become narrowed or blocked, parts of the heart muscle may not get enough oxygen. A complete blockage can cause a heart attack, which may damage the heart muscle and weaken its pumping ability.

Even without a major heart attack, coronary artery disease can contribute to heart dysfunction over time.

Heart Valve Problems

The heart has four main valves that help blood move in the right direction.

Valve problems can contribute to heart failure in two major ways:

• Stenosis, meaning the valve has become narrowed or stiff and does not open well
• Regurgitation, meaning the valve leaks and allows blood to flow backward

In older adults, aortic stenosis is a particularly important valve problem. The aortic valve sits between the left ventricle and the aorta. When it becomes calcified and narrowed, the left ventricle has to work much harder to pump blood out to the body.

Another issue is mitral regurgitation, in which the mitral valve leaks. Sometimes this happens because the left ventricle has become enlarged and stretched, pulling the valve leaflets apart so they no longer close properly.

The good news is that some valve problems now have less invasive treatment options than traditional open-heart surgery, depending on the person’s situation.

Cardiomyopathies

A cardiomyopathy is a problem affecting the heart muscle itself.

Some cardiomyopathies are related to toxins, such as heavy alcohol use over many years. This is important because alcohol-related heart dysfunction can sometimes improve significantly if alcohol is reduced or stopped.

Another condition that is increasingly recognized in older adults is amyloidosis, in which abnormal proteins build up in tissues, including the heart. This can interfere with how the heart muscle works. Newer treatments have made it more important to recognize this condition when it is present.

Arrhythmias

Abnormal heart rhythms can also contribute to heart failure.

Atrial fibrillation, for example, is common in older adults and can worsen heart function, especially if the heart rate is too fast or poorly controlled. Other rhythm problems, such as frequent premature ventricular contractions, can also weaken the heart in some cases.

This is another reason it is important to look for underlying causes. Some rhythm-related causes of heart failure can improve when the rhythm problem is treated.

Diabetes

Diabetes often travels together with other heart failure risk factors.

People with diabetes are more likely to have high blood pressure and coronary artery disease. Diabetes also affects blood vessels and metabolism in ways that can stress the heart.

Good diabetes management can be an important part of protecting heart health.

Symptoms of Heart Failure in Aging

The most common symptoms of heart failure are:

• Shortness of breath
• Fatigue
• Reduced ability to exercise or do usual activities
• Swelling in the legs, ankles, feet, or abdomen
• Rapid weight gain from fluid retention

Shortness of breath may first show up with exertion, such as walking uphill, climbing stairs, or carrying groceries. As heart failure worsens, a person may become short of breath with less activity.

Some people also notice they feel worse when lying flat. They may need extra pillows or feel more comfortable sleeping propped up. This can happen because fluid backs up into the lungs when lying down.

Other possible symptoms include:

• Chest discomfort
• Lightheadedness
• Feeling unusually weak
• Loss of appetite
• Unexplained weight loss in more advanced heart failure
• Lower blood pressure in some cases
• Higher blood pressure in others, depending on the type and stage

A key point: fatigue and shortness of breath should not automatically be dismissed as “just aging.”

Many older adults assume they are slowing down only because they are older. But sometimes the reason is a treatable medical condition such as heart failure, anemia, lung disease, thyroid disease, or another issue.

Other Conditions That Can Mimic Heart Failure

Heart failure symptoms are important to recognize, but they are not specific enough to diagnose the condition by symptoms alone.

For example, shortness of breath and fatigue can also be caused by:

• Lung disease
• Anemia
• Thyroid problems
• Kidney disease
• Liver disease
• Heart rhythm problems, such as atrial fibrillation
• Coronary artery disease
• Cancer
• Deconditioning
• Medication side effects

Leg swelling is also common in older adults and is often due to venous insufficiency, sometimes called venous stasis. This means the leg veins are not moving blood back up toward the heart as efficiently as they used to. It can cause swelling, but it does not necessarily mean heart failure. You can learn more about it here: Leg Swelling in Aging: What to Know & What to Do.

So if an older person develops swelling, shortness of breath, or fatigue, the right step is not to panic or self-diagnose. The right step is to get a medical evaluation.

How Heart Failure Is Diagnosed

A heart failure evaluation usually starts with a careful history and physical exam.

A health provider should ask about:

• Symptoms, including when they started and what makes them better or worse
• Exercise tolerance
• Weight changes
• Swelling
• Chest pain
• Past heart problems
• Blood pressure
• Diabetes
• Smoking history
• Alcohol use
• Current medications

During the physical exam, the clinician should listen to the heart and lungs, check the legs for swelling, and look at the veins in the neck. The neck veins can sometimes provide clues about whether the body is retaining extra fluid.

Common tests to evaluate heart failure

Electrocardiogram, or ECG/EKG

An ECG checks the electrical activity of the heart. It can show rhythm problems such as atrial fibrillation and may provide clues about prior heart attacks or other heart strain.

Echocardiogram

An echocardiogram is an ultrasound of the heart. This is one of the most important tests when heart failure is suspected.

It will show:

• The ejection fraction
• How well the heart squeezes
• Whether the heart is stiff or thickened
• Whether chambers are enlarged
• How the heart valves are working
• Whether there is fluid around the heart

Chest X-Ray

A chest x-ray can help assess the lungs and may show signs of fluid buildup or other lung problems.

Blood Tests

Blood tests usually include:

• Kidney function
• Electrolytes
• Blood count, to check for anemia
• Thyroid testing, when appropriate
• BNP or NT-proBNP, which can rise when the heart is under stress

Stress Testing or Heart Catheterization

If coronary artery disease is suspected, the clinician may recommend a stress test or, in some situations, a heart catheterization to look directly at the coronary arteries.

Not every person needs every test. The workup should be tailored to the person’s symptoms, health history, and goals.

Does Heart Failure Require Emergency Treatment?

Often no, but sometimes yes; it depends on how severe the symptoms are.

If a person’s symptoms are mild, they can be evaluated and start treatment in an outpatient setting. 

Other times, the first presentation of heart failure is more urgent. A person may come to the emergency room very short of breath, with severe fluid overload, low oxygen levels, or other serious symptoms.

Heart failure can also have exacerbations, meaning flare-ups where symptoms suddenly worsen. These may require urgent treatment or hospitalization.

Seek prompt medical help if an older person has:

• New or worsening shortness of breath
• Shortness of breath at rest
• Chest pain
• Fainting
• New confusion with breathing problems
• Rapid weight gain with swelling
• Severe weakness or inability to do usual activities
• Bluish or grayish skin color, depending on skin tone
• Oxygen levels that are low, if being monitored at home

How Severe Is the Heart Failure?

Heart failure severity is often described by how much activity causes symptoms.

A common system for stages of heart failure is the New York Heart Association functional classification:

• Class I: No symptoms with ordinary activity
• Class II: Symptoms with more significant activity, such as hills or stairs
• Class III: Symptoms with mild activity, such as walking short distances or showering
• Class IV: Symptoms even at rest

Clinicians also increasingly think in terms of prevention, and are starting to think of people at high risk of heart failure as “Stage 0 heart failure.”  A person with high blood pressure, diabetes, or coronary artery disease may not yet have heart failure, but they are at higher risk and should have those risk factors managed carefully.

This is an important concept: preventing heart failure, or catching it early, is often much easier than treating advanced disease.

How Heart Failure Is Treated and Managed

Heart failure treatment depends on the type, cause, severity, symptoms, and the older person’s overall health and goals.

The main pillars are:

1. Treat reversible causes when possible
2. Manage contributing conditions
3. Use appropriate heart failure medications
4. Support healthy lifestyle habits
5. Monitor symptoms and fluid status
6. Consider procedures or devices when appropriate
7. Match treatment to the person’s goals of care

Treating the Underlying Cause

Treatment should begin with understanding what caused or contributed to the heart failure.

Depending on the situation, this may mean:

• Treating high blood pressure
• Reducing or stopping alcohol
• Managing diabetes
• Treating coronary artery disease
• Treating atrial fibrillation or other arrhythmias
• Evaluating and treating valve disease
• Reviewing medications that may worsen heart failure
• Considering less common causes, such as amyloidosis

This is why it is so important to ask: “What do you think caused this, and can any part of it be reversed?”

Lifestyle and Cardiac Rehabilitation

For most people with heart failure, lifestyle changes can help support the heart and improve quality of life.  

Reducing or avoiding alcohol, in particular

These often include:

• Avoiding excessive alcohol
• Staying physically active within safe limits
• Quitting smoking
• Managing weight
• Eating in a heart-healthy way
• Following individualized advice about salt and fluid intake

Some people benefit from cardiac rehabilitation, a supervised exercise and education program. This can be especially helpful after a hospitalization or when a person needs support safely rebuilding endurance.

Salt and Fluid Intake

For people who retain fluid, reducing sodium can help prevent congestion and swelling.

Some people may also be advised to limit fluid intake, but this is not appropriate for everyone. Older adults can be vulnerable to dehydration, kidney problems, and medication side effects, so fluid advice should be individualized.

It’s best to ask the clinician:

“Should I be limiting salt or fluids, and if so, what specific limits do you recommend for me?”

Medications to Treat Heart Failure

Medications are often extremely helpful in heart failure. In some areas of medicine, we worry about too many medications, especially in older adults. But for heart failure, several medication classes have strong evidence showing they can improve symptoms, reduce hospitalizations, and help people live longer. 

Medications for HFrEF (systolic heart failure)

Current American Heart Association guidance recommends four core medication classes for heart failure with reduced ejection fraction:

• Beta Blockers
  • Examples include carvedilol and metoprolol
  • Beta blockers slow the heart rate and reduce the heart’s workload. They can help the heart function more efficiently over time.
• ACE Inhibitors, ARBs, or ARNI
  • Examples include lisinopril and valsartan
  • These medications help relax blood vessels and influence hormone systems related to blood pressure, salt, and fluid balance.
  • An ARNI is a newer combination medication that includes sacubitril and valsartan. It is often used in people with HFrEF when appropriate.
• Mineralocorticoid Receptor Antagonists, or MRAs
  • Examples include spironolactone and eplerenone
  • MRAs are gentle diuretics that also affect hormone pathways involved in heart failure. They can help with fluid balance and potassium regulation, but kidney function and potassium levels must be monitored.
• SGLT2 Inhibitors
  • Examples include empagliflozin and canagliflozin
  • SGLT2 inhibitors were originally developed for diabetes, but they have also been shown to help many people with heart failure, even those without diabetes.

Diuretics

Many people with heart failure also need a diuretic, sometimes called a water pill. These medications help the body get rid of extra fluid and can quickly improve symptoms such as swelling and shortness of breath. Furosemide (brand name Lasix) is a common diuretic used for heart failure.

Medications for HFpEF (diastolic dysfunction)

For heart failure with preserved ejection fraction, treatment has historically been more challenging. However, newer evidence has shown benefits from some of the same medication classes, especially in certain patients.

Treatment may include:

• SGLT2 inhibitors
• MRAs
• ARNI or related blood-pressure medications in selected cases
• Diuretics for fluid overload
• Careful blood pressure control
• Management of atrial fibrillation, diabetes, kidney disease, and obesity when present

Because HFpEF is common in older adults and often coexists with several other conditions, treatment needs to be individualized.

Self-Monitoring at Home

For many people with heart failure, self-monitoring can help prevent hospitalizations.

A common recommendation is to weigh yourself every day, ideally at the same time each morning. A rapid increase in weight can mean fluid is building up.

Ask the doctor what specific change should trigger a call. Many clinicians use a threshold such as several pounds over a day or two, but the exact recommendation may vary.

It can also be helpful to monitor:

• Shortness of breath
• Swelling
• Ability to do usual activities
• Blood pressure, if recommended
• Heart rate, if recommended
• Dizziness or falls
• Medication side effects

The key is to notice early worsening before it becomes severe.

Useful questions include:

• “Should I weigh myself every day?”
• “How much weight gain should prompt me to call?”
• “Should I monitor my blood pressure?”
• “What symptoms mean I should seek urgent care?”
• “Do I have a plan for adjusting my diuretic if my weight goes up?”

Heart Failure Treatment in Frail Older Adults

Older adults, especially those who are frail, often need extra care when treating heart failure.

They may be more sensitive to:

• Blood pressure drops
• Dizziness
• Falls
• Kidney function changes
• Electrolyte problems
• Medication side effects
• Dehydration

This does not mean they should not receive treatment. It means treatment should be thoughtful, monitored, and aligned with what matters most to the person.

For instance, a frail older adult may still benefit greatly from medications that improve breathing and energy. But doses may need to be started low and adjusted carefully.

It’s also important not to dismiss symptoms as “just aging.” Shortness of breath, fatigue, reduced activity, and swelling deserve evaluation, even in very old adults.

At the same time, goals of care matter. Some people want all reasonable treatments that might extend life. Others want to focus more on comfort, function, and avoiding burdensome procedures. Many people want both: to live longer if possible, but not at the cost of unacceptable side effects or loss of quality of life.

Good care requires talking through these tradeoffs.

Procedures and Devices Used in Heart Failure

Some people with heart failure may benefit from procedures or implanted devices.

Treating Valve Disease

If a valve problem is a major contributor, treating the valve may improve symptoms and heart function.

For example, severe aortic stenosis can sometimes be treated with a catheter-based procedure rather than open-heart surgery, depending on the person’s situation.

Mitral regurgitation may also have catheter-based treatment options in selected cases.

Biventricular Pacemaker

A biventricular pacemaker, also called cardiac resynchronization therapy, can help certain people who have systolic dysfunction with an ejection fraction less than 35%.

This device helps coordinate the heart’s contractions. In the right person, it can really improve symptoms, as well as help people live longer.

Implantable Cardioverter-Defibrillator, or ICD

An ICD watches the heart rhythm and can deliver a shock if a life-threatening rhythm occurs.

This device is mainly focused on preventing sudden cardiac death in people at higher risk, such as those with a very low ejection fraction or a history of dangerous arrhythmias.

For older adults, especially those with serious frailty or advanced illness, it is important to discuss whether an ICD fits their goals. Some people want this protection. Others may decide that if their heart develops a sudden fatal rhythm, they would not want to be shocked back.

For people who already have an ICD, it is also possible to discuss turning off the shock function later in life if goals change.

Heart Failure, Atrial Fibrillation, and Arrhythmias

Atrial fibrillation is a common heart rhythm problem in older adults. It can coexist with heart failure and sometimes worsen it.

When atrial fibrillation causes the heart to beat too fast or irregularly for long periods, it can contribute to worsening heart function. Treating atrial fibrillation may improve symptoms and, in some cases, heart function.

Other rhythm issues, such as frequent premature ventricular contractions, can also contribute to heart dysfunction in selected patients.

This is one reason an ECG and sometimes longer rhythm monitoring may be recommended.

For more on atrial fibrillation: Atrial Fibrillation in Aging: What to Know & How to Treat.

Can People Die of Heart Failure?

Yes, heart failure can be life-limiting, especially when it becomes advanced.

However, many people with heart failure live for years, and many die of something else. Prognosis depends on the cause, severity, response to treatment, age, other medical conditions, and overall resilience.

When heart failure does contribute to death, it may happen in different ways:

• Sudden cardiac death from a dangerous rhythm
• Heart attack
• Gradual worsening of pump function
• Progressive weakness, weight loss, and reduced function
• Repeated hospitalizations and complications

For advanced heart failure, palliative care can be very helpful. Palliative care focuses on symptom relief, decision-making support, and quality of life. Hospice may also be appropriate when heart failure is advanced enough and the focus has shifted to comfort.

These services do not mean “giving up.” They can help people live as well as possible with serious illness.

Questions to Ask the Doctor About Heart Failure

If you or an older loved one has been diagnosed with heart failure, consider asking:

1. What type of heart failure do I have?
   Is it heart failure with reduced ejection fraction, preserved ejection fraction, or something else? Is it only on the left side, or is the right side of the heart affected as well?
2. What is my ejection fraction?
   What did the echocardiogram show?
3. What do you think caused my heart failure?
   Could it be related to blood pressure, coronary artery disease, valve disease, atrial fibrillation, alcohol, amyloidosis, or something else?
4. Are any causes reversible or treatable?
5. How severe is my heart failure?
   What level of activity should I be able to do?
6. What medications do you recommend, and why?
7. What side effects should I watch for?
8. Do I need to monitor my weight, blood pressure, or heart rate at home?
9. How much weight gain should prompt a call?
10. Should I limit salt or fluids? If so, how much?
11. Would cardiac rehabilitation help me?
12. Do I need to see a cardiologist or heart failure specialist?
13. Are there any procedures or devices I should consider?
14. How do these treatment options fit with my goals of care?

The Bottom Line

Heart failure is common in older adults, but it does not mean the heart has completely failed or that death is imminent.

It usually means the heart is not pumping or filling as well as it should. The most common symptoms are shortness of breath, fatigue, reduced exercise tolerance, swelling, and rapid weight gain from fluid.

Because these symptoms can also be caused by other conditions, it is important to get a medical evaluation rather than self-diagnosing.

The good news is that heart failure is often very treatable. Many people feel better with the right medications, lifestyle support, monitoring, and treatment of underlying causes. Some people even have improvement in heart function, especially when a reversible contributor is found.

For older adults and families, the most important steps are to understand the type of heart failure, ask what may have caused it, learn how to monitor symptoms, and make sure treatment decisions are aligned with the older person’s health priorities and goals.

Once upon a time, the ER missed a pelvic fracture in one of my older patients.

Actually, this kind of thing has happened more than once, and perhaps it’s happened to your family too.

As much as we’d like to believe that our older loved ones will get the right care when they are sick or injured, the truth is that our healthcare system is imperfect, and it’s fairly common for serious problems to be missed.

Unless, of course, a proactive family caregiver knows to help the doctor focus on what’s newly wrong.

Here is a true story about why geriatricians pay attention to “changes in function” and why it’s essential that you help doctors spot any changes in function or ability.

The case: unable to walk after a fall

My patient with Alzheimer’s dementia, 85-year-old Mr. C.,  sat down short of his easy chair at home and fell. Within minutes, his daughter found him on the floor. She helped him to the chair, and they watched some TV. But half an hour later, he was unable to get up again and walk. She took him to the emergency room for evaluation.

“I’m fine. Nothing hurts,” Mr. C. told the busy ER staff more than once. “I just want to go home.” X-rays of his hips and pelvis revealed nothing, and so — after an exam that probably lasted only a minute or two — he was discharged.

Back home, however, he still couldn’t walk. He still insisted nothing hurt. “I’m a tough old bird,” he told his daughter. Later that night, though, she noticed that he grimaced every time he rolled over in bed. She knew something was wrong. But what?

The challenge: ageism and busy health providers

There are few things more frustrating than bringing your loved one to see doctors when you know something’s wrong, only to be told, “Everything’s fine.”

Often everything is fine, thank goodness. But sometimes, an important problem gets overlooked. Unfortunately, one group — frail older people with Alzheimer’s or another dementia — is especially likely to be dismissed as “okay” when they’re not.

Why? Because people with dementia aren’t accurate self-reporters, and their caregivers often inadvertently neglect to report information about their status in a way that most healthcare providers understand.

There’s also, to be honest, an issue of ageism here. Many health providers will inappropriately assume it’s “normal” or an 85-year-old person’s baseline, not to be able to walk. This means new problems and changes in functional status can easily be overlooked.

The solution: Know what to look for — and what to say

The good news is that by understanding a key concept in geriatric care, a proactive caregiver can dramatically improve the odds of getting the right answers when bringing someone with dementia to urgent care or the emergency room.

The key concept is this: Changes in mental or physical function are critically important. Be sure to mention them — because they almost always deserve further evaluation.

Example 1: Let’s say your aging mother with dementia is usually forgetful and confused about the month but consistently recognizes familiar people. If one day she’s much more confused than usual — not even recognizing the faces she sees every day — that’s a change in mental function. It could represent delirium (a sudden state of mental confusion and changes in brain function that can have many different causes). It should definitely be brought to the attention of a medical professional. Urinary tract infections, for instance, can cause delirium in older people.

Example 2: You’re caring for an elderly father with Parkinson’s who’s often a bit confused and unsteady. If he’s normally able to walk but, after a fall, he can’t, even unsteadily, that’s an important change in physical function.

So it was with Mr. C. Although his daughter had dutifully reported to the ER doctors that her father had fallen, she hadn’t emphasized that he was able to walk just fine until he fell. And because Mr. C. has moderate dementia, he was unable to articulate the pain that rendered him unable to take a step. Fortunately, after they returned home, the daughter was worried enough to call our Geriatrics Clinic, where Mr. C. was a patient. (He also has a heart condition.)

When we realized there had been a change in his function, we had him brought in for a CT scan of his pelvis, and we found several hairline pelvic fractures.

Diagnosing these hairline fractures allowed us to make a better plan to manage Mr. C.’s pain, so that he could keep walking a bit while his pelvis slowly healed. By doing this, we kept him from becoming bed-bound, which would’ve seriously decreased his quality of life and increased his daughter’s work in caring for him.

Changes in function seem like such a commonsense symptom that many family caregivers assume doctors will note these changes and take them seriously.

Unfortunately, it’s very easy for changes in function to slip under the radar of busy doctors, especially if they aren’t trained in geriatrics (the specialty of medicine that focuses on aging adults), and especially when patients and families don’t explicitly point out the changes.

You should also alert the doctors if your older loved one develops any new or increased difficulties with ADLs or IADLs. (You can learn more about those here: What are Activities of Daily Living (ADLs) & Instrumental Activities of Daily Living (IADLs)?)

Tips for Family Caregivers

Always report any notable change in someone’s physical or mental functioning to a doctor, no matter how obvious it seems to you. Be sure to specify when you noticed the change, and how quickly it seemed to come on.

And then insist on getting an answer to what could be causing that change.

 

Every May, the Administration for Community Living leads the national observance of “Older Americans Month.” The theme this year is “Champion Your Health.”

But to be honest, I prefer the theme from 2018, which was “Engage at Every Age.”

And I found myself thinking that this would be a nice opportunity to consider: just what does it mean to “succeed” or do well as an older adult?

This is important, because our understanding of what is “success,” and what to strive for, is fundamental to how we judge ourselves and others.

And for us as a society, articulating what’s involved in experiencing “good” or “successful” aging is important because it can help us understand what kinds of things we should focus on, to help more older adults age well, or otherwise “succeed” in late-life.

So, just as philosophers and others have long debated what it means to “live a good life,” we should ask ourselves what it means to “succeed” as an older adult.

This way, we can know whether we are “succeeding” as a society that supports and values its older population.

I also did a video elaborating on what it means to be “aging successfully”, which can be found on my Youtube channel.

What IS “successful aging?”

This is not a simple question to answer. It has long been the subject of vigorous inquiry and debate in gerontology. In fact, the journal The Gerontologist devoted an entire issue to the topic of “Successful Aging” in 2015.

(FYI: Gerontology is “the comprehensive study of aging and the problems of the aged,” whereas geriatrics is a medical specialty. We are related but not the same!)

I can’t summarize the debates on what constitutes successful aging here, but if you’d like to read more, this article from The Gerontologist offers a long and detailed overview of different ways that scholars have conceived of successful aging: Defining Successful Aging: A Tangible or Elusive Concept?

A common (and problematic) definition of successful aging

One prominent model of successful aging, developed in the 1990s (Rowe and Kahn), proposed that it means:

• freedom from disease and disability
• high cognitive and physical functioning
• active engagement with life

Gerontologists have gone way past this model, but this may be pretty close to what many people have in mind, when they think of “successful aging” or “aging well.”

And it’s certainly what many images of older adults convey: people who may “look older” but otherwise appear to do everything they could do earlier in life.

But there’s an obvious problem with this conception of successful aging: many, if not most, older adults will eventually not be able to meet all three criteria.

So have they failed? And: will we tend to judge that it’s their fault if they don’t remain disease- and impairment-free as they age?

A better lens on “successful aging”

This article describes a newer way to frame successful aging that I find intriguing. (The authors are Eva Kahana, Boaz Kahana, and Jeong Eun Lee.)

The authors describe a model based on the assumption that with increasing age there is an accumulation of health-related and social stressors.

They note that if it weren’t for common age-related challenges, there would be no need to distinguish successful aging from successful living at any age. (True!)

They propose that those who maintain good physical health, mental health, and engagement in social activities, without any conscious coping efforts, be referred to as “lucky agers”.

But most people will not be lucky, and hence they need to find ways to cope and adapt to age-related stressors, which include:

• Chronic illness
• Social losses
• “Lack of person-environment fit”

Coping with age-related stressors in a purposeful way, and finding ways to maintain quality of life, is called making “proactive adaptations.”

The authors go on to describe how this can be done in a “preventive fashion” (e.g. anticipating a future or impending age-related stressor) and then also in a “corrective” way, which means making adaptations once a stressor or problem has occurred.

To adapt, an older person must marshal both internal resources (attitude, optimism, coping with challenges) and external resources (available social support, finances, etc).

The main quality of life outcomes in this model include:

• Self-evaluation of success
• Life satisfaction
• Meaning in life
• Positive affective state (which basically means positive mood or emotions)
• Valued activities

You can see the model diagrammed out in Figure 1 of the article.

In short: in this model, success is not defined as remaining free of disability or disease as one gets older.

Instead, succeeding means finding ways to cope with impending or existing illnesses, losses, and other challenges, by getting help and by marshaling one’s own resilience and internal resources.

In this way, despite experiencing losses and illness and “lack of person-environment fit” (e.g. a house that is a challenge or dangerous to live in), older people often find ways to meet these challenges.

In doing so, they continue to find ways to experience positive outcomes such as life satisfaction, meaning, contentment, and they are still able to participate in valued activities.

Personally, I like this model. (Granted, it’s a little wonky, but that’s true of all substantive academic work.) I especially like the attention to the way that older adults can be proactive and exert their autonomy by anticipating and adapting to common age-related challenges. In the words of the authors, this “reflects human agency directed at stress reduction, resource development, and problem resolution.”

In other words, this model gives credit to those who acknowledge that their lives may or are changing, and purposefully engage in addressing this.

This takes a certain courage. Which, in truth, is what most older adults muster when the time comes. But you’d never know it to see most media images of older adults, which either portray them as free of late-life stressors or instead emphasize their declines without highlighting their successes in adapting, and their ability to find meaning in a new normal.

How can we support older adults in anticipating & coping with age-related challenges?

Most people will encounter losses and impairments as they age.

What if, as a society, we were less afraid of this, and instead embraced it as an opportunity to be proactive, and then to step up to challenges?

What if as a society, we were better at acknowledging and celebrating the remarkable acts of resiliency and problem-solving that many older people are working their way through?

What if older people felt more comfortable getting help when it becomes necessary? What if we were better at providing it?

These are some of the things that I’ll be thinking about during Older Americans Month.

People really can engage at any age.

We need to make sure that message is clear — and actionable — even for those who aren’t among the “lucky agers.”

Now tell me: what comes to mind when you think of “successful aging”? And what could we collectively do to help more older adults feel successful?