How to Age Better by Optimizing Chronic Conditions:
The Healthy Aging Checklist Part 4

This is the fourth in a series of posts covering the Healthy Aging Checklist.

Again, the Healthy Aging Checklist summarizes the six fundamental activities I recommend when asked what to do to maintain the best possible health while aging. They are:

• Promote brain health and emotional well-being.
• Promote physical health.
• Check for and address common aging health problems (such as falls, memory concerns, depression, incontinence, pain, isolation, polypharmacy).
• Learn to optimize the management of any chronic conditions.
• Get recommended preventive health services for older adults.
• Address medical, legal, and financial advance care planning.

In this post, I’ll cover the fourth item: learning to optimize the management of any chronic conditions.

Now, people are often very interested in “prevention” and in “staying healthy.” But far fewer people seem to be interested in making sure that they and their doctors are doing the right things for any chronic conditions they already have, and — equally importantly — avoiding the wrong things.

This is a serious oversight, because most of the “aging” problems that older adults eventually develop are due to chronic health conditions that have progressed or caused complications.

So optimizing the care of chronic conditions is very important for the prevention of future health deterioration. And it’s also vital to helping older adults feel and function their best in the here and now.

According to Medicare, over two-thirds of beneficiaries have two or more chronic conditions. Here’s a figure from the Medicare Chronic Conditions Chartbook, showing what percentage of older adults are affected by the 15 most common chronic conditions:

I can’t emphasize this enough: these chronic conditions often are the key drivers, when it comes to an older person’s symptoms, health crises, health declines, and the eventual development of disabilities.

Furthermore, I’m sorry to say this but here goes: you should not assume that doctors will provide you with optimal care for chronic conditions. Experts have estimated that patients get only about half of recommended healthcare. A large body of healthcare quality research has repeatedly documented that it is very common for older adults to receive healthcare that varies from “wrong” (e.g. totally counter to guidelines with no documented justification for this) to “sub-optimal” (which means it’s not very deficient but could and should be better).

Later in this article, I will go into more detail on why doctors often provide sub-optimal care, and what you can do about it.

But first, let’s review what’s at stake and why it’s worthwhile to make sure you optimize the healthcare of an older adult’s chronic conditions. I’ll then finish by providing some practical tips to help you be proactive so you can optimize the care of chronic conditions, for healthier aging.

8 Ways Chronic Conditions Harm the Health & Well-being of Older Adults

Here are eight important ways chronic conditions impact older adults. As you can see, optimal management of chronic conditions helps counter these eight problems.

1. Chronic conditions cause symptoms that are distressing and uncomfortable. For instance, heart failure, chronic obstructive pulmonary disease (COPD), and atrial fibrillation can all cause shortness of breath. Arthritis commonly causes pain.
   • Optimal management helps older adults feel better, which means better quality of life and well-being.
2. Chronic conditions cause symptoms that interfere with social activities, physical activities, and healthy behaviors. Painful or bothersome symptoms often interfere with older adults from engaging in their lives, or even doing healthy things like exercising. Symptoms can also interfere with an older person’s ability to manage medications, and other aspects of “self-healthcare.”
   • Optimal management means people are able to more fully participate in meaningful activities, like work, family activities, other social activities, and also in taking care of their own health.
3. Chronic conditions can get worse, especially if not optimally managed. Many chronic conditions — such as kidney disease, heart failure, COPD, and Alzheimer’s disease — exist on a spectrum of mild/early to severe/advanced. Obviously, symptoms and the risk of health crises go up when a chronic illness has advanced to a more severe state.
   • Optimal management helps minimize the progression of these health problems. This means fewer symptoms and a lower risk of complications.
4. Chronic conditions can cause new chronic conditions. For instance, high blood pressure is a condition that generally doesn’t cause many symptoms. But if it’s left poorly treated, it can bring on problems such as stroke, heart failure, atrial fibrillation, or kidney disease.
   • Optimal management minimizes the risk of developing a new related chronic disease.
5. Chronic conditions prompt treatment with medication. Medication is not necessarily a bad thing; medications are often part of a sound plan for optimizing the care of a chronic condition. However, managing medications can be burdensome and costly. Medications also can cause harm to an older adult’s health, either in the short-term (e.g. side-effects, or an adverse event) or long-term (e.g. a higher risk of dementia due to taking certain brain-affecting medications), especially in people who take 5+ medications.
   • Optimal management means choosing medications carefully and using non-drug treatment alternatives when feasible. Because medications are such a common cause of harm to older adults, a focus on judicious use can pay big dividends in terms of long-term health.
6. Chronic conditions can cause health crises and emergencies. Many chronic conditions come with a risk of sudden deterioration or another health emergency. For instance, people with diabetes can experience catastrophically high (or low) blood sugar, and people with COPD can develop an “exacerbation” requiring hospitalization and help with their breathing.
   • Optimal management minimizes the risk of a chronic condition “decompensating” and causing a visit to the ER or hospitalization.
7. Chronic conditions can cause chronic disability of the body or mind. This often happens slowly, as a chronic disease progressively damages the body or mind, but occasionally it happens suddenly (e.g. sub-optimally managed atrial fibrillation can cause a stroke). Such disabilities are a major reason that older adults lose their independence and can seriously cramp their abilities to participate in meaningful activities.
   • Optimal management delays or prevents these disabilities. It can also enable an older adult to best work around an existing disability, by providing adaptive equipment or supportive services to help a person compensate for a disability.
8. Chronic conditions can cause premature death. Most — but not all — chronic conditions decrease life expectancy, since they increase a person’s risk of dying sooner rather than later. Such premature deaths can be sudden, happening at home or during a hospitalization. Or they can happen after a period of long slow decline, and may even prompt a referral to hospice.
   • Optimal management decreases the chance of a sudden death, and also helps a person maximize life expectancy by slowing the progression of the chronic condition when possible.
   • Note: many older adults may reach a point in their lives and health at which they no longer want to avoid death or push it back. This may be true of people who are very ill, very diminished in their abilities, or are very frail. At this point, it’s key for doctors to discuss this with older adults and families, to consider whether it’s time to focus medical care on comfort and maximizing function. (We call this “reviewing goals of care.”)

What to Know About Doctors & Getting Optimal Care for Chronic Conditions

Briefly, optimal healthcare means care that is:

1. Grounded in the most recent medical knowledge.
2. Adapted to your preferences and values.
3. Made after helping you consider the various options, along with their risks and benefits.

(For more on this issue, see “4 Steps to Get Better Medical Advice from Doctors.“)

Having studied healthcare quality and also reviewed countless patient charts over the years, I can assure you that it’s quite common for an older person’s healthcare to fall short of optimal.

But to be fair to doctors, optimal healthcare is a tall order. It requires doctors to keep abreast of a constantly growing body of scientific literature and consensus guidelines. And while most doctors are well-intentioned, they are very busy, they are creatures of habit (as we all are), and most were not trained to adapt healthcare recommendations to be a good fit for an aging adult’s preferences and for what might be most feasible for that person to implement.

It’s also very easy for things to “fall through the cracks” in healthcare. For instance, an older adults might be started on medication for mild-to-moderate depression (often without having been offered the option of psychotherapy, which is another effective option).  But then the clinical team might not get around to checking on symptoms and adjusting the treatment for quite a long time, even though in principle, doctors are supposed to re-assess the patient for symptoms and side-effects within a few weeks.

So, it’s unwise to expect that if you do nothing in particular and put yourself in the hands of your doctor, you’ll get optimal healthcare. To leave things up to our flawed healthcare system is to put healthier aging at risk.

However, if you are willing to be proactive, you can greatly increase your chances of getting better care for chronic conditions.

6 Tips to Help You Be Proactive & to Optimize Care of Chronic Conditions

Having an involved and proactive approach to your healthcare is sometimes called being an “engaged patient” or “empowered patient” or even “prepared patient.” 

Here are specific things that I recommend for most older adults with chronic conditions. If you are a family caregiver, you can help your relative with these (or you can do them, if you’ve taken over another person’s healthcare).

1. Maintain your own up-to-date list of chronic conditions.

Why: You can’t make sure you’re getting optimal care for a condition if you don’t know that you have it. Many older adults and families are unaware of certain diagnosed chronic conditions that are documented in their charts. Historically, patients have left it up to doctors to keep our health records and also keep track of what should be done. This may be convenient, but it makes it difficult for patients to be active participants in optimizing their own healthcare. Instead of remaining passive, develop a habit of keeping your own list of chronic conditions.

Note: Many electronic health record systems can provide a list of active and past health “problems.” This can be used as a starting point but usually includes a lot of extra items which may or may not be relevant. To create and maintain a good list, I recommend asking your primary care doctor for help with this, and then maintaining your list in your own record system. You can also identify chronic conditions by asking about the purpose of every medication being taken, and also listing all bothersome symptoms and making sure you understand the cause of each symptom.

For more information:

• 10 Useful Types of Health Information to Bring to a New Doctor
• Tools for caregivers: Keeping & Organizing Medical Information
• How to Review Medications for Safety & Appropriateness

2. Maintain copies of laboratory results and radiology results.

Why: Laboratory results and radiology results are usually key to understanding more about a given chronic condition, such as how severe it is, or whether it’s in good or poor control. Although in most cases, older adults and families should not interpret lab results entirely on their own, keeping copies of your results means that a new doctor will be able to quickly make better sense of your chronic condition.

Note: Results are increasingly available via patient portals. However, such portals usually only show results from a specific provider, whereas many older adults have had tests done via a variety of different clinics or hospitals. Patient portals also may not show results from ER visits or hospitalizations. I recommend families obtain and keep their own copies of results, either on paper or by storing them in an online personal health record program.

For more information:

• How to Use a Personal Health Record to Improve an Older Person’s Healthcare
• How to Get Your Medical Test Results

3. Develop chronic condition self-management skills

Why: Research has shown that when people complete a course teaching them chronic disease self-management skills, they often experience better health and well-being. Many of the taught skills are not disease-specific, and include fundamental activities such as coping with pain, making medical decisions, and communicating with doctors. However, taking a self-management course customized for a particular chronic illness — such as for diabetes — is often very valuable, as it will include practical advice on managing the condition.

Note: The Chronic Disease Self-Management Program is a clinically-validated program originally developed at Stanford, and is often offered by local health organizations and non-profits. (A version exists for family caregivers, too.) An online version was piloted by the National Council on Aging, and now is being offered in partnership with various agencies and providers.

For more information:

• About the Chronic Disease Self-Management Program 
• Living a Healthy Life with Chronic Conditions (the book written by the creators of the Stanford program)

4. Learn to research best practices for managing a chronic condition in older adults

Why: As this scholarly article notes, “American physicians often fail to provide outpatient care that is recommended by clinical guidelines.” To ensure that you are being offered the right care — as well as effective non-drug treatment options, which tend to be overlooked by many busy physicians — you should know how to learn more about a chronic condition, and recommended best practices for optimizing care of that condition. This will help you know what questions to ask your doctor, and will enable you to double-check that nothing important has fallen through the cracks.

Note: There are many ways to research optimal management of a chronic condition. However, it can be a challenge to sort through the available options to determine what is authoritative and comprehensive. Try asking your doctor for recommendations on how you can learn more about optimal care of your chronic conditions; a good doctor should appreciate your wanting to educate yourself with reliable sources. In some cases, a second opinion from another clinician can help.

For those who really want to delve into the best available science and guidelines, an excellent technical resource is UpToDate.com. This is the most widely used clinical reference tool used by doctors, and includes a growing number of topic pages specific to aging adults (e.g. Diagnosis and management of late-life depression). You might be able to access UpToDate at your local medical library, or you can even purchase a short-term subscription.

Some people also look up expert guidelines. However, these may vary in their exact recommendations, depending on the authors and the topic. Doctors — and patients — are not supposed to use them as “cookbooks,” but rather as sound starting points for developing a management plan.

For more information:

• UpToDate.com: Use the Resource Trusted by Clinicians and Healthcare Practitioners Worldwide

5. Bring a relative or another trusted person to your health visits

Why: Bringing a trusted companion means an extra person to take notes on what the doctor said, or to help make sure that all important questions or concerns are addressed. A 2002 study found that companions often improve patient and physician understanding. Companions are especially helpful when an older adult has been feeling unwell, or if there have been any memory concerns.

Note: It’s essential to respect an older person’s autonomy, dignity, and desire for privacy. Companions are most helpful when there is minimal conflict between them and the older patient. You can avoid conflict by talking beforehand to clarify expectations, and maybe even set some ground rules.

If it’s not feasible or desirable to have a family member as companion, consider a professional for this purpose. Geriatric care managers (now known as aging life care professionals) often provide this service, as do professional patient advocates.

For more information:

• For Family Caregivers: Guide to Doctor’s Visits
• What Does a Patient Advocate Do?

6. Keep track of what requires follow-up, and be proactive about getting that follow-up.

Why: Most chronic conditions require regular follow-up, to check on symptoms and adjust the management plan. However, it’s quite common for various follow-up items to fall through the cracks, or be postponed indefinitely by busy clinicians. This is partly because an older adult with several chronic problems can easily generate a lot of follow-up items. But standard clinical care has not yet perfected a method of keeping track of everything, much less keeping a patient and family in the loop.

Note: For every chronic condition on your list, regularly ask yourself questions such as “What’s the status of this problem?” and “What’s the next step in making sure the treatment and management for this is on track?” This might mean follow-up laboratory work in 3-6 months, or checking to see if a certain form of therapy has relieved the symptoms, or checking blood pressure at home for a week and confirming that the new dose of medication is suitable.

Good communication with your doctors is the best way to answer such questions. However, unless your doctor’s office is exceptionally well-organized, it’s best to be proactive about making sure that follow-up step happens. A good calendar and method of tracking tasks can be a huge help.

For more information:

• Tools for Caregivers: How to Manage Tasks & To-dos

Optimizing chronic conditions can be an effort but it’s worthwhile

You might be wondering at this point if all this is necessary, especially for “mundane” illnesses that older adults tend to live with for years, such as high blood pressure, atrial fibrillation, chronic kidney disease, or COPD.

Well, strictly speaking, nothing is truly necessary. You can certainly go on as patients have usually done, which means hardly ever reviewing their medical records, putting their faith in healthcare as usual, and hoping for the best.

But if you’re interested in healthier aging, then I recommend paying at least a little more attention to chronic conditions. You don’t want your whole life to revolve around researching and monitoring your health. But it can be very worthwhile to invest some time and effort into learning some “prepared patient” skills, to avoid the eight harms I list above.

You’ll learn more about the health problems you’re living with, and what to expect. You’ll find a way to make sure your chronic care management plan stays on track, and you’ll get better help from your doctors while avoiding common pitfalls.

And best of all, you’ll be helping to prevent health declines and health crises as you age. Which means healthier aging.

Questions? Comments? Please post them below.