Congestive heart failure and its warning signs
The term "heart failure" is something of a misnomer. It makes it sound like the heart has stopped working, but that isn't really the case. What congestive heart failure means is that the heart isn't pumping efficiently enough to keep up with the body's needs. "Heart inefficiency" might be a better term. With the proper treatment and lifestyle changes, many people with congestive heart failure can lead active lives for many years.
Stages of congestive heart failure . A patient's doctor might refer to a classification system devised by the American College of Cardiology and the American Heart Association. This categorizes congestive heart failure patients into four stages, from A (the person is at high risk for developing heart failure because of high blood pressure, coronary artery disease, or another medical condition) to D (the person has end-stage heart failure, requiring frequent hospitalizations or even hospice care).
At the earliest stage, someone may not even notice his heart failure, or it may seem to disappear once he starts taking medication. His heart failure might never progress past this point, especially if he takes good care of himself. Or at later stages he may have difficulty with everyday activities, like walking up stairs or carrying groceries. He may feel more fatigued than usual because his cells aren't getting the nutrients they need. Fluid in his lungs can cause shortness of breath -- especially when he's lying down -- or it might accumulate in his legs or ankles, causing painful swelling.
To keep heart failure from worsening. A patient must make major changes in his life: He'll need to eat differently, remember to take his medications, keep as active as possible, and reduce stress. Some of these changes might require breaking habits acquired over many years. As a caregiver, you can help him maximize his quality and length of life. Here are some ways to help.
Watch out for warning signs. Keep alert for worsening symptoms. Call the doctor immediately if you observe any of the following:
- Sudden weight gain (three or more pounds in one or two days)
- Increased swelling in the legs or ankles
- Shortness of breath while at rest
- A dry, hacking cough or wheezing
- Dizzy or fainting spells
- Increased fatigue or feeling unwell all the time
- Abdominal pain or swelling
Easing congestive heart failure with diet and exercise
Encourage heart-healthy eating
Following a diet specifically designed for people with congestive heart failure can dramatically diminish the disease's symptoms. The key to this diet is limiting salt, because too much sodium can lead to fluid retention, which worsens congestive heart failure symptoms. Although you should ask the doctor for specific dietary guidelines, these are some of the keys to a better diet:
- Cook with less salt. Reducing the sodium in a patient's diet doesn't mean condemning him to a lifetime of bland foods. Season with herbs, spices, and freshly ground pepper instead of salt. Citrus juices and vinegars can make a delicious base for marinating meat. For treats that are naturally low in sodium, stock up on plenty of fresh fruits and vegetables. Ask the doctor for a referral to a nutritionist who can offer more tips on preparing low-sodium foods.
- Look for sodium content on labels. Packaged foods, canned soups, and condiments are often loaded with sodium. Before buying, examine the nutritional information. Be sure to look at how many servings each package contains and how much sodium is in each serving. And don't forget to check the ingredient list: If sodium or salt is listed in the first five ingredients, find an alternative. For example, look for low-sodium versions of canned vegetables.
- Be a salt sleuth when eating out. A patient doesn't have to give up going out to restaurants, but he does need to watch what he orders. Many restaurants are willing to accommodate special dietary needs; ask your waitperson if the cook can prepare foods without adding salt or MSG. Substitute steamed vegetables or fresh fruit for French fries or rice pilaf. Ask for salad dressing on the side, or request vinegar or lemon wedges instead.
Even if someone follows these suggestions, it may not be easy for him to change a lifetime of eating habits. Acknowledge that it's difficult and listen to his concerns. Discuss wh at foods he does and doesn't like and involve him in meal planning. If he lives alone, you might help him prepare large amounts of low-sodium foods that he likes and freeze individual portions.
Keep the patient moving
It may seem counterintuitive, but if a person has congestive heart failure, he should stay as active as possible. Although strenuous exercise may overtax a heart that's having difficulty pumping, moderate exercise can actually help the heart get stronger. Other health benefits of exercise include weight loss, lower cholesterol levels and blood pressure, and improved circulation.
If he has always been a couch potato, it may be difficult to encourage him to get going. The good news is that even short bursts of moderate exercise can be beneficial. Simply parking farther away from the store or taking the stairs instead of the elevator can add more physical activity to his day. Housework and gardening are great ways for someone with congestive heart failure to get some exercise. You might also encourage him to join you in a morning walk around the neighborhood.
Of course, he needs to avoid stressing his heart. Talk to his doctor about what activities he can safely enjoy, and what levels of exercise are appropriate. You might also ask for a referral to a cardiac rehabilitation program.
Stop smoking, minimize discomfort, and manage medications to ease congestive heart failure
If you, the patient, or another caregiver smokes, now is the time to stop. Smoking decreases lung function, which makes the symptoms of congestive heart failure worse. But recognize that it's not easy to stop smoking. Here are a few ways you can help:
- Ask the patient what he thinks would make it easier for him to stop smoking. He may have suggestions you haven't thought of.
- Encourage him to talk about his feelings and what he's going through. Smoking may be a comforting lifelong habit; let him mourn a little.
- You may be tempted to nag or yell if he slips up, but it's more effective to be supportive. Be positive and encouraging -- and vent your own frustration to a friend instead.
- Help him avoid situations that may trigger the desire to smoke. If he's used to enjoying a cigarette after meals, try going for a short walk outside instead.
- Be understanding as he goes through withdrawal. Try not to take it personally if he's especially irritable, short-tempered, and tired.
- Quit smoking yourself. If you must smoke, don't do it around the patient. Not only will your smoking make quitting more difficult for him, but the secondhand smoke may worsen his heart failure symptoms.
If he finds it too diff icult to quit on his own, talk to his doctor. Nicotine replacement therapy, support groups, and counseling may all be helpful.
Symptoms of congestive heart failure, such as swelling and shortness of breath, can be very uncomfortable. Here are some ways you can help someone feel better:
- Comfortable, nonbinding clothing and shoes may make it easier for him to tolerate the leg and ankle swelling that often accompanies heart failure.
- Support stockings, which you can purchase at your local drugstore, may alleviate leg swelling during the day.
- Pillows that elevate a person's head at night may help him breathe more easily while sleeping.
- Limited amounts of salt and liquids can minimize retention of fluids, significantly lessening his symptoms.
Staying on top of medications
One of the most important things for managing congestive heart failure is to take medications consistently and according to instructions. Know which drugs the person you're caring for needs to take and how often he should take them. Also find out what to do if he misses a dose.
If he lives alone, you can fill a pillbox with the medications he should take each day of the week. You can also post a simple daily medication schedule on his refrigerator or in his bathroom so he can check off each dose as he takes it.
If he has difficulty following the schedule, you might want to call him at regular intervals to make sure he's taken his medications.
Making the most of doctors' appointments
Start with a notebook
One of the most important aspects of managing congestive heart failure is keeping track of symptoms, medication side effects, and other concerns. Writing down this information in a notebook will help you the person in your care stay on top of any changes in his condition.
Encourage him to get in the habit of recording basic information whenever possible, including his weight, diet, activity level, breathing difficulties or coughing, and medications taken plus any side effects. Have him note any changes in his condition, including swelling, shortness of breath, and fatigue. Finally, you both should jot down any questions or concerns you'd like to bring up with the doctor.
When visiting the doctor
Most patients have a lot of visits to different doctors. T o get the most out of appointments, bring the notebook and try to do the following:
- Prepare a list of questions before each visit. Leave spaces for the answers.
- Take notes during the appointment. If either of you doesn't understand something, don't be afraid to ask for an explanation.
- If the person you're caring for isn't following treatment or lifestyle recommendations, make sure the doctor knows it. Trying to protect him isn't in his best interest.
- Do your best to understand all the doctor's instructions before you leave, but don't hesitate to call the office if you have questions later.
Stay on top of depression and anxiety
Depression and anxiety are common in people with congestive heart failure. Feeling unwell, being unable to do some of the things he once enjoyed, and uncertainty about the future can all contribute to feelings of sadness. But if a patient seems consistently unhappy, he may be depressed. Look out for these signs of depression, and if you notice any, notify his doctor:
- Frequent crying episodes
- Feelings of hopelessness or worthlessness
- Poor appetite or increased appetite
- Sleeping too much or not enough
- Increased agitation and restlessness
- Loss of interest in life
- Expressing thoughts of dying or suicide
Depression is a serious problem that requires evaluation and treatment. But you may be able to help manage his moods with these activities:
- Help him stay active and connected by doing things he enjoys. Talk to the docto r about any physical restrictions he may have and how to get around them.
- Help him structure the day around activities that give him pleasure and a sense of purpose. For example, he could plan to meet friends for lunch, or enjoy a leisurely walk through the mall.
- Try to stay positive and upbeat, but don't foster unrealistic expectations. Instead of saying, "You'll be hiking again in no time," you might say, "If we keep walking together every day, you'll probably notice that it gets a lot easier."
- Let him talk about his fears and concerns. If it's difficult for you to listen to his feelings, you may want to find someone for him to talk to -- perhaps a therapist or some other mental health professional. A support group may also be helpful.
Help a patient help himself
Whether he lives alone, with you, or in a long-term care facility, you should encourage him to care for himself as much as possible. Although you may be tempted to take care of everyth ing for him, he'll feel better about himself if you help him perform tasks on his own. As long as he's able, he should be involved in managing his symptoms and making decisions about his treatment. By taking on too much responsibility for him, you risk taking away his independence (which can lead to depression) -- and exhausting yourself in the process.
Plan for the future
Depending on the severity of his congestive heart failure, he may still have many years of active living ahead of him. But you both should realize that his condition could ultimately worsen. As the disease progresses, talk to him about what end-of-life treatments he does and doesn't want. Find out at what point he wants a do-not-resuscitate (DNR) order added to his medical chart. Talk to him about a living will and an advance health care directives . Although these conversations can be painful, it's useful to remember that these are important decisions.
You should also discuss future plans with his doctor. Ask about his prognosis whenever his condition or treatment plan changes, and don't hesitate to ask tough questions about what you can reasonably expect. Having as much information as possible will make it easier for everyone to make difficult choices.