As the Population Ages, How to Make Geriatrics More Widely Available?

This headline above is the one I’ve been waiting for. But the one this past week in the NY Times was more in line with the usual narrative: “As Population Ages, Where Are the Geriatricians?

Now, I’m always glad to see geriatrics in the news, because this helps people know/remember that geriatrics exists.

But this article was like many: heart-warming stories of how we take better care of frail older adults, gloomy statistics on how few geriatricians we have, the requisite comments about how few doctors are signing up to train as geriatricians and how it might be because the pay is less than other doctors.

There was also the usual conflating of geriatrics with geriatricians — there’s mention of the efforts to train other clinicians in geriatrics but it’s brief. Overwhelmingly, the message seems to be that you need one of these special docs to be your PCP (or your mom’s PCP) if you want better health while aging. But these docs are scarce and getting scarcer, so disaster looms for an aging population.

My concern: this feels like a discouraging message.

Given the very definite shortage of geriatricians, I want to see headlines how we might improve healthcare for older adults even though we are short on geriatricians.

In other words, how can we leverage what we know and do in geriatrics?

Ideas on Making Geriatrics Care More Widely Available

What we need are some well-researched magazine articles on the topic, but in the meantime, here are a few ideas I’ve been thinking about:

“Virtual Geriatrics” for information and consultations

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Epic Medication Reconciliation Fail: A True Story

pills isolated on white background

pills isolated on white background

Today I want to share a true story that I’ve been mulling over recently, as I ask myself when will we start to see more substantial gains in health care quality.

It’s the story of a 94 year old woman who was sent from her memory-care residential unit to the emergency room, due to nausea and vomiting. She ended up being hospitalized for about 48 hours, for UTI.

(Sad but true aside: her family has asked for hospitalization to be avoided unless absolutely necessary for comfort. But the facility feels they have to send her to the ER if she falls, vomits, or otherwise looks seriously ill. Argh.)

Before hospitalization, she was only taking vitamin D and a daily aspirin and a multivitamin. She’d been in the memory unit for years due to dementia, and on minimal meds since “graduating” from a stint in hospice a few years ago. Because she’s chair-bound and it’s hard for her to leave the facility, she hasn’t been to her PCP’s office in years. Instead, I come and see her at the facility once or twice a year.

Guess how many medications she was discharged from the hospital on? Fourteen.

As in, fourteen new daily medications to be taken indefinitely! (There was also a course of antibiotics for UTI plus a few new PRN medications.)

I thought I was hallucinating when I saw her med sheet at the facility. [Read more…]

Still Waiting on A Personal Emergency Response System to Recommend

I’ve been interested in the PERS (personal emergency response system) offerings for quite some time, because families routinely ask me about these. The classic PERS device is a pendant device with a button to push, and often I see older adults in assisted-living facilities wearing these. (Do facilities offer residents a discount on these? Are facilities getting a commission? Or does it help facility staff do their work? I’ve never known.)

Residential facilities aside, in my work PERS devices come up especially for vulnerable older adults who live alone. I know many seniors who have fallen, fractured something or otherwise been injured, and have not been found for hours or even days. Needless to say, lying injured on the floor is often disastrous for health, and such falls often prompt a permanent relocation to a more supportive — and generally more expensive — living situation.

So I certainly understand why people are drawn to PERS devices, assuming an older adult is willing to wear it — but many forget or don’t want to. A PERS also has to activate when an emergency occurs, either by automatically detecting a fall or problem, or because the user triggers it.

Should we be using PERS devices that require users to call for help? Studies generally find that most older adults do not trigger their call system after a fall. Here’s a quote (emphases added by me) from this very interesting study of older adults and falls: [Read more…]

Physician Autonomy vs Patient Participation & Information

This image went viral on Facebook earlier this week. It generated over 125,000 shares and over 7000 comments.

There’s been some good commentary on it (I especially like e-Patient Dave’s post), which I won’t recap here.

Instead, I want to share some thoughts as to how these issues might affect our quest for improving the healthcare of older adults.

Here are some specific things that I’ve either observed or had reported to me over the past several years:

1.Many doctors do not, in fact, provide optimal care to older adults. It pains me to say this, as  I know these clinicians are usually working very hard, have good intentions, and are badly hobbled by a dysfunctional practice environment. But it’s true, and I want to call out two variants of the problem. [Read more…]

Why Is It So Hard to Get Detailed Medication Info from Assisted Living?

pills isolated on white background

pills isolated on white background

Here is a need which I’d like to see new technologies address: the need for improved and facilitated communication about medications in assisted living.

This comes up often in my clinical work and in this post I’ll share a recent true story, illustrating some of the issues. But it’s not just a problem for me; it’s an important aspect of the care of a growing aging population, which will require better integration of health care and “life care.”

Today, it’s common for people in assisted-living to be on many medications; residents of these facilities tend to have many chronic health conditions. (For an excellent overview on who’s in assisted-living and the challenges facing the industry, see Howard Gleckman’s post “The New World of Assisted Living.”)

And many of them pay to have the facility do “medication management”; this gerontology article states that this is a major reason for moving into assisted-living.

What exactly “medication management” means seems to vary a bit depending on the facility, and perhaps also on state regulations. Generally, the facility obtains medications from a pharmacy – it often seems to be one they have contracted with — and dispenses medications to the residents, based on the orders of clinicians.

Having a layer of professionals involved in medication dispensing can be pretty useful, especially when older adults have developed cognitive impairment. After all, you have someone else making sure the medications are obtained from the pharmacy, keeping medications in a safe place, and reminding patients to take them.

As a clinician, I greatly appreciate being able to know whether a patient actually took a prescribed drug. That’s because when people live independently, they often don’t take their medications as prescribed, and it can take a lot of effort to find out just what they are taking, and how often they take it. (Never mind the time and effort required to go into the reasons why they may not be taking their medications consistently, which is important and patients often have good reasons.)

So medication management in assisted-living should make this problem easier for me. But so far, it’s not all that easy for me to leverage the information that a facility has, regarding medications.

I’ve been thinking about this recently because one of my patients in assisted-living fell seriously ill recently. And it was her leaving me a message complaining about her PRN pain medication that alerted me to her significant decompensation.

Does Anyone Track Changes in PRN Medication Use?

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The Physician and the Fitbit

IMG_4643About six weeks ago, I lost my Fitbit Flex.  I’d been wearing it for two years, almost to the day.

This apparently makes me an anomaly. Consumer surveys suggest that many people — perhaps even most — lose interest in their devices within a few months.

I’m not surprised that many people would abandon using their tracking devices. People have a lot going on in their lives. It never seemed very plausible to me that vast numbers of “ordinary” people would adopt technology to change their health habits.

But does that mean wearables will be useless in healthcare (the organized part of the system) or “health care” (the way people take actions to improve their health or the health of someone else)?

It is really too soon to say. So much depends on whether a company like Fitbit can better understand what different types of users want and need from a device. I personally believe that the people who are most likely to benefit health-wise from the data-gathering capabilities of a device are also the ones who are most likely to be involved with healthcare professionals. People like Joan, for instance.

This is actually why I purchased a Fitbit in the first place. In the fall of 2013, it was a popular wearable device and I wanted to see whether it might be able to help address some common issues that we often help people with in primary care.

In this post, I’m going to share my own experience with my Fitbit, including how I can envision it being useful in the context of primary care. But if you are interested in wearables for older adults, I highly recommend reading this AARP report (July 2015), in which they studied the experience of 92 older adults using sleep and activity trackers. (Lots to pick apart in that report; perhaps in a future post.)

There is also some extremely interesting information on the state of the digital health industry here, summarizing Rock Health’s 2015 report on consumer adoption trends in digital health.

Could a Fitbit Help With These Two Primary Care Issues?

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Louisville & Creating the Future of Aging Care in a City

ok louisvilleLast week, I had the honor of speaking at the Louisville Innovation Summit, where the theme was “Creating the Future of Aging Care.” This was my first time visiting Louisville, which is the home base for several large organizations in healthcare and long-term care.

Much of the conference was interesting (you can see the program here) but what captured my interest and imagination the most was this: in his keynote, Paul Bennett, the Chief Creative Officer of IDEO, urged the city of Louisville to take the lead in reimagining aging.

Now, in truth I’m not really sure what he has in mind when he says this and I suspect that it’s different than what I think of. To begin with, he explained that IDEO is launching a global project on aging called The Powerful Now. Here’s how the project is described on their site:

“AGING IS BEING REDEFINED.
NOT AS A PATH OF DECLINE, BUT ONE OF RENEWAL.

Doesn’t that match your own hopes, wishes, and desires? To become more curious. More engaged. More vibrant. Physically and emotionally. Deeply connected to the ideas and the people who matter to you.

The Powerful Now is about bringing the power of creativity to how we conceive of, design, and experience aging. If you were to add up all the people who are fifty years and older, they would be the third largest economic superpower on Earth.”

Hm. I am all for reimagining aging in positive terms. But what I care most about is solving the age-associated problems that cause older adults and their families the most excess suffering.

What I want to see is a city that creates or implements effective systems for optimizing the health, function, wellbeing, independence, and dignity of older adults. And I want to see a city that succeeds in doing so especially for older adults who are experiencing:

  • Medical complexity, meaning multiple chronic illnesses or health problems such that they often encounter the hospital or emergency room
  • Chronic impairments of mind, body, or both, meaning dementia or chronic impairments of physical function
  • Difficulty managing ADLS and/or IADLs (which is usually due to acute or chronic impairments of body or mind, obviously)
  • Residence in assisted-living or a nursing home.

The images we use as we articulate our vision of better aging are important. Paul Bennett spoke of how moved he was by seeing older adults in a Shanghai park, waltzing as they did their group exercise.

Very nice. But I want to see images of people with walkers waltzing. I want more images of people who need support, and yet are still living vibrant lives and contributing to the community around them. You might have mobility impairments and need services and because you are GETTING the services you need, you are able to volunteer and help your community benefit from your wisdom or experience or education or even just presence as a friendly person.

I also want to see a city that effectively helps family caregivers support their older loved ones with the problems above.

Taking on such a project at a city level actually makes a lot of sense. To help older adults live their best lives, even as they face the common challenges of aging, you need to integrate health care, social services, housing, employment policies (esp as regards family caregivers), and much more. Seems to me that a city would be a good laboratory for experimenting or attempting to implement best-known practices. Once one city has made progress, it can serve a  model for other cities.

So if Louisville wants to do this, what needs to happen?

I actually know very little about what enables cities to mobilize on a big project like this. But if I were to get going on this, I’d start by making a list of what’s needed, and then I’d look for promising approaches to meet each need. Then I’d work on implementing those approaches and making a plan to assess how well it’s working as you go along, a la Plan-Do-Study-Act method.

(After drafting this post I found that AARP does have a network of “age-friendly cities” and offers a toolkit here. If anyone knows how well that’s been going for those cities, post a comment! And do they ever have conferences related to this project??)

A list of what’s needed and promising approaches would make a good agenda for a future conference.

What’s needed for a city to better support an aging population

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Health 2.0 in 2015: Big steps forward

This week I attended Health 2.0’s Annual Fall Conference for the third year in a row.

I came away more impressed than I’ve been in previous years. Here’s why.

The Unmentionables Focuses on Aging, Caregiving, and Hospice

The Unmentionables session hosted by Alex Drane is always terrific, but this year was especially so, since it focused mainly on aging and caregiving.

If the video is ever made available I’ll post it here. In the meantime, you’ll have to make do with my Storify collection.

Particularly notable: [Read more…]

Aging, Health & Innovation as Geritech turns 3

Exciting times are afoot these days.  The end of this month will mark three years of the Geritech blog, so seems like a good time to step back and consider how things are progressing with aging, health, and innovation.

What is kind of neat is that the blog’s anniversary coincides with two major health and innovation conferences: Stanford’s Medicine X, and Health 2.0 (the flagship Annual Fall Silicon Valley conference).

The medical education part of Medicine X is underway as I write, with the main conference events scheduled for Sept 25-27. I’m sad to not be attending Medicine X this year  –have to be in New York for a family event — but I plan to attend Health 2.0 in early October. (I will also be attending — and speaking! — at the Louisville Innovation Summit in October, which will focus on aging.)

Both Medicine X and Health 2.0, which I attended in 2013 and 2014, are hugely influential, albeit in different ways. So it’s very interesting to review their programs (see here and here), and consider what they are presenting in terms of aging, the care of people with multiple chronic illnesses, and helping older people with functional limitations.

I’m happy to say that both conferences are featuring more programming specific to aging this year!

But first, my own gut impressions when thinking about what’s changed — and what hasn’t changed — over the past three years.

Then I’ll briefly share which upcoming sessions at Medicine X I’ll be especially sorry to miss. I can’t even watch the Medicine X livestream as I’ll be on planes or with family for the next three days. But you could watch! (And I’ll cover Health 2.0 in a future post.)

What’s changed in aging and health over three years

Honestly, at a high level and considering what counts the most — the experience of average older adults and their families — I would say not much, although good things do seem to be brewing. For instance:

The average healthcare experience of older adults and caregivers hasn’t changed much. This is my impression, based on what I hear patients and families complaining about and based on the stories I read in the mainstream press.

Now, many facilities and providers are innovating and trying to improve healthcare, and technlogy is playing a factor in that.

But the improvements seem to either be quite localized (I’m thinking of Mayo’s August 2013 study using Fitbits to improve recovery after surgery; this hasn’t become the post-op norm as far as I know) or of middling impact when it comes to people’s healthcare experience (e.g. more widespread patient portals, Blue Button downloads).

This isn’t to say that all the work on innovation and digital health has been useless, of course. It’s more to say that I don’t see major change. Yet. (Do you??)

Which means that either

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Case Study Part IV: What Joan Really Needs From Her Healthcare

senior health and medications

Today, I’m going to share the fourth and final part of my case study about Joan, a 79 year old woman struggling to manage her many chronic conditions.

I created this case study for my upcoming ebook, because over the years I’ve noticed that different people can have very different perspectives on a single person’s health challenges.

So in the book, I cover the perspective of Joan herself, the perspective of Joan’s worried family caregiver, and then the viewpoint of Joan’s primary care provider, Dr. Miller.

But of course, there’s one more perspective that’s essential to consider, if you are developing tools to help people with their health. That’s the external “expert” analysis and perspective, which I share below.

When it comes to healthcare — or anything important — we can’t assume that front-line users know just what is best, and what’s most likely to help them achieve their goals. That’s why truly useful tools must facilitate “best care,” or at least better care. Here’s what that could look like for Joan.

What Joan Really Needs From Her Healthcare

Dr. Miller’s not a bad doctor. But he’s busy, he’s under pressure to meet quality measures, and he hasn’t been trained to modify healthcare for older adults.

Like many doctors, he’s pretty focused on Joan’s documented health diagnoses. But what Joan really needs is for someone to help her with her health problems. I’d list these as follows: [Read more…]