Case Study: The Story of Joan & Her Health

Did you know: in 2010, 46% of fee-for-service Medicare spending went to those 14% of beneficiaries who had six or more chronic conditions. (See Fig 3.2 of the 2012 Medicare Chronic Conditions Chartbook.)

You might think those are unusually sick seniors. But when I practiced primary care internal medicine, I saw people with 6+ conditions all the time. As you can imagine, they tend to see doctors a lot. (That data is in Figure 2.4 of the chartbook.)

It’s actually not that hard to end up with several chronic conditions by age 65: a history of smoking and being overweight in middle age will easily bring on 6+ chronic conditions later in life. And many of those seniors don’t look that sick or disabled.

But they struggle with their symptoms, and they especially can struggle with an overwhelming amount of “self-healthcare” to manage.

If there’s anyone who would benefit from digital health technology, it’s them. They need help with their health. Their primary care providers need help helping them. Their adult children are worrying. Oh and, we want to help them in order to minimize ED visits and hospitalizations, which are distressing for seniors and expensive for all of us.

Unfortunately, over the past three years I’ve found very little that seems usable and useful for these seniors with multiple chronic conditions.

So as part of my upcoming ebook about better digital health for seniors, I’ve written a little story. It illustrates the situation of Joan, an older woman struggling with multiple conditions. I’ve even included her medication list.

As you read this, consider the following:

  • If you’ve developed or are using a digital health app or service: do you think it will work for Joan?
  • More importantly: what do you think would be most beneficial to Joan right now, to help her with her health?

Joan’s Health Story (According to Joan)

Joan, aged 79, is more than a little tired of dealing with her health.

She didn’t always have health problems. She had a career and raised her kids and earned a good pension that supports her now that she’s retired. She lost her husband to a heart attack years ago, but she’d be doing fine on her own if she didn’t have to keep going to the doctor all the time.Maybe she hadn’t taken the best care of herself, but who knew the difference? Everyone smoked. And she quit five years ago anyway. She’s maybe a little overweight, all right, but you try having three kids and see if you stay slim.

She puts on a brave face but she feels a crippling guilt sometimes for not looking after her health. Maybe it’s her fault that she has hypertension now, and high cholesterol. She knows her diabetes and the osteoarthritis in her knees can probably be traced back to her weight, and her doctor’s told her that smoking caused the chronic obstructive pulmonary disease, and maybe the atrial fibrillation too.

He said something about her kidney function last time, too. She can’t remember what it was. He didn’t seem like he was that concerned, so she won’t worry about it just yet.

She tries to take her pills when she should, although she slips up more when she’s feeling depressed.Joan's prescription meds

She has seven prescription pills and two inhalers, plus she takes vitamins and calcium. When her knees hurt – which is almost all the time these days – she takes over-the-counter painkillers. She likes the PM versions; they help her sleep. One of them is bad for the kidneys, but she can never remember which one. It’s either the Advil or the Tylenol. Who can keep track?

On top of all that, she’s supposed to keep a strict diet for the diabetes and check her blood sugar every day. But the doctor hardly ever looks at her glucose logs anyway, and it hurts, sticking yourself every day like that. And she’s tired. She’s alone now, and she hurts all the time.

They want her to exercise too, to lose weight. But it’s so hard with her arthritis, and she’s too tired to do much of anything. She often gets short of breath even when she’s not running around, from the COPD. Or is that her atrial fibrillation? One of them, anyway.

The doctor said she should try checking her pulse when she feels short of breath but who wants to check a pulse when you can’t breathe? She just wants to sit down and rest until she feels better. She doesn’t even know how to take her pulse, anyway. Sure, you put your fingers on your wrist, fine, and then you count. But for hJoan's health diagnosesow long? She doesn’t even wear a watch – how’s she supposed to keep time?

Between the doctor’s visits and the shortness of breath and the arthritis pain, it’s gotten so hard to do the things she wants to do. She can barely see her friends or do anything fun. She just hurts all the time. Susie, her daughter, is worried she’s depressed. She doesn’t really think so. She’s not sad or anything like that. She just doesn’t want to do much. She just wants the pain to go away.

She fell down the other day. She’s not sure why. She just felt light-headed, stumbled, and fell down in her living room. It took her a while to get back up, and Susie was mad at her. “Mom, you need to tell the doctor. It can be dangerous for you to fall at your age.”

“I did tell the doctor. She says to check my blood pressure next time and let her know if it happens again.”

Susie didn’t like that. She kept saying how Joan needs to take care of herself, before all the health conditions get worse. Susie’s a good girl but she doesn’t understand. She’s raising her own kids. Joan remembers what that was like. Sure, you’re tired all the time, but your body still works. You can still run around after them. You can still remember the ballet recitals and the doctor’s appointments and the way they like their sandwich made. Suzie just doesn’t understand, that’s all.

It’s hard being older with health problems. The doctors give you so much stuff to do and remember, but you can’t remember everything. You can’t run around getting things done. No one seems to realize that.

Comments

  1. This is an eye-opener, Dr. K. You could be describing any number of seniors I know, including my late mother (who was coincidentally also named "Joan" and just a few years older than your Joan when she died in her nursing home.

    Your Joan is just one more fall away from spending the rest of her limited days left on this earth in such a facility. I'm not a physician, but I've been reading more and more lately about the trend towards deprescribing especially in the elderly, and it seems Joan might be a prime candidate for a medication review.

    Why, for example, is an almost-80 year old woman taking statins, which have been linked in some studies with an increased risk for falls in older adults? Joan needs to stop taking anything that makes her feel worse, and to start doing anything that makes her feel even a tiny bit better – like playing with an affectionate pet visitor, for example!

    You mentioned twice in this post that she "hurts all the time" which tells us something important about every other issue she presents. It's virtually impossible to focus on health (or socializing, or sleep, or exercise, or taking your meds) while living with pain and fatigue.

    What Joan does not need, in my opinion, is a digital app or other form of "nanny tech" to nag her into compliance with doctors' orders (despite what the tech hypesters will insist about their life-altering miracle devices that will change health care as we know it).

    When will your new e-book be coming out? Looking forward to that…

    regards
    Carolyn Thomas

    • Carolyn, thank you so much for this thoughtful comment. I'm glad to know this story resonates with you.

      Agree that Joan is at risk. I think the entrepreneurs don't usually think of someone like her when they think about "prevention," but optimizing her health issues could certainly prevent or delay further decline, or a catastrophic event such as a fall.

      More importantly, optimizing her health would help her feel better, and she'd be more able to participate in her community.

      Re statins, agree that they are likely overprescribed to many, including seniors. That said, overtreatment of hypertension and diabetes is probably a more common cause of falls in seniors.

      Whether technology will help Joan or further burden her is a good one. After the recent White House Conference on Aging, Susannah Fox wrote a post noting that really good technology often feels nearly invisible to us…think of electricity, or all the tech under the hood of our cars, or the work that our washer and dryer achieve. How soon we'll have such technology for self healthcare is hard to say though. So far I think most tools don't seem to make things much easier.

      But fundamentally, technology is supposed to help us do something more efficiently, or help us do more with our effort. Joan has a lot to do. It needs to be made easier.

  2. I love reading this blog. I have the opposite going on with my mother. She is almost 90 years old and really does not do well with new tech. My sister and I have gotten her cell phone after cell phone and she just does not do well with them. Our problem is more dealing with her high blood pressure and depression. I and I guess my sister are more comfortable with it being high as opposed to it being too low and increasing her risk of falling. I would be more comfortable with her just getting regular prompts on a landline reminding her to take her meds

    • Leslie Kernisan, MD MPH says:

      Thanks for commenting. Your situation sounds pretty common, I don’t see people in their 90s taking to cell phones very often. Tablets seem a little easier, depending on how they are set up. (Some are designed specifically with a simplified interface.)

      Re BP, I do encourage families to get a home BP monitor. The Blipcare monitor connects directly to wifi so no smartphone or tablet required, and it makes it much easier to get more info on how a senior’s BP is doing. (The initial set up is a pain however, and someone still needs to make sure the senior uses the monitor.) I have info on how families can choose & use a BP monitor here.

      How to help seniors remember to take meds and how to know if they have taken their meds is a perennial bugaboo. If landline prompts work for your mom, that’s great!

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