Aging in Place: What are the problems to solve?

I came across a thought-provoking report recently, titled “Technology for Aging in Place 2016,” by Laurie Orlov, a market analyst for aging technology. The report seems to be an update to her 2014 report on aging and technology, which I commented on in this post.

As always, I’m interested in how business people conceive of needs and approaches to solutions, and how that compares to our view of the needs and issues as aging health professionals.

A striking fact which I hadn’t previously appreciated is that many older adults remain in their homes while aging because they can’t afford to move elsewhere. Per Orlov:

Median net worth of the 75+ age range is now $156,000, inclusive of home equity (see Figure 1). This is deferring moves to assisted living – its move-in age now a mid-80’s and frailer demographic. But boomers are right behind them – and even less able to move in. They have simply not saved enough – holding an average retirement savings portfolio of only $136,000 – enough for just two years of a private assisted living community like Brookdale.

Orlov also cites this AoA data summary, which reports that

  • About 28% (12.5 million) of noninstitutionalized older persons live alone (8.8 million women, 3.8 million men).
  • Almost half of older women (46%) age 75+ live alone.

In short, we have a growing population of older adults, many of whom have limited financial resources, and many of whom live alone in the community.

What percentage of older adults are living in their own homes was unclear to me; Orlov states “Eighty percent of older adults today live in their own homes,” however the reference provided does not address this particular statistic.

To me, “living in your own home” means you own the home. I did find a very good report on aging and housing from Harvard’s Joint Center on Housing Studies, which notes:

Among those aged 80 and older in 2011, fully 60 percent had lived in the same residence for 20 or more years. Another 18 percent had occupied their homes between 10 and 20 years.

However this data is from the American Housing Survey, so presumably it is referring to older adults who are already in community housing, as opposed to all older adults.

The NIA report “Growing Older in America” does provide data on living situations and says 79% of older Americans live in their own homes, however this report is based on Health and Retirement Study data from 2002, and 2002 is starting to feel like a long time ago. Hence, I am still left wondering just where older adults are living, and it would be nice to see updated data addressing this issue.

The most important questions to ask, to address aging-in-place

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The geriatrician & social media: On goals & motivations

Social media

Patricia Bach, a geriatric psychology colleague who is active in social media, recently emailed me a question: how to encourage more clinicians in geriatrics and long-term care to use social media?

In particular, she asked me “What do you feel is the ROI for geriatricians to use social media/networking in their professional roles?”

This is an interesting question to consider. After all, we have a limited number of geriatricians available for a growing older population. We also each have only so much time and energy in every day.

So how should each of us be spending our time? How much should be on social media, and do we all need to be using it?

I myself really like blogging — obviously — but was a reluctant adopter of shorter-form social media. To this day, I have a minimal personal social media presence. I only got going on Twitter because I started this blog in the fall of 2012. For me, Twitter was a good way to learn about digital health and connect with others interested in tech and aging.

Then I started using Facebook in 2014, mainly because I was focusing more on my geriatrics content for the public, and at that time Facebook seemed to be a better platform for interacting with the general public, compared to LinkedIn or Twitter. (I would say this is still true.)

In adopting social media for these reasons, I was manifesting something that is very important to consider when it comes to physician behavior — or really any person’s behavior — with a respect to engaging in a certain activity:

  • What are the most important motivators and interests for the person? What are they most eager to accomplish? How does the activity address those?
  • What are the demotivators? What are the downsides to engaging in the activity?
  • How much friction or difficulty is involved in engaging in the activity?

You can also consider an activity in terms of “Return on Investment” (ROI), however, this term doesn’t usually take into account how soon the return is going to arrive. And we know that people are much more motivated by concrete returns that happen fast — and are related to something currently of great interest/appeal/fear to them — whereas they discount returns that are coming way off in the future.

Social media is about communication and networking

Back to social media itself. It is fundamentally about communicating and networking. So to use it sensibly, I recommend individuals — or larger entities — consider the following: [Read more…]

How many phone calls & faxes does it take to evaluate a common complaint in assisted living?

If we are going to provide compassionate and effective care to an aging population, at a cost we can all afford, we are going to have to get better at dealing with health concerns that come up often.

I am perpetually struck by how much effort and friction is involved, when I have to address certain common health issues.

Today I’m going to share a recent example: new confusion in a 90-year-old elderly woman who lives in assisted-living. Goals of medical care are to avoid hospitalization, and to focus on optimizing function and comfort.

Brief backstory: this elderly woman has Parkinson’s disease, but generally has very good cognition. She has private 24-hour caregivers because she can’t get up out of chairs on her own, needs stand-by supervision when she gets around her apartment with a walker, and needs to be taken by wheelchair to the dining hall and other locations within the facility. She also needs help with continence care. And, she’s been getting home health services for the past few months, for a sacral pressure sore.

As you can see, lots of people involved in her health and care: private home aides, home health agency RN, assisted-living facility staff (which includes their own RN), and an attentive adult child who visits often. This lady is essentially home-bound but very occasionally gets out to see her neurologist or another healthcare provider.

And now for what happened with confusion. For me the story started when the woman’s son sent me a message, saying his mother was now having delusions and crazy thoughts, and that her paid caregiver said she hasn’t been herself for the past 36 hours.

So this sounds like delirium: worse than usual mental functioning, generally brought on by an illness, stress on the body, or sometimes by a medication side-effect.

In other words, this is a common concern that comes up for many older adults, especially if they have a chronic condition that can cause cognitive impairment, such as Parkinson’s.

And cognitive impairment is apparently very common among assisted-living residents. Here’s what a 2014 Health Affairs paper says:

Estimates derived from national data indicate that seven out of ten residents in these residences have some form of cognitive impairment, with 29 percent having mild impairment, 23 percent moderate impairment, and 19 percent severe impairment. More than one-third of residents display behavioral symptoms, and of these, 57 percent have a medication prescribed for their symptoms. Only a minority of cognitively impaired residents reside in a dementia special care unit, where admission and discharge policies are more supportive of their needs.

Given this data, delirium must be very common in assisted-living, and you’d hope that a clinician would be able to evaluate and manage without too much hassle. But let’s see what happened in my case.

Evaluating a worsened confusion complaint in the real world

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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:


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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