4 common senior health problems that need solving

I noticed a few weeks ago that Brian Quinn over at RJWF Pioneer was asking for problems for the holidays. Apparently he is frequently approached by people with solutions, not with problems.

I wish he and I could switch places for a few weeks. You want problems? I’ve got problems, going up the wazoo (not my own, fortunately) and out the ears (which I do look in; lots of older people hear better once that wax is removed).

For instance, in my last post I mentioned some very common problems that I’ve discovered among most of my patients, even among my wealthy white educated Medicare patients.

In this post I’ll clarify these problems a little bit more, and share some thoughts on some approaches that I can envision helping solve each problem. (Hint: I can see a future for tech solutions here.)

Disclaimer: These are big complicated problems. I briefly list a few reasons why they happen, but this obviously can’t be comprehensive. (There’s a reason why expert workgroups produce such long reports.)

Real problems of real elders (whether wealthy or not)

• Prescription of medications that cause confusion and worsened balance in seniors (and may increase the risk of developing dementia: see here and here). 
• Why it happens:
• Many common prescribed (and OTC) medications are “psychoactive”. These are the ones that usually come with warnings to not drive or operate machinery.
• Most doctors know, when asked, which medications have these side-effects, but they underestimate how likely it is that an older patient will be affected.
• What could help:
• An app or other service that helps patients and caregivers quickly figure out whether a prescribed medication is on the Beers Criteria. This is a list of 34 medications and types of medications that are “potentially inappropriate” for older people, and was last updated in 2012.
• A Beers Criteria App exists for healthcare providers, but I haven’t found one yet for patients and families.
• The app should provide guidance on how to constructively engage providers when an potentially inappropriate medication is prescribed. The American Geriatrics Society offers suggestions here.
• Most important is that the app make it super easy for patients to enter the medication name into the app. Has anyone yet developed a way that patients can take a picture of the prescription bottle, or barcode, or QRS code? (I’m so tired of medication apps that require people to laboriously type in medication names — huge usability killer.)

• Dementia that goes undiagnosed for far too long; once diagnosed, inadequate education and support for family caregivers
• Why it happens:
• PCPs are too busy; they have too much to do, and far too little time.
• Many PCPs are uncomfortable doing cognitive screening, both because they haven’t done it often and because they aren’t sure exactly what to do with the results (nobody likes to open a can of worms).
• What could help getting diagnosis started:
•  Cognitive screening is now supposed to be part of Medicare’s annual wellness visit. A suitable app could help patients and caregivers be proactive in gathering practical information prior to the visit. This should include a questionnaire on ability to manage IADLs independently; problems with IADLs are a good sign that further cognitive evaluation is needed. One could also include a short questionnaire based on something like the Alzheimer’s Association’s 10 signs.
• I currently find no app available to help patients and families prepare to bring up a concern of cognitive impairment to a clinician. Does anyone know of one?

• Lack of care coordination among multiple specialists and care sites
• Why it happens:
• Many reasons, including siloed information, not-yet-widely-compatible HIT systems, clinicians unused to having to coordinate with others and share information.
• Those patients and families who are willing to keep their information and move it with them have found it hard to obtain and organize their information. (I’m eager to see if the new Blue Button output will help.)
• What could help:
• This problem’s too big to address in this post. Eventually we’ll have better personal health records and health information exchange.

• Inadequate understanding of overall health status, health trajectory, and prognosis
• Why it happens:
• Many reasons; generally clinicians are lacking the time, comfort, and sometimes experience in addressing the “big-picture” with patients and families, especially if that big picture isn’t looking so rosy.
• What could help:
• Clinicians need a lot of training and support in order to do their part. Apps and programs are sorely needed to help calculate life expectancy, likelihood of dying in next few years, etc. Right now it takes a lot of work to get the right data right now; imagine if clinicians could instead ask Siri (or IBM’s Watson). Then they could focus on the task of sharing the info with the patient (this is hard, and before especially tough talks I still review something like the Fast Facts for Palliative Care, or Uptodate).
• While we wait for millions of clinicians to get more training: it would help if patients and families could be coached in how to ask their providers to address big-picture issues, by regularly saying things like “How do you expect my overall health and function to evolve over the next five years?” Or “How important is managing this condition, in the overall context of my loved one’s health?” (This is when we can opt to not do routine cardiac testing in the dementia patient who is peeing blood and losing weight — true story from several years ago! We really need to help both clinicians and families see the forest before addressing the trees.)
• Coaching and patient education interventions have been developed and tested; the issue is making them more widely available and usable for patients and families.

Ok, I will list ideas for addressing the second half of my list in my next post.

In the meantime, if any clinicians or others have ideas on how to address the above problems, please comment or email me.

In a nutshell

Even wealthy educated older adults repeatedly suffer from certain pervasive problems in outpatient healthcare. These include the prescribing of risky medications, late diagnosis of cognitive impairment, lack of care coordination, and inadequate understanding of overall health status and prognosis.

In this post, I briefly summarize some key causes for these problems and some ideas for addressing them.

I’d love to be pointed towards any practical tools or technologies that can help clinicians, patients, and families address these issues.