This post is a continuation of the previous post, and briefly describes five more problems that I often come across in my older patients, regardless of education and socioeconomic status. I have some preliminary ideas on how tech tools could help, and of course am open to any and all feasible solutions.
(Disclaimer repeated: These are big complicated problems. I briefly sketch out a few reasons why they happen, but there is of course more to them than I can describe here.)
More real problems of real elders (whether wealthy or not)
- Lack of non-pharmacological treatment for conditions such as
depression, gait instability, pain, incontinence, and dementia behavior
management - Why it happens:
- Because it’s easier to for busy clinicians to prescribe a pill than
to negotiate and arrange for non-pharmacological management, even though
a non-drug approach is often safer and preferred by patients. - Because clinicians may not be aware that there are non-pharm
alternatives that have been proven to be effective. Examples include
physical therapy for gait problems and pain, psychotherapy for
depression and insomnia, bladder training or timed toileting for
incontinence, and REACH to help caregivers manage dementia. - What could help:
- I’d love to see an app for older adults that lists several common
diagnoses that can benefit from non-drug management. This could be done
in an evidence-based way. Ideally it would somehow make it very easy for
the provider to prescribe/refer, too. - Patients and caregivers need help speaking up and asking for alternatives.
- Procedures and diagnostic evaluations of unclear clinical benefit
- Why it happens:
- Providers are used to ordering lots of procedures and diagnostic evals – reflexes and habits die hard
- Patients often request them (in part because they overestimate the likelihood of benefit)
- Providers may not actually have time to think or look up likely benefits
- Explaining the likely benefit to patients is time-consuming, especially when they have their hearts set on some test
- What could help:
- For clinicians: tools that make it very easy to access statistics related to the likelihood of benefit.
- I myself really like knowing the Number Needed to Treat (and Number Needed to Harm). Clinicians also should be able provide at least approximate “base rate” data to patients, i.e. if a cardiac cath is under consideration in order reducing heart attack risk, clinicians should not only say approximately how many people have to be cathed to avert an important outcome, but they should also be able to say roughly how many individuals are expected to have the heart attack or other outcome over the next 5-10 years.
- As a clinician I can usually find some of these numbers by checking UpToDate or searching the literature, but it’s way too labor and time-intensive to do routinely.
- Note that decision aids help with some of this, but I find it’s often not so easy to find a suitable decision aid right as I’m clinically working.
- For patients and families: there should be patient-oriented versions of the data above.
- Patients should also be coached on how to ask about expected benefit and base rates every time a significant procedure or test is recommended. Ex: “How are you expecting that I’ll benefit from this procedure, and what is the likelihood that I’ll actually benefit?“
- In truth we need a national push to improve health literacy when it comes to numbers and statistics, and then we need point-of-care tools that make the data easily available AND provide tips on how to convey it/digest it.
- Decision-aids are helpful but it needs to be easier for clinicians to find a good aid for the topic at hand, right when they need it.
- I love the way Amazon shows me what’s been popular, and what other shoppers like me have looked like. Would be great to see similar features in an online decision-aid repository:
- easy to search based on features/filters (like age & general health condition of patient)
- clinicians being shown items used by similar clinicians, i.e. it should know I’m a geriatrician and should show me items downloaded or flagged by other geriatricians
- Lack of clarification of values, goals, and care preferences
- Why it happens:
- Most providers haven’t had enough training or practice discussing values/goals/care preferences with patients and families
- Providers also tend to be very rushed and they focus on what is urgent and easier to take care of
- Patients and families often don’t realize the importance of articulating values and goals, and may not realize that their healthcare could be provided differently. (There is quite a lot of research demonstrating that patients often — but not always — prefer less aggressive medical care, when offered enough information and a choice.)
- Patients and families need support in asking clinicians to accommodate their preferences.
- What could help:
- We should certainly keep trying to educate providers, but my guess is that we’ll get faster results if patients and caregivers start using advance care planning tools like PREPARE, created by my UCSF colleague Dr. Rebecca Sudore.
- I’d love to see tools that coach patients and families on how to constructively insist that clinicians discuss values and goals. Has anyone come across some?
- Inadequate symptom monitoring and management, including inadequate pain management
- Why it happens:
- It’s often hard for providers to remember to follow-up on a symptom, especially in older complex patients who have multiple items which could be addressed in the visit
- Providers may not be very comfortable addressing certain types of symptoms, especially those for chronic conditions that aren’t curable or don’t respond easily to a prescription (everyone prefers to work on something that feels very doable)
- Patients and families often are not told how to track a symptom and the response to a proposed management plan, or they lack the tools to make this easily doable
- What could help:
- Clinicians need EMRs that keep track of unresolved symptoms, and keep prompting the care team to follow-up and address. Likewise, patients and families should be able to access something similar. That way in preparation for the next visit, clinicians would be reminded that here is a symptom that needs follow-up, and patients should be prepared to close the loop or follow-up on an unresolved problem brought up at a previous encounter.
- We need to operationalize a Getting-Things-Done approach, which systematizes the capture of what needs to be done, and helps everyone identify the next step needed to move forward on a project.
- We really need apps that work well as symptom trackers! Trying to dig data out of the patient’s memory is slow and error-prone.
- Those that are combined with sensors that collect data passively sound promising. For example, for elderly diabetics who may be symptomatic from hypoglycemia (a clinician should wonder whether an elderly person’s woozy spells are low blood sugar versus some other cause), one could use one of those blood sugar sensing patches, along with some kind of app that would prompt the patient or caregiver to report dizzy spells or other events.
- An app I really want: a symptom tracking app that allows the clinician to easily program in what symptom should be recorded. Let’s face it, it would be a pain to look for one app to track urinary symptoms, another app to track difficulty eating meals, another app to track episodes of confusion, and then another to track pain. The other day I tried to find an app to log episodes of fatigue and low energy in a friend, and I gave up after 15 min. Too many dang choices, none of which seemed suitable.
- Better: an app in which it’s easy to program what you want to track, and how often the app should ping the patient/caregiver to log. Bonus if you can import in from a library of symptom templates (Pain: location, intensity, what you were doing, what you did for relief, how it worked, etc. Confusion in elders: situation, precipitating factors, how long it lasted, time of day, etc)
- Re helping clinicians find suitable apps, Happtique is kind of a step in the right direction but not yet usable enough for my purposes, and couldn’t point me towards the fatigue tracking app I desire. (Also nutty that all these app developers expect clinicians to pay for their app before trying it. You’d think they’d offer every clinician at least 30 days free.) Just as we need a better user-interface to search for suitable decision aids (see above), we need it to sort through apps. Maybe Amazon should start an app store?
- Frustration and confusion with the healthcare system
- Why it happens:
- Too many reasons to list here! The system is poorly organized, poorly coordinated, and we do a terrible job of involving patients in their own care, and of helping patients understand what our plan is for them.
- What could help:
- I like the idea of a collaborative health record, in which both patient and care team can follow a common problem list. Just like Basecamp helps people collaborate on a joint project, EMRs should offer similar project management capabilities.
- Roni Zieger recently wrote that hospital beds should have a touchscreen at bedside, showing the patient all orders and the plan. I like it!
- In general, we need sooo many improvements…progress is being made within healthcare, but if a critical mass of patients and families can mobilize and insist on participating in their healthcare, I think the needed changes will come sooner.
- So far the more prominent e-patients (“equipped, enabled, empowered, engaged”) I’ve read about seem to be younger than my patients. Is there a movement for older e-patients with multimorbidity, or for their e-caregivers?
In a nutshell
Even wealthy educated older adults repeatedly suffer from certain
pervasive problems in outpatient healthcare. This post covered: difficulty getting non-pharmacological treatment for common conditions, procedures and diagnostic evaluations of unclear clinical benefit, poor attention to values/goals/preferences, inadequate monitoring and follow-up of symptoms, and frustration/confusion with the healthcare system.
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.
