aging health needs

Aging in Place: What are the problems to solve?

March 11, 2016

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

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

February 12, 2016

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

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

January 29, 2016

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

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

November 20, 2015

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?

Louisville & Creating the Future of Aging Care in a City

October 23, 2015

Last 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.