GeriTech

In Search of Technology that Improves Geriatric Care

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Sleep, Stress, and Sustaining Behavior Change

If you are interested in the non-pharmacological treatment of insomnia, an interesting item ran in the NY Times this week: “How Exercise Can Help Us Sleep Better.”

This particularly caught my eye for a few reasons. The main one is that sleep problems are a common complaint among older adults. And exercise is something that I’ve often recommended as part of an approach to improving sleep, whether the patient was a sixty-some year old caregiver, or a more elderly person with dementia.
Plus, as I’ve mentioned in a prior post, I myself have had frequent struggles with insomnia, and have sometimes applied to patients what I’ve learned from myself.
The thing is, it didn’t really seem that I slept much better on days when I got more exercise. Still, I’ve continued to recommend exercise to caregivers and frailer elders alike, given how beneficial exercise is over all. (It’s linked to better strength, better function, better mood, better health outcomes, better glucose control, etc.)
Do most of them manage to increase their exercise? Well, no. At least, not as far as I could tell, and determining how much people’s exercise levels have changed is a challenge because so far, I’ve mostly had to rely on people’s self-report, during a visit. (I’m still waiting to have a patient or caregiver use a Fitbit or other activity tracker.)
And does exercise in fact improve sleep? The Times article describes a fascinating new research study addressing this topic. 

A clinical study of sleep and exercise

To summarize: the study randomized 11 sedentary women (avg age 61 years old) with insomnia to a program of exercise 3x/wk versus no change. 
After four months, the women who were exercising regularly did have better sleep, and were sleeping on average 45-60 minutes longer every night.
But here’s the kicker: it took literally months of exercising before sleep got better. And on a day-to-day basis, most participants did not sleep better on days when they exercised. 
According to the Times article (the study’s author was interviewed), this is at odds with most research & the experience of many people, which is that exercise = better sleep that night.
However, Dr. Baron, the study’s lead author, notes that many studies of how exercise affects sleep used people who didn’t have insomnia at baseline. She goes on to explain that people with insomnia may be “neurologically different,” and have a “hyper-arousal of the stress system.” But if they maintain an exercise program, after a few months they do start to sleep better, which Dr. Baron attributes to a dampening of the stress response.
The study also found that participants exercised less on days after sleeping poorly, so in the short-term it seemed that sleep had more of an effect on exercise than vice-versa. 
The Times article concludes with Dr. Baron advising readers with chronic insomnia to start exercising regularly if they aren’t already doing so, but to bear in mind that improvements in sleep probably won’t be immediate and could very well take months.

Implications for the practice of geriatrics and general medicine

Would one find similar results if one studied a group of 85 year old women with poor sleep? And what if they had dementia? No one knows, and it’s quite possible that the results would be different since both aging and cognitive impairment are known to modify sleep patterns.
Still, these results are very important to the practice of geriatrics, because the study group sounded very similar to a population that we often work with: family caregivers.
Chronically stressed? Not enough time to exercise? Can’t sleep well at night?
Sound like anyone you know? Actually, it sounds a bit like me and other working mothers who have too much on their plate, but it also sounds like the women I see bringing their elderly loved ones to see the doctor, frazzled by the strains of worrying about a parent and taking on more and more caregiving duties.
And, the chronic stress of family caregivers is a very serious public health problem. It affects the health, wellbeing, and even workplace productivity of the caregivers themselves. Plus it often has a direct bearing on the health and wellbeing of the elderly person being cared for.
In general, stress is a huge and thorny problem in healthcare and for society. As a physician, I’ve often diagnosed stress as an important contributor to some significant health problem we’re trying to manage. But it’s very difficult to help people reduce their stress.
This study sheds some light on why: reducing one’s internal reactivity to stress takes time. A behavior change meant to reduce stress may need to be sustained for months. 
This is a tough challenge for all involved. Tired and stressed caregivers want relief now, and don’t have a lot of energy and bandwidth to stick with a behavior change for months. Clinicians want to help (and if they’ve kept up with best practices, want to help the patient minimize the use of pills for sleep or anxiety), but it’s hard to find a way to get patients to sustain behavior changes.

What tech solutions might help?

It’s not hard to envision how technology solutions might help. For those caregivers who have a smartphone or can access technology, it should be possible to
  • Log sleep and exercise. Ideally, with as little hassle as possible. Collecting this data can be helpful to clinician and caregiver when they meet to follow-up on a plan to increase exercise, decrease stress, and improve sleep. 
    • In some cases following data in real-time might help people maintain a behavior or technique (such as in biofeedback). 
    • Whether caregivers would find it helpful on a daily basis to see how much they’d slept every night is unclear to me; it could potentially be stressful to not see sleep improving as quickly as one wants it to.
  • Provide reminders and support to help caregivers maintain the exercise habit. There must be some way to leverage technology to help caregivers (or any patient/person) maintain an exercise habit, but I’m not sure which would work the best for the caregivers I work with. 
    • In fact, the multiple options available (there are so many apps/services available to help people meet fitness goals!) is a problem: making a choice is difficult!
    • Caregivers and patients would probably appreciate and value a recommendation from clinicians, but it might be hard for clinicians to make a recommendation unless it’s a product the clinician has already tried for him/herself.
      • We may also see companies aggressively market themselves to doctors, in hopes that their fitness app will be “prescribed.” I have mixed feelings about this since historically when business markets to doctors, the patients are not always well-served by the results.

In search of tech tools to try

Ok, so now let’s play a fun game called “Help-a-Doc.”
I am willing to try an app or service in the next few months to log my own sleep and exercise, and also to help me start and maintain a 3x/wk exercise habit. (And let’s see if it improves my sleep, which could stand to get better.)
If you have a recommendation to meet any of the needs above (sleep tracking, exercise tracking, and behavior change support), please post in the comments below, or drop me a line.
I’d like to eventually have some specific tools to suggest to caregivers and other non-frail adults who are struggling with sleep, exercise, and stress.

Individualized medical decision-making: still harder than it should be

Shouldn’t everyone get an individualized assessment of likely benefits, burdens, and risks before making a big medical decision? 
I was asked this question recently, during an interview for an Internet radio show on aging, called “Reaching for the Gold.”
Per my host’s request, I’d been explaining the practice of geriatrics, and talking about the geriatric approach to addressing the medical needs of older adults. Since I’d mentioned that aging often brings on greater risk of side-effects or complications from anesthesia, the host, Harriet Tramer, asked me whether older adults should be trying to avoid surgeries. I responded by trying to explain the idea of balancing likely benefits versus burdens and risks, before making a decision about surgery. Some surgeries seem more likely to lead to substantial benefits than others. Some situations seem riskier, or more burdensome, than others. Hence, an individualized approach is best.
Which led Ms. Tramer to ask me the question above: shouldn’t everyone — not just the elderly, or those seeing geriatricians — get this type of individualized counseling before deciding to pursue an operation, or making another type of big medical decision?
Well…yes! Patients of any age can benefit from this type of individualized counseling, which is sometimes referred to as shared-decision making. It enables patients to make more informed decisions. It can also help patients obtain care that is a better fit for their values and preferences. And in some case, it might improve outcomes, if patient and clinician decide to forgo a risky procedure. Last but not least, individualized assessments of likely benefits and risks could improve the value of healthcare (value = benefit/cost), if such assessments result in patients forgoing expensive procedures that are unlikely to be helpful.

This type of individualized care is good for everyone, but is especially beneficial as people get older. Since older adults tend to have more chronic conditions and disabilities, there is more to consider when trying to identify benefits, risks, and burdens of a given course of action.

But there is a downside to engaging in this kind of collaborative and individualized medical decision-making: it requires time, energy, and effort. And for clinicians, not only does it take time and energy to have the conversation with patients and families, but it also usually takes time and energy to figure out just what are the risks, benefits, and burdens when a specific patient faces a specific medical decision.

Could technology make this process of estimating risks, benefits, and burdens easier for clinicians and patients?

The challenges of individualized medical decision-making

Several years ago, one of my elderly primary care patients developed memory problems. He had been pretty hale and sharp, in relatively good health. But then he started to complain of difficulty remembering things and organizing himself, and after a thorough evaluation, we diagnosed him with Alzheimer’s disease.

Before he became too impaired, we talked about his preferences for healthcare in the future. He voiced a preference for not spending too much time in the hospital, and he wanted to avoid surgeries and procedures unless they were likely to really improve his quality of life. And of course, he didn’t want to be kept on life support if he were terminally ill.

About a year later, he’d progressed to moderate dementia, and his medical decision-making had been taken over by a professional conservator. He developed a bad cold, and the urgent care doctor did an xray to evaluate for pneumonia. On xray, he didn’t have pneumonia. He did, however, seem to have a lump in his lung, and a follow-up CT scan confirmed a small-medium lung mass, suspicious for cancer.

And now what to do? The usual next step would be to have the lung doctors biopsy the mass. Small localized lung cancers in particular can often be treated with surgical removal (unless the biopsy shows that it’s one of those cancers that is unlikely to be successfully treated with surgery.) But this patient was elderly, and had dementia. Which meant that surgery would be more burdensome to experience, and came with higher risks of complications during and immediately after the surgery.

The conservator and I weren’t sure what to do. When patients are making decisions for themselves they often just make a gut decision (undoubtedly influenced by the doctors around them) and don’t always want statistics and details. But I wanted to make sure we’d considered the decision properly, and the conservator certainly wanted to be sure of doing right by the patient.

We needed data:

  • How likely was it that the mass was likely to make him feel symptomatically sick and/or shorten his life, if left untreated?
    • The oncologists refused to answer this question, saying they absolutely needed a biopsy sample before they’d hazard a guess.
  • How likely was the patient to find the biopsy procedure uncomfortable? What was the risk of complications? (And how do we factor in the risk of things like getting delirium or distressed by the procedure, and subsequently falling at home?)
  • If he had the biopsy and it turned out to be the type of cancer that was likely to be cured by surgery, what would be the risks/benefits/burdens of the surgery, and would the conservator consider them acceptable?
  • What was the patients overall prognosis and life expectancy, even before taking into account the new lung mass?
As you can see, a tailored assessment of risks, benefits, and burdens became very complicated, very quickly.
We never did get the exact statistics, although I did spend a fair amount of time looking things up in my medical references, and talking to my specialty colleagues. 
In the end, we decided to not get a biopsy, and instead repeat the scan in several months to see if the mass was growing. Not because we’d biopsy him at that point, but because we decided it would be useful for us to know if the patient was suffering from an advancing lung cancer. We also, of course, made plans to follow the patient’s weight, appetite, and function.
What would’ve been the alternative to this process? Here are some other ways the situation can play out:
  • Physician decides the patient should next have a biopsy. Patient and conservator go along with what the physicians recommend. 
  • Physician decides the patient is elderly and has dementia and so should not have further complicated medical care. Patient and conservator go along with physician’s recommendation.
  • Physician tells conservator: the decision is up to you, and tries to avoid influencing the conservator’s decision. The conservator may or may not try to look things up on the Internet, or otherwise get more information. Most proxies, in my experience, do not ask the physician “which choice do you think is likely to give this person the best quality of life over the next five years,” but I wish they would.


Facilitating individualized medical decision-making for everyone

Individualized decision-making is important. If we want more patients to be able to access it, we’ll need to develop better tools and resources.

To date, the main resources available are decision aids, many of which have been carefully developed by non-profit experts and are of high-quality. When a good decision-aid can be located and used, patients and clinicians generally benefit.

The trouble is that decision-aids are often not available for the decision at hand. To begin with, a good decision aid can be hard to find online; many are only made available as an institutional subscription, so individual patients and small clinical practices may not be able to access them.

Another problem is that decision-aids are usually created for a certain common condition or decision, and are tailored to help an “average” patient. Unfortunately, I know of no pre-made decision aid meant to help elderly patients with dementia consider their options for diagnosis and management of a suspicious lung nodule. Dementia and advanced age are complex factors because they both introduce a lot of variability into the factors of risk, benefit, burdens, and preferences.

Still, although I don’t expect there will ever be a pre-fabricated decision aid available to help with the situation I described, I do think that the right tools could go a long way in helping clinicians and patients and families make decisions for frail elders. For example, we might eventually have easier access to calculators (perhaps relying on information gleaned from big data) that can capture the patient’s physiologic data and present us with better information on prognosis and risk during procedures. (I like ePrognosis, but it doesn’t yet feel like something I can use in clinical practice.)

Technology, data, and a new culture of shared decision-making hold such promise. Within the next, say, ten years, will we see it turn into real improvements for the real sticky situations affecting elders and their families? Will it soon be easier for all clinicians to provide better help, to all patients?

Neat idea for financing dementia services

For those interested in alternative ways to provide geriatrics care, here is a very neat practice that I learned about last month: MemoryCare. (Thanks to Scott Kuhlman of ecpmd.com for the tip.)

Located in Asheville, North Carolina, MemoryCare is a “non-profit charitable corporation, established to meet the rapidly growing need for appropriate assessment, treatment, and support for memory-impaired individuals and their families.”

Similar to my own practice, MemoryCare is consultative and is designed to complement existing primary care. They offer an indepth evaluation, expert assistance on managing dementia, and have a special focus on supporting families and caregivers.

And how is this wonderful service financially feasible for them to provide? MemoryCare has an interesting approach:

  • The “clinical portion” is covered by Medicare/Medicaid. 
  • An additional $495 yearly fee is charged to the caregiver, to cover “supportive care and training of caregivers over a one year period.”

This is a neat way to offer a service that would be financially unsustainable otherwise. As many people know, helping families with dementia concerns is often very difficult within conventional fee-for-service (or even HMO) care, because it is time-consuming and involves no reimbursable procedures. And Medicare doesn’t allow providers to accept Medicare while also charging extra (for those services covered by Medicare).

But by taking a fee from the caregiver, rather than the patient, the clinic is effectively able to charge a patient and family a little extra, for what sounds like a whole lot of needed geriatric expertise and support in coping with dementia. This, according to the website, includes phone support between visits, and one hour follow-up visits.

The fee itself works out to $41.25/month, and the clinic’s website states that they fundraise “so that no family will be denied this service due to inability to pay.”

Unlike my own consultative services, MemoryCare requires a referral from a PCP or neurologist. It’s not clear to me whether this is out of respect for the traditional habit of allowing PCPs to determine what additional care their patients should access, versus necessary to facilitate insurance payment for MemoryCare’s services.

In general, I’d expect that most PCPs in the area would be thrilled to refer to a special service that can help families cope with memory-problems. Still, I would think that more patients and families might access this type of service if no PCP referral were required, although it’s also possible that some families need a PCP’s encouragement in order to seek out (and pay for) this extra care.

I myself am deeply impressed by this model of care, and hope to some day talk to the founders and others involved with the practice. We need more such creative ideas, to better meet the needs of an aging population and their caregivers.

Also, wouldn’t it be nice if Medicare beneficiaries could set aside some of their outpatient Medicare money for discretionary purposes? (I’m thinking of something similar to a small HSA.) They could then choose to spend it on an additional service such as MemoryCare, or perhaps extra assistance at home, or perhaps a geriatric care manager. This would certainly give the patients/consumers a little more influence in shaping Medicare services to their needs, although I suppose we’d have to take steps to protect the beneficiaries from scammers out to siphon off their discretionary funds.

Hm. We must keep collectively thinking about all this. The status quo is certainly not sufficient.

For a more scholarly description of MemoryCare’s practice, there is a nice short article in the Alzheimer’s & Dementia journal here.

Have you come across any other interesting models for providing — and financing — geriatric care? Post a comment or drop me a line.

Geriatrics Bound in Saskatchewan

[The following clinician guest post is by Dr. Magda Lenartowicz, an internal medicine resident in Saskatchewan, Canada. Thanks Magda!]


I am an internal medicine resident
interested in Geriatrics. No, scratch that, I am a resident GOING to be a
Geriatrician. In fact, I was an undergraduate student in Gerontology before
medical school, and I have had an interest in the care of older adults for as
long as I can remember.
I am also Canadian, and you will not find
one single “eh” in this entire diatribe. But I digress.
In the past year, I have had several people
question my resolve – “why would you possibly want to do Geriatrics?” And, I
have had my share of the not-so-subtle comments suggesting my interest in
“bowels and bladders” is not real medicine.
Ok, I am a big girl, I can take some
ribbing.
I choose to take this behaviour as an
opportunity to think about what my answer to this question really is.  Not just the off-the-cuff indignation I
sometimes feel, but the real reason I am so driven to do this.  The top two points that have come up so far are:
 a.)
I find Geriatric medicine to be complex, fulfilling, and one of the few
opportunities in modern medicine to practice a truly holistic type of medicine
(taking into consideration mental, physical AND social health),
and b.)… well, this is going to take a bit
more of an explanation.
I work in a province that has ONE, that’s
right, ONE board certified Geriatrician. There are several family practitioners
with additional training in the care of the elderly, but even they are not
enough. The province has a million people (yes, the entire province), of which
about 15% are over the age of 65, which means there is one Geriatrician for a
population of 150,000 – that’s not workable even if you only reduce this to a
subset of those over 80. This is farm country, and there are many very hale folks
over the age of 80 still living on farms. There are also many folks with
varying degrees of cognitive and functional impairment living independently on
farms. That is slightly more worrisome.
We do not have a Geriatric Assessment Unit
anymore – the 10-bed unit closed in 2009. Yes, you did read this right. In a province
with one Geriatrician and all those older people there is no place for older
adults to go. There were not enough doctors and others to sustainably staff the
unit. So now, our older folks stay in hospital, or if they are lucky, get moved
to the transitional care unit where they wait for long-term care. Those of my
patients who are elderly and cognitively impaired, but have no medical issues,
have absolutely nowhere to go. Those who DO have real medical issues have
nowhere to go once they have overcome their acute issues. Well, there is our
Geriatric Rehabilitation Unit, but it is very specific in what it offers and
again, does not have enough spots. So the worry becomes – will my older
patients succumb to a hospital-acquired ailment and die there, even though a
quick hospital discharge to an APPROPRIATE step down unit would have been
better? I think about this often.
As a cherry on top, our beautiful new
psychiatry unit has no acute beds for those with dementia. You are welcome to
figure out how this makes any sense. I still haven’t. I have had to assess
patients with dementia, deemed as “aggressive” and surrounded by guards, in our
ED’s psychiatry isolation room. When I talked to the patients, it turned out
the problem was being alone, disoriented, or overwhelmed. The frustration? I
had nowhere to send these people other than home or another tertiary care
hospital bed, a place where few people with dementia do well.
Yes, we do have Telehealth. We actually
have a very robust Telehealth network, and one of our neurologists and a team
of wonderful, dedicated folks puts on a very excellent Memory Clinic. Patients
love not having to travel hundreds of miles to their appointments, and when an
assessment occurs, everything is arranged for them in one day. The follow-up
takes place via Telehealth at regular intervals.
It’s so beautiful, it’s like poetry. Too
bad that funding is limited and not enough of those needing this service ever
get to use it. And I won’t mention home care at all because we don’t really
HAVE true home care visits by Geriatricians.
In one word, this is Geriatrics where I
work. Virtually non-existent. Yet we make it work, and the more I become
immersed in the minutiae of elder care, the more I WANT to take on that
challenge. I want to be a Geriatrician because there are so many things that I
can see myself changing.
So the b.) in my answer is: because there
is a need. Because when I took my oath I promised to be of service, not just self-service.
 My city is not the only place with a
dearth of Geriatricians, even large centers do not have enough physicians
interested in Geriatrics to meet the care demands of a growing 75+ demographic.
I’ll tell you what I do love about working
with older folks. I love the ability to make a real difference not just in the
office, but in their life in general. I love being able to take my time, and
really practice my art as well as my science. I especially enjoy working with
dementia patients and their partners in care, as hearing “This worked!” from a
caregiver or seeing a patient becoming less frustrated is one of the best
feelings in the world. And yes, I even love it for the bowelsJ Only fellow gastroenterologists will be able to share the rewarding
“I told you so!” when a delirium resolves simply because I prescribed some
Laxaday.
I have spent many years of my life being
embarrassed that my “talents” were in the social sciences, and not the “real”
science of physics, and math, and chemistry. I always loved the natural sciences,
but studying just those subjects felt empty unless I could combine them with
classes in medical anthropology, the humanities or linguistics. I hated rote
memorization and woke up when information lived for me, and you only get that
when you learn from people, not from books.
So now, that I am a little kinder to
myself, I see Geriatrics as that perfect canvas – being a poor visual artist,
Geriatric medicine allows me to join my patients in the creation of daily
masterpieces, one person at a time. 
[Magda Lenartowicz, MD is a second-year internal medicine resident in Saskatchewan, Canada. She divides her copious spare time between the Prairies and California, the home of her ever-patient better half. You can reach her at mlenartowicz[AT]gmail[dot]com.]

Thoughts in response to the NYT post

This past week, the NYT New Old Age Blog featured a post about me and my practice. Titled “Walking Away from Medicare,” it describes my decision to opt-out of Medicare and create a different kind of geriatric practice.

It has generated quite a lot of comments: 163 at my latest count. Most of them judge me pretty harshly. It seems that many people feel that I’m doing this for the money. And that I don’t care about society or older people.

Of course, if you know me or if you’ve been reading this blog, then you’ll know that nothing could be further from the truth. My practice is fairly small, in part because my goal in having this practice was to have a way to keep working with patients and families, while having the flexibility to pursue my other professional interests. Since I started the practice, I’ve spent most of my time writing for this blog, learning about the worlds of digital health and healthcare innovation, and thinking about how we can teach geriatrics directly to caregivers.

Although I’ve phased out working with Caring.com, I’m thinking about how I can build on what I learned there, and keep connecting caregivers to resources that leverage geriatrics expertise.

This morning, I gave a talk to a group of family caregivers, at a retreat sponsored by Family Caregiver Alliance. We talked about what caregivers should know about the geriatric approach to care, and how they can learn more about medical care that is tailored to the needs of aging adults. We talked about delirium, and how caregivers can recognize it and get better help from clinicians.

We talked about participatory medicine — they were all savvy, experienced caregivers but none had heard of the e-patient movement — and the Beer’s criteria, and then we got into how tech tools might help caregiving feel more manageable. (More on those in future posts!)

I loved every minute of it, doing this session with family caregivers. I can’t wait to participate in more events with caregivers.

So why am I writing all this? Mainly because I hope to illustrate in a time of geriatrician shortage, there many ways we can be of service to society, even if we make the decision to leave Medicare, or otherwise aren’t as available to serve patients in a one-on-one fashion.

The Future of Geriatrics 

Just for the record, I don’t think the future of geriatrics should be that geriatricians leave Medicare en masse and require that patients pay them an hourly rate, out-of-pocket, for services.

Instead, I hope my own story and struggles will foster more conversation on the following topics:

  • How should we — as a society — best deploy a very limited supply of geriatricians, given an aging population and inadequately prepared healthcare workforce? The projections are sobering. 
  • How can we make practicing geriatrics attractive and sustainable for geriatricians? Most geriatricians I know love caring for older adults, but many complain of stress and burnout. (Some have emailed me this past year, having heard of my practice.)
    • What changes to reimbursement or work structure would attract more clinicians to geriatrics? 
    • How can we make practicing geriatrics within Medicare feel more sustainable? (Answer: we may need to think beyond debt relief and 10% salary increases.)
  • How can we make geriatric care doable for ALL front-line clinicians? As people age, they benefit from a geriatric approach to their care. And for the foreseeable future, that approach will have to be delivered by non-geriatricians: the primary care clinicians who will hopefully have had some geriatric training, but didn’t do a fellowship.
    • With front-line clinicians already suffering from high levels of burnout and dissatisfaction, how can we support them in effectively caring for a growing number of older patients? 
    • Earlier this year I proposed that the job of PCP for complex Medicare patients be doable within 35 hours, which could help retain all those empathetic clinicians with young children. Other ideas?

Food for thought and future conversations, I hope.