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.