Never Say Old

As a brief follow up to her important 2011 book, Never Say Die: The Myth and Marketing of the New Old Age, the writer Susan Jacoby published an editorial in the NY Times this past week. 

Provocatively entitled,  “We’re Getting Old, but We’re Not Doing Anything About It,” she points out that the presence of 5 septuagenarian presidential candidates (Biden, Sanders, Warren, Bloomberg, and Trump) falsely encourages the population to think that 75 really is the new 50 and that aging doesn’t bring with it the risk of frailty, dementia, and disability. Jacoby, in her usual incisive way, argues this view is mistaken—and dangerous.

In fact, while many people do remain vigorous well into their seventies, and a smaller but not inconsequential percentage continue to be robust well into their eighties (and an even smaller percentage into their nineties), the risk of developing one or more medical conditions that get in the way of independence and well-being rises steadily with age. The much vaunted “compression of morbidity,” the dream that we will all remain totally intact until precipitously, preferably during sleep, we die, hasn’t quite materialized. Jacoby cites a study reporting that one in seven people who are 65 years old today can expect to experience 5 or more years of disability before they die. Dementia rates are falling—but since the size and proportion of older people is increasing, the absolute number of people with dementia is projected to rise steadily. According to the Alzheimer’s Association, there are 5.6 million people over 65 with dementia today, there will be 7.8 million in 2025—and 13.8 million in 2050. Frailty remains a major problem: a 2015 population study in the US found that while only 10.7 percent of people age 65-69 were frail, among the 75-79-year-olds the rate was 20.1 percent, and for those aged 85-89, it was 37.9 percent.

So, what are the implications of this reality? Jacoby offers three: provide more support for caregivers; encourage employers to allow vigorous older adults to continue working; and address various medical ethical issues such as physician assisted suicide. This is a good beginning—and about as much as one can reasonably put into a NY Times op-ed—but there are many others.

Here are a few additions: In the arena of housing, we need far more housing that is handicapped accessible. Doorways should be wide enough for wheelchairs, buildings should be on a single level or have elevators. In the domain of urban planning, communities need to be walkable with extensive and accessible public transportation. In terms of medical care, the overriding issue is not care of the dying, but how best to care for the living. We need far more attention to function: to maintaining and fostering basic abilities such as mobility and higher-level abilities such as cooking and shopping. To achieve this end, physicians need to assess function, they need to know how to diagnose frailty, and they need to know how to promote and support function. Physicians also need to determine the old person’s goals of care and to work with patients and family caregivers to develop an approach to treatment that is consistent with those goals.

The new year will begin in just two days. Among our resolutions for the coming year should be a commitment to making America a better place for us as we get old—and I agree with Jacoby that we should abandon the foolish euphemism “older people” and stick with plain “old.” This should be a resolution we actually follow.

Caregivers Redux

In a recent issue of JAMA Internal Medicine, Drs. Sterling and Shaw from Cornell Medical Center make a case for physicians to pay greater attention to caregivers, both informal (unpaid, typically family members) and professional (paid). They argue that physicians will do a better job caring for patients suffering from frailty, dementia, or disabilities if they include them in their visits. The authors highlight how helpful caregivers can be, both as a source of information and as an instrument for implementing a treatment plan. They are right: it is high time physicians acknowledged the importance of caregivers and expanded the sacred doctor/patient relationship to include them. To that end, the authors exhort physicians to list the names and contact information of caregivers in the medical record and to ask their patients for permission to incorporate them in health-related discussions. But they fail to grasp the extent to which caregiver involvement can transform their patients’ medical care.

It's not just that caregivers, whether a daughter or a home health aide, might whisper into the patient’s ear that she should mention she’s been having episodes of incontinence—an example cited in the paper. It’s not only that caregivers might report memory lapses that the patient does not admit or remember she has been having. The availability of an on-site caregiver may enable the physician to embark on a course of therapy that would be unthinkable without a reliable partner, someone who can try various strategies and report back on their effectiveness. Much as a visiting nurse can serve as the eyes and ears of a physician at home and thus amplify the available treatment options, so too can caregivers potentially administer medication and inform the physician of the results in real time. Caregivers don’t just manage medications, as the authors imply, by purchasing drugs at the pharmacy and perhaps putting them in pill dispensers. They can learn to adjust dosages, decreasing warfarin in the presence of antibiotics or cutting the insulin dose in the face of gastroenteritis, perhaps allowing for home instead of hospital care. And caregivers don’t just provide inputs to physicians and follow orders. They can also be valued and indeed invaluable participants in discussions about what approach to care makes sense for a given patient. Does Mrs. Jones want all possible medical treatment, however invasive and however unlikely to work, in an effort to prolong life? Or does she want, above all, to stay in her apartment and be comfortable? Or is her main concern the ability to read and to play the piano so she will accept whatever medical interventions and supportive strategies are conducive to achieving these ends. Not only can caregivers help elicit the patient’s goals of care, but they can also evaluate whether the community supports (family, paid caregivers, financial resources) are adequate to implement a given plan.

So yes, it’s time to acknowledge the existence and importance of caregivers. But letting them in the examining room is just the first step. Caregivers need to be integrated into the medical team. They have a crucial role to play, just as do social workers and nurses. They are the key to better medical care, with “better” implying care that is in line with the patient’s preferences and values, not merely care that accords with the physician’s idea of optimal care. If those preferences translate into home rather than hospital as the site of care, they may even mean less expensive care.

     For more on helping caregivers in their role as members of the medical team, see my forthcoming book: The Caregiver's Encyclopedia: A Compassionate Guide to Caring for Older Adults.

Falling Down on the Job

We’ve heard about older people who don't go out because they're afraid they will fall. A new article in Kaiser Health News reminds us that hospitals, too, fear that patients will fall--and goes on to say that hospitals respond by keeping patients in bed, which causes its own harms. This is an important issue: as the author is at pains to tell us, 30 percent of patients aged 70 and older have more trouble carrying out the most basic tasks necessary to get by (things like getting to the bathroom or eating or dressing) when they leave the hospital than they did when they were admitted. 

Some of that deterioration is directly attributable to their acute illness, but some of it stems from the way that doctors and nurses in hospitals treat people with acute illness: they put them to bed. And if they worry their patients might fall on the way from the bed to the bathroom or to the nurses’ station, they do everything in their power to prevent them from getting out of bed. They put signs on the door saying “fall risk;” they write orders indicating the patient is not to get up without assistance; in some cases, they apply physical restraints. 

Some of the interventions meant to decrease falls don’t actually work: one particularly notorious example is side rails, which until relatively recently were widely believed to prevent falls but in fact increase the chances that if a patient does manage to get out of bed he will hurt himself. Bed alarms are another strategy that studies have now shown don’t work. But even those strategies that do decrease falls come with a steep price tag if they work by keeping patients in bed: they result in weakness, in problems with self-care, and sometimes result in serious other problems such as a blood clot. Melissa Bailey of Kaiser Health News is to be commended for bringing this issue to public attention. But what prompted her to write this article now, in December, 2019? 

Was a new study published, bearing on the issue? If so, Ms. Bailey did not cite it. Did the author have a friend or family member who deteriorated during a hospital stay because she was immobilized? Not as far as we know. Were the perils of bedrest recognized only recently? Actually, we’ve known about the hazards of immobility since at least 1960. Previously, a patient with a heart attack was treated with strict, prolonged bedrest—until it became clear that this approach led to life-threatening blood clots and other problems. Is the topic new for Kaiser Health News? In fact, KHN addressed this issue in 2016: Anna Gorman published an essay with the title “Elderly Patients in the Hospital Need to Keep Moving.” This article did not make the link between immobility and the effort to prevent falls, but it did focus on the need for older patients to get out of bed and walk. Have any articles made the connection between immobility and fall prevention more clear-cut? Two years ago, an opinion piece in JAMA Internal Medicine made that link very explicit, calling their article “The Tension Between Promoting Mobility and Preventing Falls in the Hospital.” These authors argued that Medicare’s campaign to decrease falls had created disincentives to hospitals to promote mobility—with foreseeable and regrettable consequences. So, what’s going on here?

The problem is that despite the longstanding recognition that patients in general and older patients in particular need to get up and move while they are in the hospital, practice has not changed dramatically. More accurately, it’s changed since the time when heart attack patients were kept at strict bedrest for three weeks or longer, but there has been some backsliding as hospitals try to combat falls, another major problem. And Medicare incentivizes hospitals to minimize their fall rates by penalizing them financially for “injurious falls” in their patients, but it doesn’t do much to encourage hospitals to prevent “functional decline” in those same patients. 

The authors of the 2017 essay recognized the seeming conflict between minimizing falls  and maximizing mobility; their conclusion was that Medicare should also incentivize hospitals to get patients moving. It’s a great example of “teaching to the test,” of hospitals focusing on what they’re being evaluated on—to the detriment of everything else. I’m not convinced that the right strategy is for Medicare to add yet another domain to its list of areas-covered-on-the-test. At the very least, the agency should consider rewarding good behavior rather than punishing bad behavior, since I fear that further declines in reimbursement will result in generally poor quality care.

What about patients and families? What can they do to tip the scales in favor of maintaining function? They can be the squeaky wheel that asks for a physical therapy consultation. Family members can volunteer to walk with their relative in the halls of the hospital. And there’s always my favorite solution—stay out of the hospital if at all possible. When the physician in the emergency department insists “you need to be admitted,” she’s probably thinking of all the advantages of inpatient care, but not the disadvantages. So, ask about home care. It’s not the answer if you need an operation or a procedure, but if it’s intravenous antibiotics you need, or blood thinning medication, it just might make a lot of sense.