What Your Training May Not Have Taught You About Caring for Older Adults
Many health professionals work with older adults every day. This does not mean they are always providing safe, high-quality care that lines up with what matters most to the patient or what is known as age-friendly care. Stephanie Rogers, MD, is an Assistant Professor of Medicine in the University of California, San Francisco (UCSF), Division of Geriatrics. In the following interview, she describes what many clinicians miss when addressing delirium in older adults. Rogers is a member of the Age-Friendly Health Systems (AFHS) Advisory Group.
What do clinicians often misunderstand about caring for older adults?
When caring for older adults, we often make the mistake of solely focusing on a patient’s diseases. Older adults have a lot of unique issues that we need to address in addition to their diseases. Some may have functional or cognitive impairments that make it difficult to do their daily activities or things that help improve their own health. They may have hearing or visual impairments. Can they open their medicine bottles? Can they read the labels?
They may have complex social needs. They may live alone. They may not have a lot of family nearby. It could be difficult for them to access medical care or get their basic needs met like getting healthy food, bathing, or finding transportation to their medical appointments.
As a geriatrician, I was trained to look at the whole picture of someone’s life and not just their presenting symptoms. All geriatricians are trained either in internal medicine or family practice. The additional training we get is in other aspects of medical care. What I love about the job is that you can integrate all these things that you learn about the person into their medical care.
How do you understand what it means to provide age-friendly care?
For me, providing age-friendly care means providing the right care for the right person at the right time and in the right place. This means that when you’re caring for an older adult, you look at all aspects of their care and their life that are important to them and that allow them to have the greatest quality of life possible.
In a lot of ways, this means focusing on things that we normally don’t think about or teach in medical school. We learn a lot about how to treat diseases, but we don’t learn much about how to care for people’s minds or the way they do their daily activities in their homes. We weren’t trained to talk a lot about social support and how patients access medical care and get their basic needs met like food. Providing age-friendly care means thinking about a person in the context of their community and their goals and their family and providing medical care that meets those goals.
Figure 1. The Age-Friendly 4Ms Framework
Delirium is one of your areas of expertise and is most obviously part of the mentation component of the 4Ms. (Figure 1.) How can addressing the other Ms — mobility, what matters, and medication — also improve delirium care?
When we talk about what matters to patients, we know that delirium can be very distressing for them and their families. Asking families and patients about what’s important to them and what they’re worried about when they’re in the hospital can help us guide the sorts of things that we do.
For example, families often know best some of the things that help their loved one sleep at night. We also ask them to bring in pictures or photos of loved ones, pets, and favorite vacations to help continuously reorient the patient to who they are, where they are, and what’s going on. In these kinds of ways, family members can have a large impact in preventing delirium.
Medications are a common cause of delirium. Medications that are safer for younger patients can cause confusion in older adults. Any time I see a patient who’s confused or has delirium, the medication list is one of the first things I review. For example, a common over-the-counter medication like Benadryl can cause confusion in susceptible, vulnerable older adults. The accumulation of medications can also cause problems. For example, gabapentin and baclofen may be prescribed for pain. Combining them with opiate medications can have a very sedating effect, increasing the risk of confusion and falls.
Improving mobility helps to prevent and treat delirium. Getting patients out of their beds and walking around, helping them return to their normal daily activities in the hospital — such as brushing their teeth or their hair — can have a profound effect on preventing and treating delirium.
What example can you share to illustrate the intersection of all the 4Ms?
I was recently working on the medical ward and I got a geriatrics consult. The team wasn’t sure how best to help this person who had come in very confused.
The patient was normally independent at home. In the hospital, they were sleeping all the time and not getting out of bed. “We can’t get them to participate in physical therapy. They’re not waking up.” The team wondered if the patient was at the end of his life.
I did a comprehensive geriatrics assessment with medical review and noticed that the patient was on a significant number of psychoactive medications. I asked the team to slowly taper off some of those medications. Within three days, the patient was up and able to get out of bed and walk in the hallway while using a walker. They were able to participate in their daily care activities again.
As you can imagine, this was important to this patient and their family. It was what mattered to them most. The patient valued his independence. So, by focusing on the medications, mobility, and what matters to address the patient’s mentation, everything came together.
How does ageism get in the way of either identifying or treating delirium?
Providers can sometimes either overtreat or undertreat older adults. An example of this is a 90-year-old patient coming into the emergency department who’s confused, and the medical team says, “They’re just old. Delirium happens to all older people. There’s nothing we can do.” They don’t necessarily take the disease seriously and look for the underlying cause. They don’t always do the things that we know can help.
There are also many medical interventions we can do these days, but we shouldn’t do them without asking the person who is making the treatment decision what matters to them most. We don’t always explain the best-case or worst-case scenario. We need to make sure that when we do an intervention, it’s likely to lead to the outcome a patient wants.
One of the most important things to do when you meet a patient for the first time is get collateral information from the people who know the patient best. Delirium is an acute change in mental status. You won’t recognize that if you don’t know that normally this person goes out and plays golf or reads books every day. This is why it’s very important to include families and caregivers in the care of older adults.
How might you change an intervention based on what you learn about what matters most to a patient?
I recently had a patient who was having some shortness of breath after finding a stenosis in their aortic valve. There is a surgical intervention that we can do called a Transcatheter Aortic Valve Replacement or TAVR that can help with the symptoms of shortness of breath. However, sometimes these are invasive procedures and often patients are in the hospital for quite a long time and very often experience delirium during their hospitalization. Many patients also see a functional decline after this surgery. This patient was walking and getting his groceries every day. I was worried that if he had this intervention, he wouldn’t be able to get around on his own anymore.
We discussed the risks and the benefits of the procedure. He decided that his shortness of breath was not that bad. It doesn’t prevent him from doing what he wants to do, so we’re going to hold off on that intervention for now.
What is the business case for improving delirium care and prevention?
When you’re trying to prevent delirium in older people, you can have good clinical and cost outcomes. An example of this is that caring for patients with delirium can reduce the number of falls in a hospital. Studies have shown that when you have delirium prevention programs, this reduces fall rates.
Improving care and preventing delirium can also reduce costs and reduce length of stay in hospitals. Hospitals are likely to discharge patients with delirium to an institution. But when you prevent delirium or shorten its duration, you can sometimes discharge patients home, and home is generally where they prefer to be.
Editor’s note: UCSF has achieved Committed to Care Excellence status as a participant in the Age-Friendly Health Systems initiative. This interview has been edited for length and clarity.
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