The U.S. senior population has grown by 34.2% over the past decade, and today approximately 54 million Americans are over the age of 65.
If you fall into this group, you may take four or more medications, see as many as five doctors annually, and have at least one chronic health condition. You may also feel that your doctors and nurses often do not listen to your preferences or fully involve you in decisions about your own care.
According to a 2015 Journal of General Internal Medicine In a survey of more than 16,000 older adults, one in five said they experienced age discrimination by their doctors or during hospital visits. Nearly 6% of older adults said they often experienced age discrimination and that their health worsened over the next four years.
“We need to recognize that the way we manage healthcare for older patients is not the same as the way we manage 30- or 40-year-olds. We don’t talk enough to our patients about what’s important to them. We are getting better at managing their medications, but we are not doing so well at tapering off their medications. We don’t focus enough on their risk of falls,” said John Whyte, MD, Chief Medical Officer of WebMD.
Whyte recently played a key role in the development of Age-Friendly Health Systems (AFHS), a new approach to care for older adults developed by the John A. Hartford Foundation and the Institute for Healthcare Improvement, in collaboration with the American Hospital Association and Catholic University. United States Health Association. Doctors, nurses and other health care providers who treat the elderly need to be better listeners, he says. “We have to ask ourselves what is important to our older patients. It’s a simple question, but it should be asked in an explicit way by every doctor. We need to change the way we approach the treatment of our older patients.”
Can health care focus on your personal preferences and health goals as you age, and not just what your doctor thinks is best for you or your test results? AFHS recommends that physicians and nurses plan care for older adults based on what they or their caregivers value most. Every medical visit or decision should address the 4M’s, four building blocks of high-quality care:
- What matters is that older adults determine their personal lifestyle and health goals, and that healthcare providers plan their treatment with these goals in mind
- Medications they take for any condition, including whether they need each medication and whether any side effects will get in the way of doing what’s important to them
- Mobility, so that they can move safely, function in their daily lives and do what is important to them
- Mentation, to prevent or diagnose, treat and manage memory loss, dementia and/or depression
Many health care systems, such as the 1,200 CVS MinuteClinics, include the 4Ms at every appointment with an older adult, says Terry Fulmer, president of the John A. Hartford Foundation. Your doctor or nurse may ask you questions about your personal goals, values, and preferences, but these questions may be difficult for some older adults to answer.
“When I say to an older patient, ‘What are your goals?’ They might say, ‘You’re the nurse, don’t you know?'” Some older people may think they should defer to their doctor or nurse during care and let them make all the decisions, Fulmer says.
“We need to make people comfortable asking what is important to you. It is often difficult to get that conversation started. You might say, “I want to talk to you about my mobility, my mood, and my medications, all based on what’s important to me.” That’s a very robust conversation.”
What do doctors and nurses think about an age-friendly care approach when treating the elderly?
Fulmer and Whyte are among the co-authors of a new study in the Journal of the American Geriatrics Society. Results show that most primary care providers believe they should approach the care of older patients differently and take age into account when making treatment decisions, but they do not always involve the 4Ms in care.
The study is based on a survey of 1,684 primary care providers randomly selected from the Medscape database in fall 2020. Respondents included 575 physicians, 613 nurse practitioners (NPs), and 496 physician assistants (PAs).
They were asked about their views on age-friendly care from the 4M’s, and how they care for their older patients. While more than 90% of providers agreed that older patients “need a different approach to care than younger patients,” only 50% of physicians and PAs and 69% of NPs said they always consider the age of a patient. Only 36% of physicians surveyed said they ask their older patients what is important to them.
High-risk medications for older adults include those that can cause harmful side effects or interact with other medications, said Marcus R. Escobedo, vice president of communications at the John A. Hartford Foundation and co-author of the study.
Many medications for anxiety, insomnia or pain can have side effects that lower the quality of life for older people or even be unsafe for them, he says. Antipsychotics that are often prescribed to elderly people with dementia can make them drowsy and, for example, increase the risk of falls.
As we age, our bodies and metabolisms change, Escobedo says, so there may be medications that aren’t appropriate for older adults and are still overprescribed. “It could be that they are taking too many medications in general. If you have many different healthcare providers, or if you go to the hospital, you may be prescribed medication. Then you go home and these medications are not stopped.
While 84% of physicians said they assess older patients’ use of high-risk medications and screen for depression, only 78% said they taper or reduce their patients’ doses of high-risk medications or don’t use these medications at all.
“When older adults recognize potential side effects of their medications, do we listen to them? They might say something like, ‘I just don’t feel good,'” Fulmer says. Therefore, one of the 4M’s is to review your medications and see if they need to be changed. “We need to start that conversation about your medications with what’s important to you.”
The AFHS framework urges doctors and nurses to ensure older patients can move around safely so they can do what is important to them. Your healthcare provider may prescribe physical therapy or exercises to help you stay mobile.
“One of the best ways to prevent falls is to encourage older people to be physically active and just get some exercise. We help them build strength and balance. That will help you move with more confidence,” says Escobedo.
The survey found that 73% of physicians, 82% of NPs and 76% of PAs said they always screen older patients for limitations on how well they can manage. However, only 56% of physicians, 61% of primary care physicians, and 56% of PAs say they “ensure early, frequent, and safe mobility” when treating older adults.
Healthcare providers can screen older adults for mobility problems, but they need to do more to help them move better and prevent falls, Fulmer says.
“My older patients and I often talk about pre-habilitation. That’s working to get strong before an event, like a fall that causes a fracture, she says. “People want control over their lives. You can work with your physical therapist to overcome your challenges. We can say, ‘Let’s do some strength training. You can take control of your mobility.’”
Mentation is another of the 4M’s. Only 60% of physicians, 70% of NPs, and 67% of PAs surveyed said they refer their older patients who test positive for cognitive impairment, or who have problems with memory or decision making, for more testing and treating their symptoms.
Health care visits often last only ten minutes, so doctors and nurses should ask seniors how they are feeling and what activities they can do, such as going to the movies, or whether they can walk more than a block, Fulmer says.
The survey found that 43% of physicians, 37% of NPs, and 38% of PAs agreed that “it is up to the patient to tell me what their needs are.” Fulmer believes healthcare providers need to ask these questions and listen more closely to their older patients’ answers.
“It’s a conversation: ‘What is central to you at the moment?’ We need to give the elderly a voice. Let them start this conversation,” she says. The results of the study suggest that healthcare providers need more training in centering the needs of older adults.
Future generations will benefit from a more seamless health care system where all your medications, health conditions and, most importantly, personal goals and preferences are all in your map, she says. “Good care for the elderly is usually good care for everyone.”