Treating Medical Problems in the Elderly – This Information is brought to you courtesy of Healthcare Resources Home Health
Aging seniors and their families are often confounded by the complexity of issues facing the elderly (including declining income, increased debt, poor investment returns, declining health, medical crises, complex insurance programs, long term care challenges, etc…). This book (published in 2014) takes a comprehensive approach to address these challenges and provide solutions.
Treating Medical Problems
Lack of Proper Care
Below is a list of common medical conditions the elderly deal with. These are also conditions that may occur in younger people but some of them such as cataracts, congestive heart failure, chronic obstructive pulmonary disease, osteoporosis, diabetes, stroke, incontinence, dementia, and prostate problems are more unique to an older generation. Remember also that many of these conditions may coexist together in the older person.
- Cardiovascular Disease
- Congestive Heart Failure
- Chronic Obstructive Pulmonary Disease
- Back Pain
- Lack of Strength
- Eye Problems
- Rheumatoid Arthritis
- Other Immune Disorders
- Parkinson's Disease
- Problems of the Prostate Gland
- Urinary Incontinence
Older Americans account for over one third of all medical spending in this country — approximately $300 billion a year for their share of the cost. It costs about four times the amount of dollars to treat a 65 year old for health care in a given year than it does to treat a 40 year old. Even though people age 65 and older have their own health care insurance, called Medicare, Medicare simply pays the bills and up to this point has not been actively involved in promoting a better delivery system for this age group. Recently there has been much talk of Medicare supporting preventative, outcome based medicine but aside from a few minor changes little has been done. However, there is a possible change on the horizon. Medicare is currently conducting a test program and evaluating a number of hospitals for their outcome of care with patients. Instead of determining the wellness of patients by treatment protocols or medications the program is trying to identify hospitals that are more successful than others in having positive medical treatment outcomes. The intent is to reward these hospitals with a 20% bonus in Medicare reimbursements. Hospitals that are below average in meeting the standards will receive a 2% reduction in reimbursements.
Hospital admissions for the elderly are about three times those for the young. Older Americans visit a health provider at least twice as often as younger Americans. And Americans 75 years and older use hospital emergency rooms about twice as often as any other age group. With a different approach, Medicare could probably reduce older Americans' number of office visits, hospital admissions and emergency room visits.
All doctors are certainly aware of the differences in medical problems of the young and of the old. What doctors, who do not regularly treat the elderly, are not usually aware of is the fact that older people often have multiple problems at the same time and symptoms from one may be misleading or mask symptoms from the other. Consider the example above of the lady with low thyroid, malnutrition and depression. Her health care providers failed to test for or even recognize these combinations and the interplay they had on worsening her depression. They even misdiagnosed her depression as age-related dementia.
It is not to say that the healthcare profession does not treat the elderly aggressively for medical conditions that are diagnosed. The problem seems to lie with an undue focus on correcting specific problems and ignoring the underlying social, nutritional, psychological and physical activity components of an older person's health. As we have discussed previously, these components have a tremendous influence on the health of senior citizens. This is less true for younger people. Younger people are already active, socially stimulated and pursuing careers. Most healthcare practitioners don't recognize this difference and they treat the older patients only for their conditions assuming they will respond just like their younger patients. Once they have been treated many doctors, especially specialists, go on to taking care of a multitude of other patients and are unlikely to follow up over a long period with their older patients. And those practitioners who do want to provide follow-up are only reimbursed under Medicare if they can find an excuse for an office visit that doesn't include just a routine exam.
A Holistic Treatment Approach
Most practitioners who specialize in care for the elderly are aware of the above-mentioned problem with older patients and they take a holistic approach with the medical treatment of these people. An attempt is made not only to treat the specific condition or conditions but to make sure there are sufficient activity, proper nutrition and family support at home. They work closely with family members to make sure their loved ones are taking medications properly and are reporting their symptoms. They require those caring for the elderly to closely monitor health conditions and report any changes before things get worse. They meet with their patients regularly enough to monitor their health. This broad-based approach results in better health and in fewer visits to the emergency room because intervention for a worsening condition is achieved at an earlier stage.
A good example of this holistic approach is the Veterans Administration health care system. The VA system over the years has become the nation's largest geriatric care provider for older men. Almost all veterans are men and because most veterans hearken back to World War II, the Korean conflict and the Vietnam War most of them are older than age 60. Because of this the VA has found it necessary to adapt its health-care to this age group. The VA schedules regular exams at least every six months or yearly depending on available funds and personnel. A health examination always includes lab work. Screenings for cancer, cardiovascular problems, eye problems, hearing problems and many other conditions common to aging are a routine part of veteran's administration health-care. The VA was one of the first health providers in the nation to require its local hospitals to keep their records on computer and in a central database. This allows health practitioners in the system to quickly and efficiently access all information and avoid misdiagnoses and possible drug interactions. By taking a hands-on, preventative approach to the treatment of older men the system is able to keep its patrons healthier and avoid costly medical interventions due to lack of follow-up.
A significant problem with providing holistic treatment is many health insurance providers, including Medicare, will not pay for routine office visits without an underlying medical complaint. Some private health plans are starting to use so-called "pay for performance" or "outcome based care" where the overall health of the patient takes precedence over the procedures used to get there. But Medicare, up to this point, has not made this change. This makes it extremely difficult for the geriatric care provider to monitor his patients and intervene before a health problem becomes bad enough to require hospitalization or major surgery. Doctors practicing this type of medicine have to be inventive in order to provide adequate treatment. Family of the elderly can also help in this respect by "finding" medical complaints to justify setting regular appointments with the doctor.
Treatment of Depression
Older Americans have a suicide rate that is four times the national average. Much of this is a result of depression. It is estimated that 20% of the aging population suffers from depression. Practitioners not trained in geriatric care automatically assume that depression is a normal part of the aging process. This is not true. Depression can be treated just as effectively in older people as it is in younger people. But sometimes medications are not as effective in older people as they are in a younger population. Unfortunately, practitioners often rely too heavily on medications and don't try other non-medical therapies.
Many doctors simply don't choose to recognize depression and help their older patients with it. It is interesting to note that over 70% of elderly suicide victims committed suicide within one month of seeing their health care practitioner. Many of these people were not referred or treated for depression by that health care practitioner.
The Problem with the Nursing Home Care Model
Nursing homes serve two purposes. The first is to provide nursing and medical care for people recovering from illness or injury. The intent is to get these people well and return them back into the community. A second purpose for the nursing home is to care for people who have severe chronic medical or cognitive impairments and who are not expected to recover but only to get worse. These are often called long-term care residents. Rehabilitation patients and long-term care residents are typically segregated in different parts of a nursing home. Or it is often the case a nursing home will specialize only in rehabilitation or long-term care but not both.
The general attitude towards long-term care residents is they will never recover and will either die in the nursing home or be transferred to a hospital to die. Some might argue this is reality but it is also age discrimination. As we have seen in previous examples, sometimes long-term care residents are misdiagnosed or given improper medications which may make them candidates for long-term care but they may also respond to treatment and even recovery and as we saw in one example could even return home and lead a normal life. But because of the prevalent attitude towards "warehousing" long-term care residents, most nursing homes do little to try and rehabilitate these people other than treating acute conditions and making them comfortable.
Another problem is these people are typically receiving assistance from Medicaid or Medicare. These government programs only pay nursing homes to provide treatment such as dispensing medications, providing assistance with activities of daily living, treating medical conditions or giving psychiatric help. Nursing homes are not reimbursed for alternative therapies that might make patients better. Another problem is often the doctor assigned to the patient either has little interest in providing therapies to facilitate recovery or the doctor is inexperienced in geriatric care.
Unfortunately, another reason for not being more actively involved with residents is that many nursing homes in the country have large numbers of unoccupied beds. It is not in their best interest to cure a resident and return him or her to another living arrangement as that would result in a loss of revenue and there are no people standing in line to occupy the vacant bed.
This attitude in nursing homes becomes an age discrimination issue. The elderly are treated differently from other age groups. There are a small number of US nursing homes that don't rely on government reimbursement, are not concerned about occupancy rates and are free to use alternative approaches. Some of these facilities have been successful, in a number of cases, in improving the condition of their long-term care residents and allowing them to return to a community living arrangement. They typically use approaches we have already discussed such as involving residents in their own medical decisions, providing pets and plants, providing interaction with children, stressing activity and mental stimulation and in aggressively following up and properly treating medical conditions. This approach is often called "the holistic approach" to nursing home care.