The Triple A’s of Caring For Older Adults: Ask, Acknowledge, and Avoid

By Kahli Zietlow, MD

It’s no secret that the US population is aging. The Census Bureau estimates that people over 65 will double from 50 to almost 100 million by 2060 [1].  Additionally, the medical makeup of older adults is changing.  Advances in medical care have led to increased survivability, and once-fatal illnesses like HIV and certain types of cancer are now being managed as chronic diseases. This means that medical providers across a wide range of specialties will provide care to older adults.  In much the same way that pediatric patients are not just “little adults,” there are special considerations in providing care for the geriatric population.  We are just beginning to understand how aging affects pathophysiology and impacts patients’ perceptions about their care. The steps below can help provide the best care for older adults:

Acknowledge current limitations in data and guidelines

A 2011 systemic review from the Journal of General Internal Medicine found that three-quarters of clinical trials excluded older adults [2].  This exclusion occurred either directly via age cutoffs or indirectly with exclusion criteria such as cognitive impairment, multiple medical comorbidities, residence in nursing homes, or other attributes that primarily afflict geriatric patients.  In the age of evidence-based medicine, we are often left without clear guidance for the best care of older adults.  For instance, evidence suggests a stringent HbA1c goal of 7.0% in frail older adults with diabetes may lead to adverse outcomes, including hypoglycemia, cognitive decline, and falls [3]. Yet, there are no absolute guidelines to aid clinicians in determining when or how to liberalize HbA1c. Guidelines for older adults on a variety of clinical topics, from cancer screening to blood pressure to statin use, are based on minimal evidence or simply don’t exist.

When discussing issues with patients without evidence, it’s important to acknowledge the limitations.  Focusing on patients’ circumstances, such as the burden of comorbidities, life expectancy, and functional status, can help clinicians make the most appropriate decisions on a patient-by-patient basis.  Shared decision-making models can promote satisfaction between patients and providers.

Ask about what matters most

Rightfully so, the medical and lay press have paid increased attention to the importance of advanced care planning. Exploring patients’ beliefs and values in a controlled setting allows clinicians and family members to make the best patient decisions during critical illness and incapacity periods. However, this philosophy extends far beyond decisions about ICU care and code status. Understanding what matters most to patients allows caregivers to aid in large and small decision-making.

Would a 76-year-old, highly functional woman be willing to undergo a biopsy in the event of positive mammography? Would she tolerate lumpectomy and chemoradiation? Would a 67-year-old gentleman with early Alzheimer’s consider moving to a nursing home as his disease progresses? By exploring what matters most to patients, we can best help to navigate these difficult choices as they arise.

Avoid ageism

Ageism is rampant in our society and is often overlooked or even accepted [4]. Ageism may be overt or insidious.  As providers, although we strive to avoid bias in our care, ageism may pervade our practice habits. In order to tackle this problem, we must avoid the temptation to mentally lump our older patients together and instead recognize the individuality of each patient. Older adults have diverse socioeconomic backgrounds, values, attitudes, and experiences, and each deserves to be recognized as an individual. We should not make assumptions about the care or preferences of older adults based solely on their age.

Finally, we should remember that disability, dementia, and delirium, while more common in older adults, are certainly not inevitable. These and other geriatric syndromes should be recognized and treated early with appropriate, multidisciplinary care. Too often, ailments are dismissed as “growing older,” and we miss opportunities to improve our patients’ quality of life.

Duke Geriatrics

Our Geriatrics division offers robust clinical services to aid in the care of complex older patients. We have a specialty referral clinic, the Geriatric Evaluation and Treatment Clinic, as well as inpatient consult services at Duke University and Duke Regional Hospitals. Please feel free to reach out if we can provide assistance!

https://medicine.duke.edu/divisions/geriatrics

References

1. US Census Bureau. “An Aging Nation.” 2017. https://www.census.gov/library/visualizations/2017/comm/cb17-ff08_older_americans.html
2. Zulman et al. J Gen Intern Med. 2011;26(7):783.
3. Inzucchi et al. Diabetologia. 2015;58(3): 429-442.
4. “Ageism.” 2018. https://www.who.int/ageing/ageism/en/