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The Big Picture: Elderhood Part 1

Louise Aronson MD MFA and Neda Frayha, MD
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For most of us, people over the age of 65 make up a huge portion of the patients we see and the energy we pour into clinical care. And yet most of us receive woefully inadequate training to provide the best care for these patients and to overcome structural, systemic biases against the elderly. In this special conversation, Neda sits down with Dr. Louise Aronson, geriatrician and Professor of Medicine at UCSF and author of the fantastic book Elderhood to learn more about how we can take better care of our over-65 patients.

Pearls:

  • When working with elders, consider the following strategies: start by understanding goals, assess functional status, avoid over controlling chronic illnesses like diabetes and hypertension, keep Beers criteria on your radar, and consider age with tools like ePrognosis when considering “routine” screenings.

 

  • Definition:
    • Elderhood is over 65
  • Why it matters?
    • Certain disease are more or less prevalent at different ages
    • Responses to treatment are different based on age
    • Our policies and structures reinforce unconscious bias
      • Examples:
        • Older adults make up 30-50% of the inpatient services and overall are disproportionately represented in healthcare services utilization. However, our training falls far short of caring for this population.
        • Vaccine schedules are incredibly detailed for pediatrics but > 65 there are no gradations
        • Pill bottles are child proof but not easy to use for older adults
  • Examples of microaggressions?
    • Condescension: Telling someone in their 90’s, “Oh, you're not older, look at you, you're still up and at ‘em”
    • Infantilization: Saying to an elderly woman, “Oh, hello there, young lady, I know it's not polite, but how old are you?”
    • Elder speak: speaking down to someone using the tone of voice you use for a small child or pet
  • Ways in which the system reinforces microaggressions, ageism:
    • Short visits that make both the clinician and patient feel unnecessarily rushed and places each other at odds
    • Medical training does not provide adequate time for taking care of the geriatric population that makes up a large majority of healthcare utilization
    • Hospitals are not set up for geriatric populations
  • Strategies for working with elders (that also help us work with patients of all ages):
    • Start with “Tell me what brings you in today, and also can you give me a sense of who you are and what your health has been like?" for context about who the person is in front of you
    • Understand goals of care: “What matters to you most in your life right now and what are you looking forward to in the next year or five years?”
    • Document and understand functional status - gait speed, grip strength. These are often better predictors of hospitalization and outcomes of care than other clinical metrics
    • Recognize that making a person stronger and fitter at any age is really important and that physical therapists don’t get any more training in this than doctors and nurses
      • You can put muscle on a 90-year old. It will take longer but it is possible and requires putting weight in that person’s hands.
    • Don’t overcontrol chronic diseases like diabetes (A1c 7.5-8%) and hypertension
    • Dive into polypharmacy - know the Beers criteria (check out PC RAP April 2018)
    • Consider age in “routine” screenings. Use ePrognosis (https://eprognosis.ucsf.edu/) to understand life expectancy
  • Better conceptualize age:
    • If taking care of older patients is disappointing or depressing or frustrating, it may be because your training has not given you the necessary knowledge and skills to do, but they can be acquired
    • Reframe older age of a positive and not a negative thing - “Tell me what the best things about your life are right now.”
    • Reframe our questions to elders the assume a different “work” - volunteering, taking care of grandkids, hobbies
    • Push elders to value themselves and reflect on purpose and meaning
    • Focus on areas of lost function that may have eroded more recently as an intervention point to encourage those people to modify and get that function back
    • Encourage growth and creativity
    • Explore diagnoses fully without writing them off to old age: 
      • Walk them through options to further work-up and if it feels they would benefit from knowing, move forward with it

 

References:

  1. Aronson L. Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life. New York, New NY: Bloomsbury Publishing; 2019. 
  2. ePrognosis. https://eprognosis.ucsf.edu/index.php

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Hippo Primary Care November 2020 Written Summary 254 KB - PDF

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