Aging With Grace: Clinician’s Guide To Healthy Aging

Healthy aging has become a daily clinical problem as more and more older patients live longer with more comorbidities. The primary goal for the care of older patients should be to promote maximal function, prevent disability, and promote independence and quality of life. By implementing several simple strategies for quality of life, the patient and clinician can focus on what really matters. Patients and clinicians should assess function routinely, avoid medications whenever possible, prevent falls and delirium, preserve hearing and vision, and support patient social resources. The health system should organize care that is team-based, home-focused, and community-linked so that older adults can live safely and healthfully at home, avoiding unnecessary hospitalization, and going on to live full and rewarding lives.

Why It Matters

As patients and clinicians get older together, our definitions of “good outcomes” shift. Many older patients consider success to be being able to walk, being cognitively clear, and going home after a hospitalization. While blood sugar, blood pressure, and cholesterol levels are still important, evidence is accumulating to suggest that these measures are relevant to clinical decision making primarily as predictors of future functional decline. Strong disease targets can do harm for many older patients, causing dizziness, fatigue, falls, and polypharmacy as they struggle to adhere to the recommendations of multiple clinical guidelines. A function-first approach to clinical decision making can help us to choose treatments that are safe and effective, maximizing quality of life for patients.

Most falls and decline have only a few critical “tipping points”. A fall can lead to walks being stopped, reduced activity, frailty and more falls. A brief hospital stay can lead to delirium, sleep disturbance, frailty and loss of independence. New medications can have side effects that cause confusion, constipation, low blood pressure or urinary symptoms that can trigger many more problems. Healthy Aging is about preventing these problems before they occur and rapidly restoring function should a fall or decline happen.

Function is a much stronger predictor of illness or outcome in patients than an isolated lab value. I have to say I found this to be absolutely fascinating.

More than any other laboratory value, measures of gait speed, balance, muscle strength, and functional activity predict short-term outcomes in older adults. Such “physiologic reserve” measures predict the risk of falls, hospitalization, and loss of independence and serve as indicators of an older adult’s need for help and as targets for intervention. Functional measures also have prognostic implications and are the focus of interventions provided by geriatricians and other healthcare professionals, including physical therapy, assistive device use, home safety modifications, and medication management.

Multimorbidity makes disease-by-disease care less useful

Managing multiple chronic conditions at the same time requires more than just setting treatment targets for each condition. Even achieving the treatment targets for one condition can become problematic when conflicting targets and an unrealistic workload are created for the patient and their carers. A healthy aging approach prioritises, simplifies and focuses on relieving symptoms, safety and function. It can facilitate shared decision-making by framing care in terms of what the person wants to be able to do.

There is a persistent bias in systems and payment models that favour short term acute care over prevention.

Many prevention and retardation of decline services are undervalued because they save money down the line. Home care, rehabilitation, fall prevention programs, caregiver training and support, and other social determinants of health can help older Americans age in place but are not equally accessible to all. Shortages in the geriatrics workforce and in primary care, uneven distribution in how care is delivered, and holes in coverage for long-term supports and services all contribute to unnecessary disability. We see this reality play out in repeated trips to the ED, unnecessary hospitalizations, and poor discharges because home realities were not addressed.

Equity is central to healthy aging

While curative treatment is important for seniors with chronic illnesses, social determinants like housing, food security, access to transportation, safety and social connection must also be considered. In fact, when developing a “perfect” medical plan for seniors, it is crucial to consider how a senior’s lived situation may impact their ability to successfully carry out their medical plan. A senior with several chronic illnesses who lives alone with risk for falls may need help with transportation to office visits if he cannot drive. A senior taking costly medication for high blood pressure who cannot afford it may need assistance with that. Rural residents and those of limited financial means are particularly vulnerable to poor health outcomes due to delayed care. Helping patients and their families identify and connect with resources that support these determinants of health is a large part of helping patients and families develop medical plans for healthy aging.

Who It Affects

Healthy aging is beneficial to individuals of all ages, but particularly crucial for older adults managing one or more medical conditions, experiencing frailty, sensory deficits or cognitive changes. For frail older adults, there is less “reserve” and they are more susceptible to illness from daily stressors such as the flu, hospitalization, or changes in their current list of medications. Their recovery time from an illness or injury may be longer and they may need levels of care, such as rehabilitation, that are step-down from nursing home care. In addition to promoting healthy aging, older adults with sensory deficits (vision or hearing) or early signs of cognitive changes require special consideration in safety measures and planning for daily living tasks prior to a medical crisis.

A healthy aging approach to care recognizes the special needs of patients who have few social supports, live in a rural setting, or have a low income. In planning the care for these patients, the medical and nonmedical needs must be addressed in order to best promote overall health. Patients’ mode of transportation to and from doctor visits, the patient’s and their families’ ability to schedule appointments at appropriate times, and early detection of acute complications resulting from injury or illness all may be affected. Patients and their families with low incomes may have difficulty purchasing nutritious food for themselves and their families as well as affording safe and cool housing. Many patients and their families may have trouble affording adaptive equipment, hearing aids, and the needed battery replacements for hearing aids. Several therapy services for older adults are not as accessible in rural settings, placing older adults at risk of long-term disability resulting from falls and hospitalizations.

These are all the stakeholders in healthy aging: physicians, specialists, hospital teams, and home health care providers, all involved in a continuous, person-centered process of healthy aging that requires thoughtful consideration over time. All healthcare providers from primary care physicians to pharmacists, physical therapists, occupational therapists, behavioral health clinicians, and social workers are stakeholders in healthy aging. Healthy aging involves many elements: physical activity and strengthening, a safe home environment, effective management of medications to prevent polypharmacy, management of mood and cognitive changes, and access to resources in the community.

Family members and caregivers are vital partners in the care of older adults. By assisting the older adult to remain at home safely, the family member or caregiver prevents unnecessary hospitalizations and delayed treatment. Family members and caregivers manage medications and prescriptions, prepare healthy meals and snacks, transport the older adult to medical appointments, assist with bathing and dressing, manage lifting tasks, and make medical decisions on behalf of their loved one. In addition to providing care to the older adult, family members and caregivers also may work outside the home, care for school-age children, and manage the needs of other family members while trying to manage their own health and wellness. To prevent caregiver burnout, physicians must include the caregivers in patient education, clearly define the role of each family member in the older adult’s care, make complex medical regimens as simple as possible, and provide caregivers with training and education on skills that can be performed safely and effectively, such as bathing, lifting, and managing incontinence. Clinicians also must link families with local and national resources that provide caregiver respite and support.

Better healthy aging – where older adults fall less, avoid delirium, take medications safely, receive early home support to recovery from illness or injury, and require less emergency medical services, hospital and long-term care – is good for individuals and families and good for providers and employers. Healthy aging is also good for industry and for healthcare systems. Better upstream care can reduce health system use and improve care. So healthy aging is a clinical issue, a system performance and policy issue. Healthy aging is affected by, and in turn affects, policy and payment decisions. These decisions affect access to home care and rehabilitation, to long-term services and supports, and to the workforce to provide them.

What Changes

This healthy aging model for practice shifts focus from traditional outcomes to safety, decision making, use of teams and community resources. Straightforward and not overly complex, it looks at what predicts decline and what predicts quality of life.

1) Start every plan with “what matters most”

Prioritize patients’ concerns and develop testing and treatment plans that target their major objectives. Ask: What is the one thing you want to be able to do in a year? What is the one thing that worries you most about your health? What is your greatest fear? Our patients worry that they will not be able to walk, worry that they will have to move to a nursing home, worry that they will become too ill or disabled to take care of themselves or their families, worry that they will die early of cancer or a worsening of their illness. They worry that they will become a burden to their families. Their goals for care are to decrease their pain, to help them sleep, to improve their mental status, to allow them to be as independent as possible, and to allow them to continue to function physically.

Trading-offs can be made more realistic by framing them in terms of potential gains and losses in terms of function and burden. For example, if lowering blood pressure will cause dizziness and falls, setting an increased target may be a reasonable decision. Similarly, the plan for diabetes management could emphasize avoiding hypoglycemia and preserving cognitive function over lowering A1C as much as possible. SDM allows for making choices between conflicting evidence-based recommendations, and helps in individualizing these recommendations in order to address the patients’ unique needs and preferences.

2) Make functional assessment routine

After illness, medication changes or falls, Function should be a vital sign. A number of domains should be assessed for vital function including: gait and balance; muscle strength; vision and hearing; cognition; mood; continence; nutrition; pain; and sleep. Many of these tools take only a few minutes to complete and have only a few questions. Assessing a patient’s Functional Status or Function at admission will serve as a baseline for future comparison and will assist the clinician and patient in developing the most appropriate level of care and in implementing interventions that will promote safe and effective return to independence.

Assessing for falls risk is important since falls are a common and preventable occurrence. Ask patient/family about history of falls and near falls, fear of falling, and dizziness/syncope. Measure blood pressure while standing if patient reports symptoms of orthostatic hypotension. Identify potential home hazards, inadequate lighting, slippery floors, loose rugs, lack of grab bars, etc. Refer to PT for balance training and strengthening exercises as indicated. Consider referral to OT for home safety assessment when available.

3) Shift medication strategy toward safety and simplification

Medication review and deprescribing are two of the 6 core interventions for healthy aging. Review all medications to de-escalate medications that could be contributing to falls, confusion or adverse drug events and attempt to deprescribe. Schedule a medication reconciliation at discharge from hospital and from visits to the emergency department. Many patients take medications not listed on their chart, including over the counter medications and nutritional supplements. Consider what patients are really taking versus what is listed in the chart. Ideally, medication reconciliations should be performed annually as well.

Deprescribing should be targeted to patient symptoms and goals, not just the number of medications. Look for dizziness, fatigue, constipation, daytime sleepiness, “brain fog”, etc. Consider which high-risk medications or combinations of medications may be causing these symptoms. Identify candidates for deprescribing (sedatives, medications with significant anticholinergic effects, duplications, not prescribed for indication, not perceived to be providing benefit). Develop a tapering plan and make follow-up appointments to reassess the changes in symptoms.

Simplification of regimens is important for patients who cannot see well or who are otherwise relying on memory for their medications. Many drugs can be switched to once daily dosing, and written instructions should be provided in clear language. Patients may also benefit from blister packaging, coordinated refills, and caregiver involvement. Dosage adjustments for patients with renal impairment and liver disease should also be considered. Finally, the need for ongoing use of expensive medications with a long time-to-benefit in frail patients should be reconsidered.

4) Treat rehabilitation and activity like a prescription

Strength, balance and endurance training are some of the most powerful exercises to promote independence and to prevent disability. As a physician, provide your patients with progressive exercise to help them improve their strength, balance and endurance. Include activities that require resistance, balance training and activities such as walking or cycling at the patient’s level of ability. Describe the type, frequency and progress of exercise to your patients. Refer your patients to physical therapy following a fall, hospitalization or evidence of weakness.

Helping people to do the things they want to do. Reducing pain and facilitating people with disability to engage in activities that they are capable of and wish to do. Identifying and managing causes of pain including osteoarthritis, neuropathic pain, foot problems and poorly fitting footwear. Providing advice about use of assistive devices and ensuring they are correctly fitted. Small gains in pain control and activity confidence can translate into large increases in activity and social participation.

5) Prioritize sensory health and cognition

Hearing and vision loss can be isolating, increase the risk of falls, and lead to depression and cognitive decline. By aggressively screening for hearing and vision problems and promptly referring these patients for appropriate evaluation and treatment, you can provide incredibly rewarding care for both your patients and practice. We can easily screen for hearing and vision problems and determine if any exist and can be easily treated to improve safety and enhance quality of life.

Cognitive screening is not for every context or purpose. First, screening should begin based on clinical indications, and efforts should be made to ensure safety assessment and planning for the individual found to have cognitive impairment. Many questions for patients and caregivers might revolve around issues of adherence to medical regimen (are medications/doses being taken as prescribed) or evidence of memory for important obligations (Are bills paid on time). Patients and their caregivers might comment about changes in how the individual gets around their home and community. Have the caregiver noticed changes? If impairment is found, the focus should be on safety and support. Should someone dispense and manage medications/doses? Assess risk for driving and for transporting self? Involve family members (with patient’s permission)? Connect individual and/or family with resources in the community for support and advocacy. Consider potential, reversible causes of cognitive impairment.

6) Treatment of addiction must include mental health issues and social connections. There is no reason to think of these qualities as existing apart from the rest of human nature.

Depression, anxiety, grief, and loneliness can have a negative impact on older adults with health problems and impede effective health management. Look for signs of these problems in your patients. Addressing these problems and enhancing social support can help patients manage these problems and motivate them to get better sleep, eat well, and participate in their rehabilitation.

Screening for social needs should have a clear next step. Screening for social needs asks a series of questions about food access, housing safety, and other basic necessities. When this connectivity and resources are in place, patients and families can be linked to local programs, social work, and care management. Simply bringing a patient’s first meal delivery, arranging a ride to a doctor’s appointment, or introducing them to a fun recreational activity can begin to break down some of the isolation and work towards stability.

7) Support advance care planning in your role on an ongoing basis.

Advance care planning is an important part of healthy aging. Planning ahead helps patients to maintain their independence and avoid unwanted, unnecessary, and unwanted aggressive medical treatments during serious illness. We strongly encourage our patients to 1) identify a surrogate decision-maker, 2) discuss their values and expectations with family members and healthcare providers, and 3) complete advance directives (such as a living will and power of attorney for healthcare). In addition, we encourage our patients to identify several desired outcomes and the specific trade-offs they would not wish to make (e.g. severe cognitive impairment, dependence in daily activities) based on their individual values and priorities.

These conversations are most powerful when done proactively throughout the health care planning process. We encourage revisiting these conversations following major health changes, new diagnosis, or hospitalizations. Organize documents in a place that are accessible in all health care settings. Copy and distribute documents to family members for ready access.

8) Build team-based workflows and safer transitions

Care of older adults with complex medical conditions requires a team of clinicians from various disciplines to address all of the complex factors at play, including functional status, medications, physical rehabilitation needs, psychological and social changes associated with aging as well as the social determinants of health. Simplify referrals to therapy, pharmacotherapy review, behavioral health services and social services as appropriate. Shared care summary could include treatment goals, patient’s functional status at baseline and at follow up, high risk medications, and fall risk. Brief contact with patient’s caregiver(s).

The Transitions of Care initiative should include a basic safety bundle to address the issue of readmissions and confusion during care transitions. A minimum of the following elements should be included for every patient transitioning out of the hospital: 1) Medication Reconciliation; 2) Delirium Risk, Prevention and Detection; 3) Mobility; 4) Follow-Up; 5) Home Support. Patients should be able to explain to their families how they plan to take all of their medications at home, where to obtain additional doses of medications if needed, what transportation options are available to return home, and what 3 warning signs will indicate the patient needs urgent assistance.

9) Technology should take some of the burden off, not worsen economic inequality.

In addition to supporting extended care for individuals with mobility limitations through the inclusion of Telehealth, remote monitoring and risk-flagging, these technologies can be designed to ensure accessibility for individuals with limited internet access or hearing loss. For example, some platforms may offer phone-based options, while others incorporate caregivers or community-based resources to support links to care for individuals with mobility limitations. The primary purpose of these technologies should be to support continuity of care and early problem detection, rather than to serve as a potential barrier to accessing care.

10) Practical next steps clinicians can implement now

Make functional questions and answers a part of daily practice; Review and optimize medications; Screen patients for a risk of falls and depression; Check hearing and vision; Document patient goals in every care plan. Screen for social needs and have a referral pathway in place; Include caregivers and family members in the care planning process with patient consent. After a patient has recovered from an acute illness, reassess their treatment intensity and focus on evidence-based treatment with rapid, tangible impact on daily function. Connect patients and families to skilled therapy, simplify and optimize medications, promote healthy sleep, and treat pain to prevent further injury and hospitalizations. The simple, enduring steps to better brain health can translate to fewer falls, less hospital time, and more years of healthy, safe, and independent living.

References:

https://www.cdc.gov/healthy-aging/about/index.html https://pmc.ncbi.nlm.nih.gov/articles/PMC11267466/