America’s senior population has grown by 34.2% in the last 10 years, and today about 54 million Americans are 65-plus.
If you’re in this group, you may take four or more medications, see as many as five doctors each year, and have at least one chronic health condition. You may also feel that your doctors and nurses often don’t listen to your preferences or fully include you in decisions about your own care.
According to a 2015 Journal of General Internal Medicine study of more than 16,000 older adults, one in five said they experienced age discrimination from their doctors or during hospital visits. Almost 6% of older adults said they faced age discrimination frequently, and their health worsened over the next 4 years.
“We must recognize that the way we manage the health care of elderly patients is not the same as how we manage 30- or 40-year-olds. We are not talking to our patients enough about what matters to them. We are getting better at managing their medications, but we don’t do as well at taking them off their medications. We don’t focus enough on their risk of falls,” says John Whyte, MD, WebMD’s chief medical officer.
Whyte recently played a key role in developing 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 partnership with the American Hospital Association and the Catholic Health Association of the United States. Doctors, nurses, and other health care providers who treat older people need to be better listeners, he says. “We need to ask what matters to our older patients. It’s a simple question, but it needs to be asked in an explicit way by each physician. We need to change how we approach treatment of our elderly patients.”
The 4Ms: Your Goals Shape Your Care
Could health care focus on your personal preferences and health goals as you age, not just what your doctor thinks is best for you or your test results? AFHS recommends that doctors and nurses plan care for older adults based on what they or their caregivers value most. Every medical visit or decision should cover the 4Ms, four building blocks of high-quality care:
- What matters, so older adults set their personal lifestyle and health goals, and health care professionals plan their treatment with these goals in mind
- Medications they take for any condition, including whether they need each drug and if any side effects interfere with doing what matters to them
- Mobility, so they can move safely, function in their daily life, and do what matters 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 in every appointment with an older adult, says Hartford Foundation President Terry Fulmer, PhD. Your doctor or nurse may ask you about your personal goals, values, and preferences, but these questions can be hard for some older people to answer.
“If I say to an older patient, ‘What are your goals?’ They may say, ‘You’re the nurse, don’t you know?’” Some older people may think they need to defer to their doctor or nurse during care, and let them make all the decisions, Fulmer says.
“We need to make people comfortable with this question of what matters to you. Very often, it’s hard to get that conversation started. You might say, ‘I want to talk with you about my mobility, my mood, and my medications, all based on what matters to me.’ That’s a very robust conversation.”
Half Consider Age When They Plan Care
How do doctors and nurses feel about an age-friendly approach to care when they treat older people?
Fulmer and Whyte are among the co-authors of a new study in the Journal of the American Geriatrics Society. The results show most primary care providers believe they should approach care for older patients differently and consider age when they make treatment decisions, but don’t always include the 4Ms in care.
The study is based on a survey of 1,684 primary health care providers randomly selected from the Medscape database during the fall of 2020. Responders included 575 doctors, 613 nurse practitioners (NPs), and 496 physician assistants (PAs).
They were asked for their opinions on age-friendly care or the 4Ms, and how they care for their older patients. While more than 90% of providers agreed that older patients “require a different approach to care than younger patients,” only 50% of doctors and PAs and 69% of NPs said they always consider a patient’s age in routine care. Only 36% of the surveyed doctors said they ask their older patients what matters to them.
High-risk medications for older people include drugs that may cause harmful side effects or interact with other drugs, says Marcus R. Escobedo, vice president of communications at the Hartford Foundation and a study co-author.
Many drugs to treat anxiety, insomnia, or pain can have side effects that lower an older person’s quality of life or are even unsafe for them, he says. Antipsychotic drugs often prescribed for older people with dementia can make them drowsy and increase the risk of falls, for example.
As we get older, our body and metabolism change, Escobedo says, so there may be medications that are not right for older adults that are too often still prescribed. “They may be taking too many medications overall. If you have lots of different providers, or if you go into the hospital, you may be prescribed medications. Then, you go home, and these drugs are not stopped.”
While 84% of doctors said they review older patients’ use of high-risk medications and screen for depression, only 78% said they take their patients off or lower their dose of high-risk meds or avoid using these drugs at all.
“If older adults do recognize possible side effects from their medications, are we listening to them? They may say something like, ‘I am just feeling off,’” Fulmer says. That’s why one of the 4Ms is to review your meds and see if any need to be changed. “We need to start that conversation about your medications with what matters to you.”
Mobility and Mentation
The AFHS framework urges doctors and nurses to ensure that older patients can move safely so they can do what matters to them. Your health care 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 do physical activity and just some movement. We help them build strength and balance. That will help you be more confident as you move,” Escobedo says.
The survey found that 73% of doctors, 82% of NPs, and 76% of PAs said they always screen older patients for limits on how well they can get around. However, only 56% of doctors, 61% of NPs, and 56% of PAs said they “ensure early, frequent, and safe mobility” when they treat older people.
Health care providers may screen older people 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 you have an event” like a fall that causes a fracture, she says. “People want control over their life. You can work with your physical therapist to get ahead of your challenges. We can say, ‘Let’s do some strength training. You can take charge of your mobility.’”
Mentation is another of the 4Ms. Only 60% of doctors, 70% of NPs, and 67% of PAs surveyed said they refer their older patients who test positive for cognitive impairment, or having some problems with memory or making decisions, for more tests and treatment for their symptoms.
Make the Most of Short Office Visits
Health care visits are often as little as 10 minutes long, so doctors and nurses need to ask older people how they feel and what activities they are able to do, like going to the movies, or if they can walk more than one block, Fulmer says.
The survey found that 43% of doctors, 37% of NPs, and 38% of PAs agreed that “it is up to the patient to tell me what their needs are.” Fulmer believes providers need to ask these questions and listen more carefully to their older patients’ responses.
“It’s a conversation: ‘What is front and center for you right now?’ We need to give older people a voice. Let them start this conversation,” she says. The survey’s results suggest that health care providers need more training in how to put older adults’ needs front and center in their care.
Future generations will benefit from a more seamless health system where all your medications, health conditions, and, most importantly, personal goals and preferences are all in your chart, she says. “Good care for older adults is usually good care for everybody.”