Delivering Quality Care to an Aging Population
As the owner and director of Northwest Geriatrics, a practice near Seattle, John Addison, MD, FACP, treats mostly elderly patients with one or more chronic conditions. During his medical career spanning over three decades, Addison has acquired enough information on geriatric medicine to fill a textbook or two. But he’d need to carve out time to write it—no easy feat, since demand for his practice's services continues to grow.
Addison isn’t alone. Many providers treating Baby Boomers, adults born between 1946 and 1964, find that business is booming. Per the World Health Organization (WHO), today’s adults are less likely to die from infections or accidents, and more likely to see their golden years, which means more adults will require health care well into their 80s and beyond.
In its Global Health and Aging Report, the WHO predicts that the global population of adults over 65 will nearly triple between 2010 and 2050, ushering in a dramatic shift in national and global demographics. By 2030, all Boomers will reach 65. Soon after, people over retirement age will outnumber youth for the first time in U.S. history. The US Census Bureau reports that by 2035, 78.0 million Americans will be older than 65, compared to 76.4 million younger than 18. Per the WHO, the population of older adults is expected to significantly outnumber children by 2050.
Though demand for senior-centered health care is swelling, the real “boom” is just beginning. The oldest Boomers, born in the 1940s, are now reaching their 70s, with another decade or so before they reach the so-called “frail elderly” stage of life. The National Institutes of Health (NIH) predicts that by 2030, the population of the “oldest old,” born before 1946, will reach 9 million.
That means that providers like Addison caring for the oldest among us—our parents, neighbors, teachers, and someday, our peers—must manage increasing patient panels while preparing for even bigger challenges down the road. Meeting this burgeoning demand will require significant societal shifts in the way geriatric health care is defined, directed, and delivered.
THE ACCESS ISSUE
Access to health care is one of the top issues facing today’s older patients, and disparities in access to care will continue to grow, says Robert L. Urata, M.D., a family-medicine physician in Juneau, Alaska. As a family physician in a remote, rural clinic, Urata cares for patients throughout their lifespan and serves as volunteer director for Hospice and Homecare of Juneau. He sees patients struggle with access to care in a remote region where specialists are few and transportation challenges abound; Juneau is not completely accessible by car, and air travel provides vital connections to specialist care. While some of Urata’s older patients can afford to travel by plane for chemotherapy or surgery, others are place-bound.
Transportation presents a barrier to care for patients living in regions far less remote than Alaska. Today, 3.6 million patients miss or delay needed medical appointments because of transportation problems, per a report in The Gerontologist.
Financial constraints create another barrier to care, even with Medicare coverage. The Commonwealth Fund reports that nearly 20 percent of today’s seniors do not seek care for an acute medical problem because of financial constraints. Medicare reimbursement rates make it hard for primary-care providers to make ends meet, says Urata, so patients using Medicare consistently report that they can’t find a primary-care physician or get an appointment to see a provider within a reasonable timeframe.
The nation’s severe shortage of primarycare physicians further restricts access to care. Per the Kaiser Family Foundation, more than half of the country’s primary-care needs go unmet. As the population of older adults continues to swell, burgeoning patient panels will strain health-care resources.
This problem is particularly acute in rural communities, where the gap between primary-care needs and available providers can exceed 80 percent, says Katie Smith Sloan, president and CEO of LeadingAge, an education and advocacy organization based in Washington D.C.
“The rural population is older than the population at large, and there are fewer health-care providers in those communities,” says Smith Sloan. “Not just physicians, but therapists, mental-health professionals, social workers, and caregivers. It becomes very hard to provide the high-quality care older people deserve.”
VIRTUAL REALITY
Sorting through the financial, demographic, and social issues impacting seniors’ access to care is undeniably complex, and solutions aren’t simple. But advances in telemedicine—care delivered through a video chat or a voice call on a computer or a mobile device—may hold promise, enabling place-bound seniors to receive health care without leaving their home, and enabling doctors to treat more patients without spending precious time out of the office. The stereotype of the technophobic senior who shuns computers is, thankfully, disappearing. Providers shouldn’t assume that older
patients are less tech-savvy than their younger counterparts, says Ralph A. Rossi MD, MPH, a primary-care physician at Seattle’s Polyclinic. “Among my older patients there’s a wide range of comfort with technology; we have an electronic patient portal that some older patients have embraced.”
Per new research, many of today’s older patients are far from technophobic. A 2018 report in International Journal of Emergency Medicine shows that virtualmedicine acceptance and utilization rates are high among people over 65, and satisfaction rates are consistent with those of younger patients. A systematic review in the Journal of Telemedicine and Telecare found that virtual health care promotes independence and helps seniors better understand health-care information.
Advances in technology are helping address some barriers to care, says Smith Sloan. “This is a fast-growing area, ranging from telemedicine—important particularly in rural settings, or where older adults can’t easily travel to a doctor’s office—and the efficient exchange of relevant health information electronically to addressing the needs of people living with dementia or preventing social isolation,” she says. But technology may present yet another barrier for seniors. Some patients in remote areas may not have access to the highspeed Internet necessary for a video chat, or even reliable phone service, notes Urata. Complex electronic portals that aren’t userfriendly for seniors, like a chat interface with very small text or spotty audio, further discourage seniors from using these portals; the Journal of Telemedicine and Telecare reports that complexity is a top telemedicine complaint for seniors.
One solution to the access problem is remarkably low-tech, says John Addison of Northwest Geriatrics. The good oldfashioned home visit, with health-care workers bringing health care to aging patients, can work well for practitioners and patients, providing high-quality care and reducing emergency-room visits for patients who can’t get to the doctor on their own. The trick for providers is making the economics of home visits work, says Addison. Clinicians with lower operating costs can make this model work, but for some, home visits aren’t economically viable.
THE POLYPHARMACY PROBLEM
Providing high-quality care to aging adults means treating a growing list of invisible disabilities facing the elderly, from mental illness to sleep disorders to osteoporosis, says Addison. “Often we’ll treat the acute issue—like the fracture that results from the osteoporosis—and only afterward begin to address the underlying invisible illness,” he says. Because many invisible ailments are side effects of medications taken for other conditions, polypharmacy is a growing problem for seniors, says Smith Sloan. Polypharmacy, defined as taking multiple prescription medications concurrently, impacts millions of elderly patients: half of today’s older adults take five or more medications. Multiple studies link polypharmacy to an increase in adverse health outcomes like falls, hospitalization, and death.
Polypharmacy may compound another problem facing the elderly—that of persistently high rates of depression and suicide. A new study from the University of Illinois at Chicago reports that a third of U.S. adults may unknowingly take prescription medications that increase the risk of depression and suicide. The elderly have the highest rates of suicide, with few programs in place for prevention, per a systematic review published in Crisis.
Here again, the solution may lie in simplification. The growing trend of “deprescribing,” or helping patients reduce the number of medications they take, can help eliminate some problems associated with polypharmacy, says Addison. “We often find patients taking twice as many medications as they need, and we can cut the number of prescriptions in half quite safely,” he says.
Bob Urata also works to “deprescribe” when possible. This means taking care to avoid beginning medicines unless they’re necessary, and working across care teams to avoid unwanted medication interactions. “We try not to start our elderly patients on medications unless they really need them,” he says. “Using medicines correctly and judiciously helps patients treat the problems they have without creating new ones.”
Helping elderly patients achieve better health and overcome hurdles associated with access to care, financial constraints, and polypharmacy requires consistent, coordinated care between clinicians, specialists, home health workers, and family caregivers, but the results are worthwhile, says Addison. “Today, we have the ability to share health information across a team of providers like never before, so we can work together with specialists in a really coordinated way,” he says. This customized, compassionate care is helping create brighter futures for elderly patients, today and for years to come.