Putting Older Patients First

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Image from Pixabay

Recently, Dr. Leonore Buckley published a commentary in JAMA on witnessing her brother’s hospitalization and subsequent decline. As a physician and caregiver, she provided a unique perspective on the disjointed, often alienating process of being a hospitalized patient in contemporary medicine.

Most physicians or nurses who have recently worked on an inpatient unit have witnessed this phenomenon. Dr. Buckley outlines some of the challenges in the care of her brother, Tom:

  1. Unclear responsibility. It was unclear to Dr. Buckley who was ultimately responsible for Tom’s care – a single point person whom she could approach with questions. She states: “the medical teams came and went with rotating attendings we never really got to know.”
  2. Iatrogenesis. Tom developed a secondary infection after receiving antibiotics, anasarca after receiving intravenous fluids, and delirium after being in an unfamiliar environment for several days. Older patients are particularly prone to such adverse consequences of hospitalization; for example by one estimate, up to one in three experience delirium.
  3. Immobility. Physical therapy was available only sporadically, and Tom deteriorated in part due to lack of movement. This is all too common in hospitals, with therapists often unavailable on weekends, and stretched thin during the weekday.
  4. Lack of patient-centeredness. Dr. Buckley reports that she felt like she “was standing in front of an express train of technology” that couldn’t be stopped. As one example – Tom went to dialysis in a windowless room from 4-8 PM most evenings, therefore missing dinner. Exhausted afterwards, he refused to eat. Other details as well – the continuous alarms that disrupt sleep, the lack of privacy – are all too familiar.

Dr. Buckley does credit the physicians and nurses with being well-trained and providing well-intentioned care. And in my opinion, individual clinicians don’t deserve blame for this – the problem is one of a healthcare system built for maximum efficiency that, somewhere through the process of adapting quality metrics, discharges before noon, and the latest in advanced monitoring technology, lost sight of what matters most – an individual person, sick and often bewildered, who needs other human beings to help them recover.

This is a complex problem without a single solution, but there is progress on many fronts. For example, the John A. Hartford Foundation has identified  “age-friendly health systems” as a priority area and is working with organizations to achieve several aims, including aligning care with older patients’ specific health goals, implementing delirium prevention strategies, and ensuring mobilization on a daily basis. Medical centers such as Johns Hopkins are piloting rehabilitation programs in critically ill patients, mobilizing them early in their disease course to avoid functional decline.

Such efforts are laudable. And, as the number of Americans age ≥85 is expected to triple over the next three decades, they are essential to a future healthcare system that puts patients first.

 

By: John Dodson, MD, MPH

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The Domain Management Approach for Holistic and Patient-Centered Care of Older Adults with HFpEF

parag_officialOur recent Council review paper from the American College of Cardiology Geriatric Cardiology Section Leadership Council enumerated the potential role for a multi-domain approach to caring for older adults with heart failure.  As shown in the proposed Domain Management approach to heart failure, domains including medical, mind and emotion, function, and social environment should be routinely considered when caring for older adults with heart failure.

While this Domain Management approach is applicable to any type of heart failure, it is especially relevant when caring for individuals with heart failure with preserved ejection fraction (HFpEF), a subtype that comprises 50% of heart failure cases across the United States.  HFpEF may be described as a geriatric syndrome, as aging processes including biological changes to the cardiovascular system and age-related comorbid conditions have been implicated in its pathogenesis.  Indeed, epidemiologic studies have shown that HFpEF disproportionately affects older adults.  Consequently, management of patients with HFpEF should incorporate aspects of care needed to address the unique vulnerabilities of older adults.  For example, patients with HFpEF almost universally experience multimorbidity (the condition of having multiple chronic conditions) and polypharmacy (high burden of medications); frequently experience cognitive and functional impairment; and often experience changes within their social environment relating to social support, their peer network, and/or financial state.  The Domain Management approach provides a framework for clinicians to address each of these four domains, promoting a holistic approach to heart failure care.

What might the application of a Domain Management approach in clinical practice for the care of patients with HFpEF look like?  Our recently-established Heart Failure with Preserved Ejection Fraction Program at Weill Cornell Medicine/New York Presbyterian Hospital could offer a model for incorporating the Domain Management approach.  For the medical domain, we obtain a detailed history that focuses on both cardiac and non-cardiac conditions, and also perform a thorough review of medications (with physical pill bottles when possible) that include prescription medications, over-the-counter medications, and nutritional supplements.  We pay special attention to the number of medications and regimen complexity, both of which can undermine medication adherence.  For the mind and emotion domain, we routinely screen for cognitive impairment (via the Mini-Cog, which takes <2 minutes to administer) and for depressive symptoms using the PHQ-2/9 (2-4 minutes), both of which can negatively impact self-care.  For the function domain, we screen for frailty and mobility limitations by conducting the short physical performance battery (approximately 5 minutes) which assesses core strength, balance, and gait speed.  We also inquire about orthostatic symptoms and a history of falls.  Our functional assessments have particularly important implications on prognosis as well as decision-making with regard to blood pressure targets.  Lastly, for the social environment domain, we take a detailed social history that includes an assessment of their social network and sources of emotional and financial support.  To address potential concerns related to this domain, our HFpEF Program has a dedicated Social Worker.

While formal assessment of each domain increases the duration of the office visit, we believe that the Domain Management approach facilitates a more nuanced approach to caring for older adults with HFpEF that is comprehensive and patient-centric.  Information acquired for each domain can have a significant impact on discussions relating to the potential benefits and risks of various diagnostic and therapeutic interventions.  Accordingly, we believe that the Domain Management approach is critically important to facilitate shared-decision making.  Whether the Domain Management approach can improve outcomes is unclear; in the future, we hope to share our experience as it relates to outcomes.  Until then, it would seem that any process that can help with decision-making in a complex condition like HFpEF would be worth the extra time and effort.

By: Parag Goyal, MD

Dr. Goyal is an Assistant Professor of Medicine in the Division of General Internal Medicine and the Division of Cardiology at Weill Cornell Medical Center, and is leading a new HFpEF program at New York Presbyterian/Weill Cornell Medical Center.