What Matters

What matters most is the starting point for the 4Ms. When people have multiple health conditions, as many geriatric patients do, their healthcare may not address their personal priorities or may even become burdensome to them. People differ in what they are hoping for and what kind of care they are willing and able to do. The only way to understand what matters most is by asking our patients and their families.

With your hospital patients, you may start with a simple question, like “What are you hoping for from this hospitalization?”  Patients may share that they want to avoid a nursing home, or want to stay connected with friends and family, or they may express preferences for more pain control versus more lucidity.

In the primary care setting, advanced care planning can align longer term medical care with a patient’s preferences.  You may see your PCP preceptor ask a patient what is most important to them and what they consider an acceptable quality of life.

You may also see documents that record patient’s preferences. The traditional advanced care directive, or Living Will, directs treatment only when someone has a terminal condition or is permanently unconscious. These clinical situations are uncommon, so Living Wills are often of limited utility.

A patient can designate one or more durable powers of attorney for healthcare (DPOA-HC) who can take over decision-making if they are incapacitated.  By law, if a DPOA hasn’t been designated, health decisions fall first to the patient’s spouse or registered domestic partner, then to their adult children, then their parents and then their adult siblings. If these default decision makers are estranged, have differing beliefs, or suffer from medical or cognitive issues of their own, it may be particularly important to identify a DPOA whom your patient trusts.

POLST or MOLST (Physician or Medical Orders for Life-Sustaining Treatment) forms outline patient preferences for resuscitation and other treatment, such as respiratory support, hospitalization, artificial feeding, and antibiotics.  A POLST or MOLST follows the patient across care settings and can guide many decisions that EMTs or ED physicians may need to make in the face of an acute issue.

Sometimes these topics can seem daunting to patients. Resources such as Honoring Choices: Pacific Northwest can provide a framework for conversations with family members, DPOAs, and clinicians.  This website also has patient-friendly DPOA-HC and Advanced Care Directive documents and a place for people to note their goals and values and what they consider an adequate quality of life.

Mobility

Mobility is the next key assessment for older adults.  Most are still able to manage independently, and in the community, only one in five people over 85 require any assistance with self-care. However, one-third of elders fall each year and falls are the top cause of fatal and non-fatal injury in this population.

Falls are not an inevitable part of aging. They usually have multiple contributors, both intrinsic to the patient (like functional impairment, vision loss, or neurologic problems) and extrinsic to the patient (like medications or tripping hazards). Proactively identifying and addressing these risks may prevent a fall that could change (or end) your patient’s life.

To assess for functional impairment, start with a quick screen.  If your patient reports difficulty with managing their medications, their finances, or bathing, or if you observe clues like difficulty getting up from a chair, perform a full assessment with an ADL/iADL questionnaire. ADLs are activities of daily living, which are basic self-care tasks. Instrumental ADLs require more cognitive and physical capacity and are needed to live independently in the community.

All older adults should also be screened yearly for falls. A single fall suggests the patient needs further evaluation and a referral to physical therapy for strength and balance training. Screening for fall risk can also be done with physical exam, using a test called the Timed Up and Go (TUG), which is demonstrated in the video below.

1. Mark a line on the floor or identify another object 10 feet from the patient.
2. Give your patient the following instructions: “Rise from the chair, walk to the line, turn, return to the chair and sit down again.”
3. Time your patient as they perform this task. People who take more than 12 seconds have limited physical mobility and are at high risk for falls.

Recognizing mobility limitations may allow you to target interventions to help maintain your patient’s independence. Interventions that could support your patient include:

• Physical therapy can improve strength and balance and decrease the risk of falls
• Occupational therapy can identify and address safety risks in the home environment
• Assistive devices such as tub grab bars can allow someone to safely bathe
• Social supports can “fill in” for identified impairments – i.e. Meals on Wheels, Access van transportation, or in home caregivers

Mentation

Memory and mood should be assessed yearly or any time concerns are brought up by family.  Cognitive impairment is common – three percent of those over 65 suffer from cognitive impairment, and the prevalence doubles every 5 years after that.

The Mini-Cog is a quick and well validated way to screen for cognitive impairment and is commonly used in the clinic.

Step 1: Three word registration.  

Look directly at your patient and say “Listen carefully – I am going to say three words that I want you to repeat back to me now and try to remember” After listing three words, ask the patient to repeat them, giving them three chances to repeat them back.

Step 2: Clock Drawing.

Give your patient a piece of paper with a circle on it and say: “Next, I want you to draw a clock for me. First, put in all of the numbers where they go.” When that is completed, say: “Now, set the hands to 10 past 11.” Repeat instructions as needed as this is not a memory test and give your patient up to 3 minutes to complete the test. Score 2 points for a normal clock, 0 points for an abnormal clock.

Step 3: Three word recall.

Say “What were the three words I asked you to remember?”  Score 1 point for each word recalled.

Interpreting the test.  Add up the points for clock drawing and recall.  A score of 3 or more indicates a lower likelihood of dementia, although some degree of cognitive impairment is still possible.  If the score is 2 or less, your patient needs further evaluation and testing.

In the example below, the patient receives 1 point for recalling one word and zero points for an abnormal clock. The video starts at the 1:42 and you can stop at 4:52.

Mood should also be assessed at least yearly.  Depression is a common problem in older adults, but it is not a normal part of aging. People with chronic illness and with functional impairment are at higher risk of developing depression, and of course both of these are more likely in older adults.  Elders with depression are also at higher risk for suicide, especially older males.

Medications

Regular review of all medications is the final M of age-friendly healthcare. People over 65 account for 30% of prescription and 40% of over-the- counter medications sold in the United States. One third of elders take 5 or more medications (polypharmacy) which is associated with both higher healthcare costs and more nonadherence to treatment.

The risk of adverse drug events (ADEs) is also proportional to the number of medications used.  Up to one third of elders have at least one adverse effect of a drug in a year, and an estimated 20% of hospitalizations in this age group can be attributed to ADEs. Those with polypharmacy have a significantly higher rate of falls, emergency department use and hospitalization.

Contributors to ADEs in older adults include:

• Decreased clearance of medications by the aging liver and kidneys, leading to increased drug levels
• Changes in body composition with increasing fat & decreasing muscle, impacting how drugs are stored
• Increased sensitivity to drugs with anticholinergic properties and to benzodiazepines
• Interaction of multiple medications – the risk of ADEs is proportional to the number of medications taken

The American Geriatric Society Beer’s list identifies drugs that elderly people should avoid if possible. Even though some of these drugs are commonly prescribed for younger patients (or are available over the counter), they can cause serious problems in older people. Here is a link to the “Top 10” medications that we should avoid or use with caution in older adults. This is presented in patient-friendly language.

Resources and References

Advanced Directive for Dementia

Lawton –Brody Instrumental Activities of Daily Living Scale (IADL) (alz.org)

Depression is Not a Normal Part of Growing Older | Alzheimer’s Disease and Healthy Aging | CDC