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Chapter Quick Links:
Unmet Healthcare Needs
Unmet Needs of the Elderly Often are not Met
II. Many Needs of the Elderly Are
Not Being Met
Unmet Healthcare Needs
All too often the geriatric patient consults several different physicians for multiple chronic conditions and then fills prescriptions at different pharmacies, all
with a complete lack of coordination. The resulting fragmented healthcare puts the elderly patient at increased risk of further complications. Clearly, the healthcare needs of the elderly
require a different approach to case management.
The current healthcare system often fails to meet the healthcare needs of the elderly, as follows:
- Inadequate time with primary care physician;
- Inattention to chronic disease management;
- Uncoordinated patient care;
- Minimal outpatient follow up;
- Poor access to specialty care;
- Minimal pharmaceutical coordination;
- Little attention to extra-medical needs [Innovations in Eldercare, The Advisory Board
Company, 1997].
Many elderly patients have at least one reasonably detectable chronic illness, e.g. cardiac condition, diabetes, respiratory problems and so forth, that is the
focal point of treatment. Unfortunately, other chronic, potentially serious conditions often go undetected.
Such undetected conditions may include depression, cognitive impairment, vision and/or hearing problems, malnutrition, gait instability, urinary incontinence, sexual dysfunction and elder abuse [The Merck Manual
of Geriatrics, 2nd Edition]. Thus, the presenting symptoms, indicating that the elderly patient is ill, may be totally misleading as to the nature and location of the primary disease process. The diagnostic
process for the elderly necessarily needs to be different.
Some specific areas of particular need for geriatric patients embody urinary
incontinence, including the proper use of catheters; polypharmacy; use of physical and/or chemical restraints; prevention or early detection of osteoporosis; degradation of skin integrity; and malnutrition. Each of these conditions individually can put the elderly patient at increased risk of the others. Several of these chronic conditions often coexist in the same patient, resulting in significantly
diminished quality of life. Management of the older patient needs to address these issues in an integrated multidisciplinary setting.
Catheters: More than 15 percent of persons over the age of 85 have urinary incontinence [Management of the Elderly Patient]. Conditions
leading to urinary incontinence include urinary tract infections (UTIs); fecal impaction; prostatic hypertrophy; atrophic urethritis/vaginitis; prolapse of the uterus/urethrovaginal wall; pelvic mass; bladder
stones/tumors; or neurological lesions on the sacral nerves [The Merck Manual of Geriatrics, 2nd Edition]. Often patients can benefit from use of a well-managed indwelling catheter to avoid the problem
of infection that can result from long-term catheterization. This process should include maintenance of systematic records.
Polypharmacy: Common metabolic changes occur with age, and these changes put elderly patients at increased risk of experiencing toxic doses of medications. Persons over 65 use 34 percent of all medications and take an average of 4.5 medications at any one time [The Merck Manual of Geriatrics, 2nd Edition].
Potential problems of polypharmacy include interactions with prescription and over-the-counter medications, often combined with malnutrition and/or alcohol abuse. Consequences may also include increased risk of falls and fractures. A comprehensive medication record needs to be maintained for each elderly patient.
Restraints: Use of certain psychotropic drugs and/or physical restraints can impact negatively on the elderly, including death. Alternate
effective, more humane, modalities need to be implemented, decreasing the use of inappropriate and excessive medication of geriatric patients with "difficult behaviors." [Untie the Elderly Resource Manual: A Resource Manual for the Elimination of Physical Restraints in the Care of the Elderly in Nursing Facilities]
Osteoporosis: Osteoporosis or decreased bone density places a significant percentage of elderly at increased risk for fractures, effecting twice as many women as men over 70 [The Merck Manual of Geriatrics, 2nd Edition].
Prevention techniques need to be developed to reduce the development of this condition and its consequences. Exercise, adequate nutrition,
hormone therapy and pharmacology, including calcium supplementation play a role in prevention and treatment. Early assessment and intervention are critical.
Skin Integrity: Decubitus or pressure ulcers continue to be a significant management problem in chronic care, especially in the elderly, partially due to
their less than optimum nutritional status. Use of special foam, water, air, air-loss, and/or air-fluidized cushions, mattresses and/or beds are needed aid in the prevention and healing process ["Skin Care and Decubitus Ulcer Management in the Elderly Strocke Patient"].
Nutrition: At least one in every four elderly patients is malnourished and is not getting proper nutrients because of the aging of the
gastrointestinal system, combined with deficiencies, excesses and/or imbalances in food or diet [Tasteful Solutions to Elderly Malnutrition]. This is especially true for hospitalized or
institutionalized patients. There is a great need for geriatric nutritional screening.
Cognitive Impairment: Cognitive impairment may range from mild forgetfulness, confusion and/or depression to senile dementia, including Alzheimer's disease. An estimated four to five million Americans have some form and degree of cognitive failure, including about 15 percent of those over 65 and about 2 percent of all other ages [The Merck Manual of Geriatrics, 2nd Edition].
Dementia is the most common syndrome in the elderly, affecting more than 15 percent of persons over 65 and as many as 50 percent of those over 80 [The Merck Manual of Geriatrics, 2nd Edition].
Healthcare providers need to evaluate and consider the degree of cognitive impairment in the assessment and treatment of each elderly patient.
Impaired Mobility: Impaired mobility among the elderly is generally related to osteoarthritis, which is the leading cause of physical disability in persons over 65 [The Merck Manual of Geriatrics, 2nd Edition].
This reduced mobility needs to be recognized by healthcare providers as a potential barrier for the elderly to access appropriate healthcare.
Vascular Disorders: Cardiovascular disorders in the elderly may range in severity from mild hypertension to disabling angina or congestive heart failure. In 1990, heart disease was the number one cause of death in persons 65 or older [The
Merck Manual of Geriatrics, 2nd Edition]. In addition to heart disease,
vascular disorders may involve peripheral vascular disease, aneurysms, thrombi and others. Because the elderly are at increased risk of the potentially crippling and life-threatening nature of these disorders, older patients need to be fully evaluated and treated for vascular disorders.
Cancer: The elderly are at much greater risk of cancer, which was the second highest cause of death in persons 65 or older in 1990. Incidence of cancer in older patients is highest for prostate cancer in men and breast cancer in women, followed by colon cancer and lung cancer [The
Merck Manual of Geriatrics, 2nd Edition]. Protocols need to be established for screening for these cancers in the elderly.
Pulmonary Disorders: Pulmonary disorders, most commonly forms of COPD (chronic obstructive pulmonary disease), often restrict the activities of the elderly. During the last fifteen years, the incidence of COPD has risen more rapidly than any of the other nine major causes of death [The
Merck Manual of Geriatrics, 2nd Edition]. Cigarette smoking is believed to have contributed to more than 80 percent of the cases of COPD.
Pulmonary disease in older patients needs to be recognized and treated at the earliest possible stage in an effort to forestall functional impairment.
Any of these conditions individually can put the elderly patient at increased risk of the other conditions. Several of these chronic
conditions often coexist in the same patient, resulting in significantly diminished quality of life. Management of the older patient should address these issues in an interdisciplinary setting, with the care and
treatment of the specialists being coordinated by the geriatrician.
With earlier, more efficient healthcare management, seniors with chronic, but relatively stable, health problems should be able to live more satisfying and enjoyable lives well into their "golden years."
Because of visual and auditory problems of the elderly, physicians and other care providers need to allot far more time to take the relevant history, perform
examinations, discuss care options, and other care issues.
Often these matters need to be discussed with the primary caregiver to try to ensure that appropriate follow-up care occurs. More than any other segment of the population, the older patient needs a well coordinated care plan.
Overall Needs of the Elderly Often Are Not Met
In addition to many of these primary healthcare needs not being met, the elderly also have ancillary needs that are not being adequately met.
Reduced mobility, altered cognitive function, lack of information, financial constraints and changes in family structure or living arrangements may all impact negatively the elderly person's access to healthcare. These physical, functional, psychological, educational, financial and sociological changes need to be incorporated as part of the overall geriatric services.
Because of physical changes in older patients, including decreased mobility and gait disturbances, healthcare facilities need special modifications
since the elderly need softer chairs with armrests in waiting rooms, reception desks low enough to accommodate wheelchair accessibility, more open spaces in waiting rooms to maneuver a wheelchair, and overall more
recognition to accommodate the limited mobility of the elderly. Books and/or magazines with large print are a simple accommodation. Bright colors and clocks with large numerals are other considerations. The physical environments of healthcare facilities need to become more geriatric user friendly.
Overall, the lack of functional ability in the senior patient often is not adequately recognized or addressed during visits to the physician, who tends to focus
primarily on the current or immediate problem at hand. The physician also often does not emphasize the benefits of exercise as a means of forestalling cardiovascular and other health problems. Limited time and other
constraints of third party payers tend to exacerbate these problems. The decreased functional ability of the older patient needs to be recognized and exercise programs need to be established to forestall
further deterioration.
Likewise, psychological problems of the elderly are often not taken into consideration by examining physicians. Loneliness, changes in living arrangements, and
lack of socialization may lead to mild depression and/or anxiety in the older patient.
When these types of mild psychological problems are ignored, they often tend to fulminate into more severe conditions. The key is to recognize and take action to provide socialization opportunities and activities to stimulate the mind.
Community education needs to include such issues as what to expect with normal aging, advanced directives, long-term care planning, respite
care, elder law and financial planning. Patient and caregiver education with regard the potential health problems needs to cover nutrition; preventive screening for osteoporosis, prostate cancer, and diabetes;
incontinence; use and abuse of medications and/or alcohol, including impact on mood and perception; cardiovascular diseases and their complications; dementia, depression and other cognitive disorders; immobility and
rehabilitative care; sensory impairment; and other areas where increased knowledge is the key to better quality of life for a longer time. Lack of information or education often leads to further
healthcare complications.
The elderly and/or their caregivers also need information and education with regard to financial issues. The complexities of private insurance, Medicare,
Medicaid, Veterans Administration, and other federal programs are often confusing to the most astute and may be completely overwhelming to older patients.
Long-term healthcare insurance is becoming more prevalent, but again the extent of coverage may not be clear. More information and education needs to be made available in formats that are accessible and user-friendly to older patients. Seniors also need information to make informed decisions pertaining to advanced directives, e.g. healthcare proxies, living wills and so on, as well as information pertaining to final arrangements. Senior community organizations need to provide more coordination and better accessibility to this type of information.
The frail elderly are often uprooted from the homes where they lived most of their lives, only to be relocated in a "senior" community or some form of
assisted living or nursing home where they may not know anyone. This relocation
may further exacerbate their fragile psychosocial status, as may loss of a spouse or other family or friends. Seniors may also be subject to elder abuse and/or neglect. These stresses often adversely effect the health of the elderly. Healthcare providers and senior community organizations need to be more cognizant of the increased impact of these stresses on older persons. More comprehensive, integrated support systems in the community are needed.
Overall, because of its complexity, geriatric healthcare is fragmented with a lack of integration the healthcare itself and between the physical, functional,
psychological, educational, financial and sociological factors that are so intimately interwoven. The uniqueness of the geriatric healthcare needs has not been fully recognized. Healthcare of the elderly
needs to be fully integrated with complete interdisciplinary assessment of the geriatric patient.
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Continue to Chapter 3, "
Impact of Fragmented Healthcare Spreading Dissatisfaction"
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