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Chapter Quick Links:
Spreading Dissatisfaction
Growing Awareness
High Utilization
Chronic Problems Complicate Utilization
Senior Attitudes Are Changing
Selected Case Examples
Some Conclusions
III. Impact of Fragmented Healthcare
SPREADING DISSATISFACTION
Increasing numbers of seniors and their families and caregivers are dissatisfied with the outcomes of their interactions with healthcare providers.
Growing publicity about this dissatisfaction is being caused by the increasing number of elderly, their lengthened lives, and the swelling reimbursement difficulties are causing growing publicity about this dissatisfaction. This dissatisfaction is multiplying and will ultimately have to be addressed.
Growing Awareness
As the number of elderly has grown, their healthcare problems have become a common subject in the popular press.
Advertisers target the senior market for goods and services, thereby alerting the rest of the population to the challenges of growing older. Of greater significance is the growing number of the elderly who are taking their concerns and experiences onto the web. Chat rooms and other information exchange opportunities are helping individuals confirm that their bad experiences are not singular. There is a rapid escalation in the number of healthcare/elderly web sites available from reputable sources, such as leading academic medical centers and healthcare systems. Information
obtained from these sources is being used by the elderly and their families and caregivers in physicians' offices, hospitals and elsewhere.
Seniors are the most rapidly growing segment of the population in their use of computers and the internet.
Computer classes are some of the best attended educational opportunities for seniors in health system membership programs. Certain systems report wait times of up to six months for their classes.
Concomitantly, seniors are living better than ever before in this country.
Income and wealth have grown on a broad basis. Prevalence of disability among seniors by age has shown a steady decrease in recent decades. For example, there were an estimated 1.2 million fewer seniors disabled in 1997 than there would have been had disability rates per thousand not declined since 1982 [Innovations in Eldercare, The Advisory Board Company, 1997].
High Utilization
Medicare and Medicaid have changed the way seniors are cared for in our healthcare system but there are repercussions that families of seniors do not
recognize and many seniors have yet to experience. Lack of access and attention are primary examples coupled, oddly enough, with over utilization.
In 1998, 27.3 percent of family practitioners in the U.S. refused to accept new Medicare patients.
Different reasons were given in the survey responses but more than 20 percent of the physicians answered candidly that the reimbursement was "inadequate." [American Academy of Family Physicians, 1998].
Although seniors have more health problems and concerns than younger patients do, there are indications that physicians spend even less time with senior patients.
In one study, internal medicine physicians spent 12 percent less time per visit with patents 75 years of age and older than they did with those 45 to 64 years of age ["Health: United States 1995", U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics] .
Not surprisingly, approximately 10 percent of seniors (over 65 years of age) accounted for almost 70 percent of Medicare costs in l993 [Health Care Financing
Review, 1995, Statistical Supplement (no later publication available)]. In the same year, 17 percent of seniors accounted for 83 percent of Medicare costs. Utilization of
hospital services is much higher among seniors than the rest of the population.
Seniors were admitted to hospitals in 1997 at the rate of 375 per thousand population while those under 65 years of age were admitted at a rate of only 84 per thousand. There were approximately 34 million enrollees in Medicare in 1998 [Health
Care Financing Administration].
Seniors experience many more clinical conditions than younger individuals.
They are, for instance, 26 times more likely to have cataracts, 16 times more likely to have cerebrovascular disease, 9 times more likely to have ischemic heart disease and 8 times more likely to have prostate disease.
Chronic Problems Complicate Utilization
Almost half of all seniors over the age of 75 have a severe disability and, of those seniors over 65, almost 20 percent are diagnosed with depression disorders
(nine times the rate among those under 65 years of age). Suicide rates are 21 per hundred thousand, almost twice that of those under 65. Drug mismanagement is a similar problem. Medicare
enrollees are admitted to hospitals 17 times more often than are those under 65.
Unfortunately, 17 percent of all hospital admissions of seniors is due to adverse drug reactions. Drug mismanagement also accounts for approximately 32,000 hip fractures from falls each year and 16,000 automobile accidents [Medicare Strategy, Innovations in Eldercare; Health Care Advisory Board].
Seniors are subjected to almost eight times as many side effects of hospitalization as those under 65.
More than 40 percent of seniors over the age of 70 leave the hospital with an unwanted side effect, the most common of which are muscle/bone loss, depression, incontinence, skin degradation, dehydration/malnutrition and delirium. These unwanted side effects then begin a downward spiral among the elderly. One-third of seniors has reduced function* at discharge and more than half have not recovered more than 90 days later. Of those discharged with reduced function, more than a fourth are rehospitalized within three months and 15 percent are newly institutionalized.
*Function is related to the six activities of daily living (ADLs): eating, toileting, bathing, walking, transferring and dressing.
Senior Attitudes Are Changing
Seniors and especially their caregivers are asking more questions of healthcare providers. At times, they feel the necessity to
challenge the provider to justify a particular recommendation.
Working against this type of two-way communication is the attitude many seniors have toward physicians. They view them as almost "god-like" and, therefore, not persons to question or challenge. This makes it possible for many physicians to be lax about the advice given to seniors. As indicated earlier in this document, physicians tend to spend even less time during office visits with the elderly than they do with younger patients.
Conflict is also a common result of the challenge to providers in today's healthcare system.
Conflict can occur with the physician as well as with the family/caregivers. Physicians have been known to inform challenging seniors to take their "business elsewhere." Seniors treated in such a manner typically are intimidated and are very reluctant to repeat the challenge. Also, as indicated earlier, Medicare enrollees frequently find it difficult to become part of a primary physician's practice. The other major conflict development potential is between the senior and his or her family/caregivers. This conflict results from the senior's unwillingness to challenge the physician but the younger person's recognition of the need to do so. Seniors fear that the younger ones will jeopardize their patient/physician relationship.
Selected Case Examples
Several case stories from real life dramatically illustrate just how significantly an elderly person's life can be changed by a healthcare experience.
An 81-year-old male was admitted through the ER with a broken hip from a fall. His hip was replaced; during his hospital stay a post geriatric assessment
was conducted. The geriatrician discovered that the patient had been using two different heart medications from two different physicians. Both medications did the same thing under different names and had
dizziness as a side effect. Without the assessment he would have been "successfully" discharged to go home and fall again.
A physician with a large Medicare practice continually prescribed medication dosages that were the same for his older as well as his younger patients. He
recognized no difference between the two populations. A 78-year-old female patient was presented to the ER with the symptoms of a stroke. Due to the number of medications that the woman had in her purse,
a pharmacist knowledgeable in geriatrics was called to the ER. He discovered that she was being severely overmedicated for her age. Upon interviewing the patient's daughter who was present, the
pharmacist also learned that the medications were being administered only twice daily, although some showed clearly that more frequent dosages were directed. The daughter's explanation was that "I
work and I don't trust Mother so I just give them morning and evening when I am at home. I didn't know it was a problem.
I tried to call the doctor but he never called me back. He is quite busy. Even when I take Mother to see him, he usually spends only a few minutes with us. He even said once, when I complained, that Medicare didn't pay enough for him to spend much time with us."
(Interestingly, this case also demonstrates a troubling reason that there is limited awareness of proper geriatric healthcare: the pharmacist was reprimanded by
the physician and the medical chief of staff for having any discussion with the daughter.)
An 85-year-old man was admitted with a high fever.
After several days, he was successfully discharged. Hospital records reported it to be a successful outcome. A week later his wife called and tearfully reported that she was going to have to institutionalize him because he was incontinent and she (also 85 years of age) could not care for him. In retrospect, his incontinence was probably due to misuse of catheters during his hospital stay. The wife's comment was "I would have let him die of the fever before making it necessary for me to take him out of our home!"
A surgeon and an anesthesiologist both advised a patient not to drink any alcohol 24 hours before a surgical procedure. The man, in his 80s, was a
moderate, regular drinker.
Because his metabolic rate was not that of a younger person, he had become addicted to alcohol ingested daily before the alcohol from the previous day had been metabolized. He experienced withdrawal problems during recovery and was physically restrained. His attitude worsened and he continued to be physically restrained. By the time of his discharge, he had suffered loss of mobility that he never fully regained. In retrospect, the physicians should have recognized the problem and recommended discontinuance of alcohol use further in advance. (Alternatives to physical restraints could also have been used. In many settings, not in acute care hospitals, use of physical restraints is illegal.) Moreover, a geriatric pre-op consult would have established a baseline to which the patient could have been reasonably rehabilitated.
Lastly, the frail elderly mother of an executive secretary was admitted to a hospital for surgery. In this case, the daughter was the long-time executive
secretary to the chief operating officer of a leading national hospital system. Staying with her mother in one of the system's hospitals, the daughter became concerned that the three or four physicians
involved in her mother's care were communicating only through the patient chart.
She requested a physician conference. They said they were too busy. She called the national chief operating officer (they had worked together for more than 20 years); he called the CEO of the hospital and the president of the medical staff. They said they would take care of it. The physicians still never met personally to discuss the case. The mother almost died and was saved only by the daughter's late at night intervention with assistance from a helpful nurse.
Some Conclusions
Anecdotal nightmares about the elderly in the healthcare system could go on and on. But, in the final analysis, they all lead to the same
conclusions:
- Too little recognition of chronic conditions during episodic events
- Too little recognition of physiological differences between the elderly and younger patients with respect to medication dosages
- Too much dependence on the accuracy and memory of elderly patients and their caregivers with respect to medications being used
- Too much trust in patient statements about the use of alcohol as well as lack of recognition of different metabolic rates
among the elderly
- Too little time spent by physicians with elderly patients and their caregivers
- Too little coordination and cooperation among medical disciplines
- Too little reimbursement by Medicare for time spent by healthcare professionals, thereby discouraging proper assistance
- Too little or no reimbursement by Medicare for prevention and wellness treatments and counseling for the elderly and their caregivers
- Too little "standing up for oneself" by patients and caregivers when dealing with healthcare providers
- Too few caregivers being willing or understanding the need to be a patient advocate during the first 24 to 48 hours of elderly inpatient care
- Too much reliance on physical restraints and catheters for hospital staff convenience and risk management without concern for the effects on the patient
- Too little recognition of the value of a continuum of care
- Too little emphasis on related issues in health, such as nutrition, stress reduction, social interaction, access to support, etc.
Tucked away in the corners of many healthcare professionals' minds is an underlying attitude that individuals in their mid-70s and older have
lived a full life and that under-reimbursed care should not be wasted on them. Again, most healthcare professionals in their dealings with the elderly are caring and conscientious…but hurried and harassed.
Continue to Chapter 4, "The Ultimate in
User-Friendliness for the Aging Population"
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