Helping older patients 'age in place'
Internists can help patients live at home as they age by assessing physical functioning, watching for changes in functioning, and directing them to available resources.
More than 46 million people ages 65 years and older call the United States home, but only 3% live in nursing homes and other institutional settings, according to the U.S. Department of Health and Human Services. As the U.S. population ages, more and more seniors want to "age in place," or keep living at home while adapting to the restrictions of aging.
Helping them do so involves identifying functional status, as well as the more familiar role of diagnosing a disease or managing a chronic illness, experts said. Performing a comprehensive geriatric assessment is key.
"Internists tend not to ask these questions because we focus on managing chronic diseases," said Anita Chopra, MD, FACP, director of the New Jersey Institute for Successful Aging in Stratford, N.J. "But asking is important to help us understand changes in functional impairment and how we can support patients so they can stay at home."
The initial geriatric assessment should cover four domains of functioning: physical, cognitive, psychological, and social, Dr. Chopra said. Such a comprehensive assessment takes time but is crucial to identify existing concerns and establish a baseline to detect future changes, she added. Fortunately, Medicare covers a health risk assessment as part of the Annual Wellness Visit, she noted.
New patients may balk if asked detailed questions about their home situation. Therefore, experts suggest mailing new patients a short questionnaire about functioning and activities of daily living before their visit. This form can help launch the face-to-face assessment, which should start with broad introductory questions, said Carmel B. Dyer, MD, FACP, a geriatrician at McGovern Medical School in Houston. Examples include, "Do you feel safe in your house? Are you comfortable where you are living? Are you able to do all the things you used to do and that you want to do?"
"A patient might say, 'I don't drive anymore. I used to like to have a perfectly clean house, and I can't keep that up anymore,'" Dr. Dyer said. "Answers like these raise the red flag for further questioning."
At minimum, follow-up questions should always cover food, finances, and medications, she said. She might ask patients, "How are you getting your meals? Do you manage your finances, or does somebody help you? How are your medicines managed?"
She also routinely assesses gait speed, which numerous studies have linked to functional capacity. But she recommends against combining the initial geriatric assessment with discussions about advance care directives, because this might lead patients to think their physician has prejudged their health status, she said.
Social support is also essential to aging safely in place, noted Dr. Chopra. She asks patients, "If you got sick, who would be there to help you?" For the psychological assessment, she recommends the Patient Health Questionnaire-2 (PHQ-2) for depression, following up with the PHQ-9 if needed. She and Dr. Dyer both use the Mini-Cog to evaluate cognitive function.
No matter how internists approach the geriatric assessment, "At the core, physician-patient conversations are based on trust," emphasized Mark E. Williams, MD, FACP, a geriatrician and clinical professor of medicine at the University of North Carolina Chapel Hill School of Medicine. "Patients can feel if their physician cares about them and their welfare or not," he added. "Does the patient sense compassion or indifference?"
In some cases, patients are reluctant to discuss their living situation despite all efforts to put them at ease. If that happens, "I respect that but wonder about the safety of the home and the possibility of an abusive situation," Dr. Williams said. "I bring it up again on every visit to let the person know my concern."
Sentinel events and suggestions
Internists should use subsequent visits to watch for changes that signal a recent loss of function, experts said. "Certain life events, such as falls, syncope, sudden changes in function, or illness or death of a caregiver, are sentinel events that can threaten living independently," Dr. Williams said.
Internists who identify these concerns can often recommend practical steps to help patients remain at home. For example, an occupational therapist can do a home evaluation to identify simple home modifications that help maintain independence. Nurses from home health organizations also can perform a home safety evaluation and make recommendations, such as removing throw rugs or cords that are trip hazards. "Patients can be told that this evaluation is just a good precaution," Dr. Dyer said.
Internists themselves also can make or reinforce practical suggestions. For example, they might recommend wearing a medical alert device, moving important rooms such as offices and bedrooms downstairs, or hiring someone to help with chores, Dr. Dyer said.
Certain situations merit additional interventions or family involvement, experts said. "If we detect cognitive impairment, we always involve the family," Dr. Chopra said. "We tell the patient we would like them to bring a family member with them on their next visit."
Dr. Dyer agreed. "Some seniors may resist this step, but providers can explain it as taking a team approach to safety," she noted. If patients do not want to engage family, internists should assess their mental capacity and ability to make decisions, she said. If the mental status score is within normal range, they should determine whether patients understand the risks of opting to live alone without help. A good benchmark is to check if patients can clearly articulate a reasonable rationale for opting out of support, she said.
If cognitively intact patients refuse support or family involvement, Dr. Dyer documents this in the medical record and monitors for deterioration at follow-up visits. But if patients clearly lack the mental capacity to participate in decisions and their safety is compromised, clinicians should notify the family or adult protective services, experts stressed. "These are available in every state," Dr. Chopra said.
Internists also can direct patients and families to PlanYourLifespan.org, an interactive website that helps them plan how to respond to adverse life events such as hospitalizations, falls, and dementia.
"Umpteen conversations" with families about these crises inspired Lee A. Lindquist, MD, MPH, MBA, FACP, an associate professor of medicine and chief of the geriatrics section at the Northwestern University Feinberg School of Medicine in Chicago, to develop this website with colleagues, she said.
"Individuals age 65 and older have a 68% lifetime probability of becoming disabled in at least two activities of daily living, or of being cognitively impaired," Dr. Lindquist added. "I thought, why do we merely react to the aftermath of a crisis we know might happen? Why do we fail to plan?"
PlanYourLifespan.org, a free resource that was funded by PCORI (Patient-Centered Outcomes Research Institute), features large font and high-contrast text to guide seniors through common adverse life events, advise them on home safety, and share videos and transcripts of other seniors discussing the final quarter of life, Dr. Lindquist said. Users systematically evaluate and specify their wishes, save their choices, and can then print or email them to loved ones. "Many physicians tell me about how they use PlanYourLifespan with their patients and with their own parents—especially when their parents live out of state," she added. She noted that in a randomized, controlled trial of 385 patients, the tool was significantly associated with improved knowledge of home services and planning for aging in place.
Another resource is the CAPABLE (Community Aging in Place, Advancing Better Living for Elders) program, which is funded by the National Institutes of Health and the Center for Medicare and Medicaid Innovation. CAPABLE combines both handyman services and nursing and occupational therapy home care visits to help lower-income seniors safely age in place. By focusing on both the senior patient and the home environment, CAPABLE narrows the gap between what patients can do and what living at home requires them to do, said program lead Sarah Szanton, PhD, ANP, a professor at the Johns Hopkins University School of Nursing in Baltimore.
Early assessments of the pilot program in Baltimore showed that CAPABLE participants doubled their ability to manage activities of daily living and enjoyed heightened motivation with less depression, Dr. Szanton said. "There is no perfect niche of participation," she added. "We have good outcomes no matter the age, gender, race, disability, or depressive symptoms."
CAPABLE also has yielded a three-fold return on investment, Dr. Szanton noted. Participating health organizations need to pay up front for home repairs and home visits, but decreases in hospitalizations, nursing home admissions, and specialty care more than offset these start-up costs. "It's a good fit with the shift in health care to value, but the spending comes before the cost savings," she said.
Public and private funders are now enabling Medicaid waiver programs, community action agencies, and accountable care organizations to launch 10 versions of the CAPABLE program nationwide. Johns Hopkins also offers training for nurses and occupational therapists on conducting the home visits and working with handymen, Dr. Szanton said. "All older adults are resilient until the last few months of life, as are their muscles, down to the cellular level," she added. "Leveraging their strengths by working on what they want to achieve improves their motivation and outlook to achieve other goals as well."