Caring for older patients: Not so different from caring for anyone else

ON THE COVER| VOLUME 28, ISSUE 2P28-32, FEBRUARY 01, 2022
Caring for older patients: Not so different from caring for anyone else
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Aging begins at conception. Yet, many health care providers—and much of medicine in general—tend to acknowledge aging only in patients of a certain age, whether it’s 40, 50, or 65. Once patients reach an age their provider considers them to be “aging,” which varies by provider, the providers’ focus may shift so completely toward aging that it drives all of their decision-making and they fail to consider any other possible causes of patients’ complaints. According to the U.S. Census Bureau, nearly a quarter of all Americans will be over the age of 65 by 2060. The number of adults in the 85-and-up bracket will have tripled by then. The United States will have half a million more centenarians by that year. This growth in the population of older adults will increase demand for health care and shine a brighter light on shortcomings in the system.
The problems lie in both systemic health care culture and individual practices. Pharmacists can play a key role in helping to change both.
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Ageism and its health consequences

Ageism—that is, biases toward patients based on their age—creeps into many health care encounters and can have wide-sweeping effects. Take, for example, some providers’ tendency to dismiss certain health problems as “a part of aging” rather than treat them, said Emily Peron, PharmD, an associate professor in the Department of Gerontology at Virginia Commonwealth University (VCU) College of Pharmacy in Richmond, VA. Providers may be more likely to dismiss pain, anxiety, depression, cognitive decline, and fatigue in their older patients. “A lot of times we chalk things up to ‘old age.’ Whether it’s urinary incontinence, multiple medical conditions, pain, we blame age for a lot of issues when [there are] other factors at play,” Peron explained. When this happens, treatable problems that seriously affect health and quality of life may go untreated. What’s more, when providers communicate to patients that certain health concerns are just a part of getting older, patients may accept it, which can make them less likely to get health care, follow through on preventive screenings, and live a healthy lifestyle. “I tell my patients that the minute a provider says ‘What do you expect at your age?’ it’s time to find a new provider,” Peron said.
In fact, rather than seeing a patient’s complaints as an inevitable consequence of advanced age, “any symptom in an older adult should be considered a drug side effect until proven otherwise,” said Hannah Boren, PharmD, a geriatric clinical pharmacist at Vanderbilt University Medical Center.
Ageism may also lead to overtreatment in some cases, a multibillion-dollar problem in the United States, which includes unnecessary tests, medications, surgeries, and hospital stays. Some providers may approach age itself like a disease, which helps fuel both overtreatment of benign conditions and the stigma around older age.
“That sort of thing perpetuates the stereotype that aging is bad,” Peron said.

Ageism in deprescribing

Deprescribing may come up more often in encounters with older patients. They often take far more medications than younger patients, but age shouldn’t be the only factor to prompt these conversations. “You have to look at the whole picture of the person in front of you,” said Kristen Zimmerman, PharmD, who is also an associate professor in the Department of Gerontology at VCU. “Age isn’t the only driver.” Zimmerman, who runs a deprescribing clinic at VCU, said that if a patient has a high fall risk, other risk factors for falls, and takes medications that raise fall risk, providers should address their medications regardless of the patient’s age. The same, she said, should be the case in a provider’s approach to patients whose cognitive complaints may be medication-related.
By the same token, deprescribing shouldn’t be the only way that providers address complaints in patients over a certain age. “It’s not like treatment just becomes futile when patients reach a certain age,” Peron said. “We have to look at how we can leverage other disciplines for fall prevention, too—PT, OT, social work, someone who can do a home risk assessment,” Zimmerman said. “We can’t just look at medications in isolation.”
When it comes to complaints of brain fog or memory problems, Zimmerman takes the medication list into serious consideration, but she assesses other aspects of the patient’s lifestyle and environment, too. “We know that long-term use of certain medications, such as benzo[diazepines and] anticholinergic medications, is definitely linked by dose and duration to cognitive impairment,” she said, “but we also know that adherence to good dietary practices, for example, is associated with reduced risk of cognitive impairment, too.” She adds that pharmacists should be empowered to recommend that patients with cognitive complaints see a neurologist.
Even the Beers Criteria Medication List should be taken as a consideration, not a law. The evidence-based list, published by the Journal of the American Geriatric Society, includes medications that are potentially inappropriate for the elderly. “It’s not a do-not-use list,” Peron said. “It’s simply cause for pause.” When deprescribing a medication is the best course of action, it’s important to present patients with the risks and benefits of the medication and explain how the individual risks they face might have changed since the patient started taking the medication. Not only does increasing age change the risks associated with some medications, but new diagnoses and the addition of other drugs to the medication regimen alter the risks as well.
Studies show that providers rarely update patients on the changing risks and benefits of their long-term medications as they age. This is a great opportunity for pharmacists who dispense these drugs. “With baby aspirin, for example, the evidence we have right now is that once you’re over age 70 and you haven’t had a prior [cardiac] event, the risk of bleeding increases with baby aspirin, and it hasn’t shown to prevent heart attack or stroke if you haven’t had one before,” Boren said. Therefore, the balance between risks and benefits may have changed.
Boren’s approach is to ask patients “What matters most?” so patients can weigh their concerns about the long-term adverse effects of certain drugs against the risks of stopping the medication completely. Boren takes this question from the Institute for Healthcare Improvement’s Age-Friendly Health System framework, which she recommends as a resource for pharmacists who care for older adults. For many drugs, however, there simply isn’t data on how they affect older adults. This population is frequently excluded from clinical trials in an attempt to focus the trials on a more general population. But nearly 1 in 5 Americans is over 65, and this demographic makes up an even larger proportion of Americans who take medications. “There is research bias there. It becomes this gray area where we say there’s insufficient evidence or that we just don’t know,” Zimmerman said.

Ageism in adherence strategies

Ageism may also color providers’ approaches to medication nonadherence. Too often, providers may assume that cognitive problems are the only explanation for nonadherence. “Forgetting or misunderstanding aren’t the only reasons people may not take their medications,” Peron said. “The drivers of adherence are not the same for every patient. Having someone buy a pillbox doesn’t fix the problem if the organization isn’t the issue.”
Pharmacists and other health care providers must understand why a patient isn’t taking medications as prescribed before they can develop strategies to help get the patient back on track. According to the American Medical Association, there are 8 common drivers of nonadherence. Misunderstanding is just one among them. Besides misunderstanding their regimen or finding it too complicated, patients often forgo medications due to fear of adverse effects, the cost, fear of becoming dependent, medical mistrust, a lack of symptoms, and depression. “The most innovative thing we can do to improve medication adherence is to be patient-centered,” said Tracey Gendron, Ph.D., chair of the Department of Gerontology at VCU.

Age is just a number

Patient-centered care should not end once a patient reaches a certain age. Patients continue to be as distinct and unique in advanced age as they were when they were younger. “We have a mantra in geriatrics: once you’ve seen one older adult, you’ve only seen one older adult,” Boren said. With this in mind, providers should treat older patients like unique individuals—just like they treat everyone else. This can begin with the way they talk to older patients. “If we intentionally use expressions like ‘young man’ or ‘79-years-young’ with an older patient, you are perpetuating ageism, even though you intended it as a compliment,” Gendron said. Boren admits that she was prone to using “babytalk” with older patients, calling them “honey” and “sweetie,” when she first entered the field of geriatrics. She now recognizes that’s not always well-received. It’s not uncommon for providers to take a different tone with their older patients or communicate with them in a different way than they would other patients.
A 2018 study of nurses published in Contemporary Perspectives on Ageism found that those with the most negative attitudes toward older adults were more likely to take a patronizing tone with those patients. So-called “elderspeak” may also entail slower speech, exaggerated intonation, higher pitch or volume, and simpler vocabulary. The nurses in this study were also less likely to involve older patients in consultations or decision-making. The providers also tended to consider only issues raised by other providers or the patient’s younger family members. Similar research showed that providers who held negative attitudes toward older patients were less likely to learn their names and to consider their input. Boren encourages providers to speak to older patients with respect, which includes addressing them directly, regardless of their cognitive abilities or the presence of a caregiver.
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“If a caregiver is present, I ask the patient’s permission to speak with the person who’s there with them,” Boren said. “I think both the patient and caregiver appreciate that.” Pharmacists who feel that an older patient may be better served by a pharmacist with more expertise can generate a list of senior care pharmacists in their area to share with patients. Pharmacists may also provide the names of geriatricians to patients who may need them. Many patients will be surprised to know that these specialists exist, but the specialists can also be hard to find. The general dearth of physicians who choose to specialize in the care of older adults, Gendron said, is another example of ageism in health care.
Any pharmacist who wants to do better for older patients can educate (or re-educate) themselves on the finer points of medication use in this population as well as best practices to avoid bias-driven behaviors. “The bottom line,” said Zimmerman, “is that we need to take a similar, individualized approach with patients of all ages and demonstrate an attitude that is welcoming of the aging process throughout all the care that we provide.”

 

Experts recommend the following resources for pharmacists, all of which are available online:

  • The Institute for Healthcare Improvement’s Age-Friendly Health Systems framework: Description of criteria to be an age-friendly health system in which health systems aim to align their goals and values with “what matters most” to older patients and their caregivers
  • Beers Criteria Medication List: Evidence-based, up-to-date list of medications that are potentially inappropriate for the elderly
  • PIMsPlus.org: Searchable database of evidence-based guidelines on potentially inappropriate medications (PIMs) for older adults
  • Deprescribing.org: Website that includes researched-based guidelines and algorithms to guide deprescribing and a link to a downloadable app
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Pharmacists have a role to play in counseling patients on mild cognitive impairment

Experts recommend that pharmacists
  • Perform comprehensive medication reviews to look for medications that could cause problems with memory and thinking in patients who complain of these symptoms.
  • Recommend medication changes that could eliminate adverse effects related to cognition in patients who have these symptoms.
  • Counsel patients on the importance of social interactions, exercise, diet, and sleep in maintaining cognitive function as they age.
  • Urge patients who take medications for dementia, and their caregivers, to reassess the benefits of the medication every year.

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