Older Patients, Wiser Care
The man seemed to need more blood pressure meds. Why did I withhold them?
Last updated:October 09, 2009
The case: An incomplete health assessment
I met Mr. D, 93, during a hospitalization for treatment of clots in his deep leg veins. Like many who live into their 90s, he also had a history of heart disease well documented in his charts. As the team was preparing to discharge him, the medical resident noted that Mr. D's blood pressure in the hospital had been 140/80. Since conventional guidelines recommend a blood pressure lower than 130/80 for people with heart disease, the resident recommended that Mr. D's blood pressure medication be increased.
That's when I realized she'd overlooked two factors in the patient's history:
1) Mr. D had a history of recent falls in the home. In the elderly, blood pressure medicines sometimes work too well; if the blood pressure gets too low the person can feel lightheaded, or fall.
2) Mr. D also had mild-to-moderate dementia, which probably was Alzheimer's. The diagnosis wasn't clearly marked in the chart, and like many dementia patients, Mr. D was pretty good at maintaining his social graces and answering questions vaguely when he didn't know the answer. This made it even harder to figure out why he was falling at home, and whether it might be due to feeling light-headed.
Given these issues, increasing Mr. D's blood pressure medicine was riskier than the young medical resident realized. Was changing his medicine the right thing to do?
The challenge: Not all doctors have been trained to treat the elderly.
In an ideal world, one would always get the best medical advice from doctors. But any caregiver who's spent time around us probably already knows that doctors are not all-knowing, always-right superheroes. One big reason: Often in medicine there simply isn't one clear best answer. That's why two good knowledgeable doctors can end up giving different advice to the same patient.
But another, less obvious reason people fail to get the best medical advice is that doctors sometimes don't know what the best advice is. Thus they inadvertently give the wrong advice. Sadly, this is especially true when it comes to caring for frail older people. As one ages, not only is the body more likely to suffer from several diseases at once, but one also becomes more vulnerable to the side effects of medications, as well as to other geriatric syndromes such as falls, incontinence, and decline in physical function.
So medical advice that's quite appropriate for a 60-year-old with heart disease can become risky when applied to a 90-year-old with the same kind of heart disease. Just as children require similar yet different medical care compared to adults (hence the specialty of pediatrics), elders and/or people with dementia often benefit from medical care that's tailored to their needs (the specialty of geriatrics).
The solution: Be proactive about eldercare
Luckily, our in-hospital geriatrics team noticed the important details about Mr. D's history of falls and dementia, and our input helped ensure that Mr. D's care plan was better tailored to his age and situation. The blood pressure medicine wasn't changed; instead the medical team decided to first arrange for a home evaluation, in order to find out more about Mr. D's falls.
Given that some doctors have more experience and training in caring for frail elders, it would seem like a no-brainer to ask for a geriatrician whenever an older person is sick or hospitalized.
Unfortunately, geriatric specialists are all too scarce. Currently the U.S. has one geriatrician for every 2,500 people older than 75.
In our lifetimes, there will never be enough geriatricians to tend to every older person who could benefit from their expertise. So being an informed and proactive caregiver is all the more important.
Some starting points for being a better caregiver given the shortage of trained geriatricians:
Help doctors help your loved one by providing gentle reminders to tailor their advice, for instance by asking if a new medication might cause different side effects in the elderly, or cause them more often. Many doctors simply aren't used to thinking specifically about the frail oldest old.
Learn about common syndromes affecting elders, which conventionally-trained medical providers may be less likely to ask about. No, you don't have to go to medical school, but you will be able to provide better care if you brush up on what to watch out for. Start with [falls] (https://www.caring.com/falling-down-injuries), [dementia] (https://www.caring.com/alzheimers), and [medication side effects] (https://www.caring.com/articles/medication-mistakes-that-can-kill).
Consider educating yourself about state and federal initiatives to encourage health care providers to learn more geriatrics. Who knows? The student you persuade to study geriatrics is likely to preserve a better quality of life for thousands of Mr. Ds.
Everyone providing care to the elderly needs to step up a bit to ensure optimal care. That's the purpose of this new blog:: to give caregivers and family members the tools they need to take better care of an elderly loved one -- and to interact more effectively with doctors and hospitals.
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