October 2020, Volume XXXIV, Number 7
Treating Underserved Aging Patients
Never make presumptions
Laura Pattison, MD and Morgan Weinert, RN, MSN, AGPCNP
t’s a well-known fact that Americans are living longer than they were just a few decades ago. As our ability to identify and manage chronic and acute illnesses has improved, patients might live for many years with common conditions like congestive heart failure, COPD, and diabetes. Even HIV infection, once considered terminal, can now be managed in such a way that people living with the virus can expect to live a full life. Healthcare providers now need to support patients as they face the symptoms and sometimes complex treatments of chronic conditions as they overlap and interact with aging bodies. The work is rewarding but increasingly complex.
The two of us have cared for geriatric patients of a multitude of socioeconomic backgrounds in various settings, from those who are unhoused to those living in upscale assisted living facilities. No matter the circumstance, we see that the social determinants of health (such as family and community support, financial resources, and access to transportation) have an outsized impact on our senior patients, on top of the multiple medical issues they face.
As we age, we tend to collect more than one or two chronic conditions, with symptoms or treatment side effects that can mimic or overlap with common symptoms of normal aging. A patient with COPD may also have chronic kidney disease, and severe arthritis that affects their mobility. Someone with congestive heart failure might also have memory loss, impacting adherence to medication and dietary recommendations. Visual impairment or loss of dexterity can prevent a patient with diabetes from being able to administer their own insulin. Chronic pain conditions can be difficult to manage, as we attempt to balance minimization of medication side effects (especially on balance and cognition) with sufficient pain control to enhance functioning and quality of life. Dementia, depression, and hearing loss can have overlapping symptoms as well.
Make efforts to calmly broach subjects that patients mightbe embarrassed or uncomfortable mentioning.
The COVID-19 pandemic has exacerbated the hardships that older patients face. Fear of contracting the virus has led to a reluctance, for some, to come to clinic appointments, or to seek care at all even for severe acute symptoms. Decreased contact with others can contribute to social isolation and increased depression, and some seniors also face decreased access to food and other necessities. Telehealth, unfortunately, has been an inadequate alternative for many seniors and other people living in poverty. Video or phone visits can be difficult or impossible due to sensory impairments, fine motor and dexterity issues, or a lack of technology training or equipment. Many of our homeless seniors lack consistent access to a phone, never mind a smart phone capable of video visits.
Older adults often struggle with the practical and emotional ramifications of decreased independence, and the complicated family dynamics that can come with that. This can sometimes lead them to minimize symptoms and delay needed care. Even those with significant resources are often faced with financial issues as they reach retirement and must adjust to a fixed income. Multiple co-pays may mean that patients will split or ration pills, or stop taking their medications altogether to save money. Others may choose to switch to a cheaper but much less comprehensive health insurance plan because they need to increase their monthly income. For patients who have stopped driving, getting to and from the grocery store or their medical appointment can be financially and physically burdensome, even if they have access to a senior ride service or public transportation. Some of our patients are forced into homelessness at an advanced age, for the first time in their lives, due to a home foreclosure.
The homeless population in the United States is aging rapidly due to many economic and social factors that have impacted the livelihoods of those born in the latter half of the post World War II baby boom. (https://www.aisp.upenn.edu/wp-content/uploads/2019/01/Emerging-Crisis-of-Aged-Homelessness-1.pdf)
Research is showing that older adults who are homeless or marginally housed show the medical conditions of housed adults twenty years their senior. Homelessness is in itself an “aging” experience, and unhoused adults struggle with nutrition, cognition, and mobility in ways their housed peers do not. While some older adults fall into homelessness due to unemployment or foreclosure, others come to homelessness due to mental illness or substance use. Regardless of the reason, homeless older adults often have unique barriers to medication adherence, accessing care, and taking care of their basic needs, which complicate our ability to manage their health.
We do our best to keep in mind the context of a patient’s life circumstance as we provide care. All the follow up appointments and medication education in the world cannot overcome the economic and logistical barriers that keep our patients from many aspects of wellness.
Ask older patients questions about life outside the exam room.
For our patients who are homeless, we’ve learned not to make any assumptions about what resources they have, their health literacy, or their goals. We can’t assume that they have regular access to refrigeration for their insulin, for example, or even to food (healthy or not) or running water for basic hygiene. We ask many questions, and take care to speak with acceptance and respect, and to normalize issues that might make some feel shame or defensiveness. We make efforts to calmly broach subjects that patients might be embarrassed or uncomfortable mentioning to us. All patients, of course, deserve a provider who approaches them without preconceived ideas and with curiosity about their lives. It’s particularly necessary and useful for seniors, however, given the substantial impact these factors have on their health.
Health care providers need to ask older patients questions about life outside the exam room. When possible, we involve family members in visits and communicate regularly if they’re not able to attend a visit. One patient with uncontrolled hypertension and pain ultimately revealed that he had not taken medication in over a week because he didn’t have the dexterity to get his pills out of their container - his wife usually did this for him, but she was hospitalized for a surgery. Another older patient minimized her own symptoms and often delayed visits because she was solely responsible for the care of her disabled adult child.
Many of our homeless patients are particularly isolated, without any available caregivers at all.
Older patients have often been to multiple providers over many years, and have “collected” a long list of medications. A thorough medication review is vital, as is an ongoing effort to avoid or limit polypharmacy. It’s especially important to consider the expense and complexity of medication regimens. Issues of mobility, level of functioning, and quality of life rise to the top of our priorities as we develop care plans for them.
These and other important conversations (about depression, cognitive impairment, or changing goals of care towards the end of life, for example) take time, which is not in abundant supply in most clinical settings. We rely on the involvement of an expanded care team that includes nurses, social workers, behavioral health specialists, alcohol and drug counselors, care coordinators, housing specialists, and culturally sensitive interpreters.
As healthcare providers caring for an aging population we need to become more inquisitive and even more cautious about making presumptions about our patients, their lives, and their goals. The challenge of providing sensitive and effective care for seniors in today’s unusual world requires an attentive and communicative care team and, more than ever, a curious, compassionate, and holistic approach.
Laura Pattison, MD, is a family physician at Minnesota Community Care’s Healthcare for the Homeless clinic in downtown St. Paul. Her focus is on primary care for underserved populations, including those living in poverty, with homelessness, and with severe persistent mental illness. She has a particular interest in addressing inequities in health care.
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Morgan Weinert, RN, MSN, AGPCNP, is an Adult/Gerontology Nurse Practitioner and the current Medical Director of the Healthcare for the Homeless program at Minnesota Community Care. They work with older adults who have HIV and HCV, use substances, are experiencing homelessness, and are living with mental illness.