Core Component #3: Medical Care Tailored to Frail Elders
All too often, the medical care that frail elders get is indefensibly poorly considered. Nursing home residents near death, who have no real odds of getting a net benefit from hospitalization, are moved to hospitals as “emergencies” to evaluate fevers or not eating.[57] Slightly healthier frail elders are regularly given medications that are contraindicated in the elderly, or sent for screening tests that cannot yield benefit in the remaining lifespan.[58],[59] Anxious or cognitively impaired elders who are mostly scared or overwhelmed are treated with sedating and mind-altering medications.[60] Elders living with fragile arrangements for caregiving have those disrupted by physician insistence on seeing patients in the office (or hospital). Physicians might insist upon seeing only the frail elder, leaving the family caregiver in the waiting room with critical information; or they might see the frail elder but talk only to the family caregiver, thus offending and perhaps silencing the patient and that person’s store of relevant information. Many busy clinicians simply won’t deal with the array of issues that a frail elderly person presents and will insist upon dealing with only a couple at any one visit, thus precluding a real care plan. Indeed, very few physicians want to or know how to generate a good care plan for frail elders.
Sometimes, the current focus on healthy communities and social determinants of health seems to marginalize the experience of frailty, decline and death. The claims for the merits of various improvements in population exercise, diet, housing, jobs, and so forth would seem to eliminate the experience of serious illness. However, mortality is an unyielding part of the human experience. Preventing various illnesses earlier in life is actually giving rise to the increasing number of people living with frailty and decline. Living well in the shadow of death, and living well with disabilities and decline, are certainly possible and actually provide the focus of MediCaring approaches. Much of the care plan addresses preventing complications, exacerbations, crises, suffering, and travail. Physicians, as well as elderly individuals and their communities, will learn much in the coming years as to what counts as living well in the last years of life, limited by disabilities and chronic conditions.
This chapter responds to these key questions:
3.1 What are the critical elements of geriatricized medical services?
3.2 How would MediCaring Communities develop the workforce?
3.4 What is already known about how to improve medical services for frail elders?
[57] (J. Ouslander, et al. 2010)
[58] (Caverly, et al. 2015)
[59] (Lee, et al. 2013)
[60] (United States Government Accountability Office, Antipsychotic Drug Use: HHS Has Initiatives to Reduce Use among Older Adults in Nursing Homes, but Should Expand Efforts to Other Settings 2015)
