Statistically, reported deaths over the age of 65 years are as follows: heart disease 29%, malignancy 23%, stroke 7%, respiratory disease 5%, falls 4%, flu and pneumonia 3%, and Alzheimer’s disease 2%. These figures represent the primary or presenting diagnosis as recorded on the death certificate. But is it safe to assume that these conditions alone are the main cause of deterioration in the elderly?
In his recent book My Mother, Your Mother, Dr. Dennis McCullough discusses the difficulty physicians can have deciding on the cause of death, suggesting that there have been (and continue to be) physicians who declare that people die of diseases, not from aging. I wish one of them was with me when I struggled to identify a distinct cause of death for a death certificate of an elder with advanced frailty.
Making a difference
In my observations, the health of our elders is often the effect of multiple, conflicting diagnoses and may be hard to confirm. For instance, the complications of Alzheimer’s disease, such as eating disorders, constipation and malnutrition, are frequent. Alzheimer’s patients may also encounter aspiration pneumonia, dehydration or falls due to confusion or delirium. There is also a distinct connection between cardiac conditions and cognitive decline. Conflicting medications and “over-treatment” impact both longevity and quality of life, as do aggressive cancer treatments.
As caregivers, can we make a difference if we stave off some of the complications of the core conditions and manage side effects? Some might argue that we will all die anyway despite our best efforts and medical advances, but it is my contention that with good care and best practice interventions we can avoid discomfort and actually reduce the number of medical conditions and crisis-causing situations.
Achieving positive outcomes
In the simplest situation, spouses and children can try to understand the diagnosis and follow the physician’s instructions to avoid further deterioration in their loved one. With a straightforward condition this can reduce or eliminate negative outcomes for many years with limited outside professional support.
However, things get decidedly more difficult in the presence of multiple diseases (and many of our clients have five or more diagnoses), when even the most savvy of family caregivers may struggle to become familiar with and manage their loved one’s illnesses. It becomes even harder for carers to predict the complex implications of symptoms and provide sustainable care at home.
At this time, it’s usually a good idea to involve a geriatric care manager or a case manager with nursing experience. Careful, ongoing monitoring can help predict and report symptoms to the physician early, before those symptoms progress. An increased ability to treat before a health crisis develops is a desired result.
So how can care providers partner with family physicians and other medical specialists to prevent these “poor outcomes” and how can this assist the family caregiver and the elderly person?
The following are some realistic solutions for preventing problems:
- Medical science has advanced to a point where there is a vaccine for pneumonia and the flu. Getting a flu shot each season is very important.
- Eye checkups to prevent blindness from glaucoma and corrective glasses to prevent falls are key.
- Regular dental visits for cleaning will help prevent tooth decay and spot any other dental issues that require attention.
- The complications of cardiac diseases can be reduced with diet management and meal planning, and the limited use of a preventative aspirin is often recommended.
In my experience, one of the most successful and perhaps under-utilized preventive actions is exercise. The ability of exercise to prevent and manage many diseases – including cardiac disease, obesity, diabetes and osteoporosis – is well documented. This is often, however, a relatively new idea for many elderly clients, who have seldom exercised during their lives. The good news is that my clients who embrace the concept and work with physiotherapists always improve physically as well as mentally.
Nowadays, most well-run retirement and nursing homes have physiotherapists who can work with residents on an exercise program. Sessions usually occur on a weekly or bi-weekly basis, with follow-up often being done by assistants or family members. The aim is to restore or maintain functional autonomy, improve balance (and in turn prevent falls), improve appetite and perhaps lesson the effects of cardiac disease. Many of our clients benefit from having physiotherapy in their home.
As a result of finding the right support services, most families report reduced or even an end to family conflict and marital stress. Family caregivers can be assisted by a nurse or care manager, who will be considerably closer to the client than a doctor and have a complete understanding of the disease, its process and prevention. Ideally, this will release the caregiver from missed work time, increased stress and unnecessary trips to the doctor or emergency room. And it almost always improves interactions with the family physician and other members of the care team.
A knowledgeable professional can instruct the family caregiver on how to simplify care issues by recommending services such as occupational therapy assessments, recording of medications, organizing blood tests in the home, shopping, meal planning and checking in with the elderly person in their home to prevent loneliness or confusion.
Keeping track of appointments and organizing the client’s medical records can better prepare the family for advancing disease and assist with a seamless transition to long-term care should the need arise. Experts will also know when to call for government-provided homecare services, make dietary recommendations, provide objective opinions on medical issues and organize the purchase or rental of home healthcare equipment.
Another specialist that we recommend to improve a family’s understanding of their situation is a geriatrician. Having a geriatrician involved in providing recommendations to the family physician increases understanding of disease progression, medication management and the family’s expectations for their loved ones. A list of suggested daily monitoring for family caregivers might include:
- Blood pressure/pulse and respiration rate
- Weight and sleep patterns
- Food and fluid intake and output
Few healthcare professionals can attach a cost to an elderly person’s care based on the predicted progression of their disease, and even fewer can be close enough to the client to monitor the changes as they happen. If finances are a concern and private care is a consideration, think carefully before hiring and be sure to find someone who can work with each family member (nearby and long distance). For example, a geriatric care manager would be very adept at putting together an accurate dollar figure of the total costs of health care to an elderly person, whereas a hospital-based nurse practitioner might not. Ultimately, the person you hire should know how to liaise with other team members such as trust officers and financial planners to review the future costs of care and available options.
In short, with the right support you can both organize the best care and save time, money and heartache by being able to predict and recognize the significance of multiple and changing medical conditions in your frail elderly loved one.