It may be a personal calling, a debt to pay or an act of profound love, but caring for an elderly parent or loved one can be a difficult juggling act. I’d like to give some practical advice on the medical front to the nearly 50 million Americans who are the unpaid caretakers of an aging parent or other relative.
Monitoring the health and medical needs of an elderly person is complicated. By the time someone is 65 or older, they have often suffered chronic illness for years, or decades. Obesity, for example, goes hand in hand with diabetes, which is a risk factor for heart disease, kidney disease and other ailments. At the same time, bones are more brittle, muscles weaker and immune systems less robust. By age 65, 62 percent of Americans have multiple chronic diseases. Some 23 percent of Medicare beneficiaries have five or more chronic conditions.
Experts in Elder Care
So choose a physician who will take the time to sort through the multiple problems and concerns of an older patient. Many primary care physicians (internists and family practitioners) have become expert at working with elderly patients by virtue of the fact that their practices are composed primarily of people older than 65. In addition, there is a specific subspecialty of internal medicine — geriatrics — whose members are trained specifically in the ways that we age. Just as pediatricians care for the special needs of children, geriatricians are trained in the care of older adults. In addition to thinking about treatments and cures for diseases, geriatricians have a keen eye for such concerns as how a person functions in daily living and the quality of the patient’s life.
Finding a geriatrician, however, can be tricky. There are about 7,300 geriatricians in the United States, or about one for every 2,500 adults 75 or older, according to the American Geriatrics Society. One reason for the paucity of geriatricians, internists and family physicians who specialize in caring for the elderly is that they earn less than many other medical and surgical specialists. In part this is because of the greater amount of time that they need to spend with elderly patients for which they are not adequately reimbursed. Additionally, they often have a less predictable work schedule than those in many other areas of medicine.
Whether a geriatrician or a primary care provider, make sure the physician has an interest in the way we age and will take the time to sort through ailments, medications and symptoms specific to older patients.
Some Basic Checkpoints
For the visit, be prepared to talk to the physician about the patient’s eating habits. Malnutrition is surprisingly common in older people, and can come about for many reasons that a physician can investigate. It can be due to dental problems, trouble chewing or swallowing, or a side effect of some medications. Loss of appetite can also signal depression, or may simply be because an isolated person has lost interest in preparing or eating food alone.
You’ve heard this before, but it’s important. Bring a bag filled with all the medications the patient takes in their bottles that have labels with the drug names and dosages. Not only should this include prescription drugs, but also over-the-counter medications and herbal and vitamin supplements. Alone, they may be beneficial, but a doctor will be able to recognize drugs and supplements that work against each other or team up for severe side effects. Polypharmacy is one of the major causes for confusion, nightmares and falls in the elderly, so it is really important to periodically review the medications that a patient is taking.
Two subjects that should come up in a physician visit are depression and pain. Physicians have good interview tools to determine if either one is a problem severe enough to call for additional testing or treatment.
And while it may be a touchy topic, bring up the subject of alcohol if you think your loved one might have a problem. About 40 percent of people older than age 65 drink alcohol. They may not be problems drinkers, but because so many people that age take multiple medications, and alcohol can interact with many drugs, the physician should be aware of alcohol use. In addition, aging lowers our tolerance for alcohol, and drinking can put elderly people at greater risk for falls and other accidents.
Expect the doctor to suggest some tests and lab work, but ask questions. Studies show that when people go in for a checkup, they have a 43 percent chance of having an unnecessary test done. And when the patient is elderly, the odds increase that a test will duplicate work already done recently, or will be unnecessary.
Ask enough questions so that you fully understand. Why is this test needed? Are there other options? What will happen next when test results come back? For example, maybe a test result would point to the "need" for a surgical or other invasive procedure that may be required to diagnose or treat a problem, but your loved one is too frail to withstand surgery or the procedure, or the treatment that would follow based on the possible diagnoses. So why do the test?
Make sure you understand all that has happened during the physician visit. Take a notebook and jot down details of any conditions you should be aware of, any new medications and their possible side effects, and any test results to expect. Also, be prepared with a list of questions before you go and be sure that they are appropriately addressed by either the doctor or one of his or her staff. Be sure the person you love has signed a form, complying with federal privacy regulations, allowing the doctor to talk to you and give you details of care over the phone or in person.
Finally, a topic that I’ve addressed before: Ensure your loved one has completed advanced directives and has discussed their wishes in regards to life-sustaining treatment in the context of their goals and philosophy, and that they have appointed a healthcare advocate should they not be able to make decisions.
You, the caregiver, have a lot on your shoulders, and in a future post I’ll be writing about how you can care for yourself during these trying -- and satisfying -- times.