Being old and sick in America frequently means that a doctor won’t ask you about troublesome concerns you deal with day to day: difficulty walking, dizziness, a leaky bladder, sleep disturbances, memory lapses and more.It means that if you’re hospitalized, you have a good chance of being treated by a physician you’ve never met and undergoing questionable tests and treatments that might end up compromising your health.
It means that if you subsequently seek rehabilitation at a skilled nursing facility, you’ll encounter another medical team that doesn’t know you or understand your at-home circumstances. Typically, a doctor won’t see you very often.
In her new book, “Old & Sick in America: The Journey Through the Health Care System,” Muriel Gillick, a professor of population medicine at Harvard Medical School and director of the Program in Aging at Harvard Pilgrim Health Care Institute, delves deeply into these concerns and why they’re widespread.
In an interview, Gillick offered thoughts about how older adults and their caregivers can navigate this treacherous terrain. Her remarks have been edited for clarity and length:
Q: What perils do older adults encounter as they travel through the health-care system?
A: The journey usually begins in the doctor’s office, so let’s start there. In general, physicians tend to focus on different organ systems. The heart. The lungs. The kidneys. They don’t focus so much on conditions that cross various organ systems, so-called geriatric syndromes. Things like falling, becoming confused or dealing with incontinence.
Q: What can people do about that?
A: Older people are often unwilling to bring these issues to the attention of their doctors. But if a family member is accompanying the patient, they should speak up.
Another approach is to request a geriatric assessment or consultation that will bring issues to the forefront.
Q: The next step you talk about in your book is the hospital.
A: One of the big perils in the hospital is technology, which is also its great virtue. Technology can improve quality of life and be life-extending. But sometimes it creates endless complications.
An example are imaging tests such as CT scans. Physicians hardly think of this as an invasive test. But often one has to administer a dye to see what’s going on. That dye can cause kidney failure in someone with impaired kidney function — something that’s common in older adults.
Sometimes there’s no real need for scans. An example would be an older person who becomes acutely confused in the hospital, which happens a lot. The appropriate response is to look at what’s causing the confusion and take away the offending agent. Often that’s a medication that was started in the hospital. Or it’s an infection. But the routine, knee-jerk reaction is to do a CT scan to rule out the possibility of a stroke or bleeding in the brain.
Q: What do you advise older patients and their families to do?
A: When a test is proposed, ask the doctor, “How important is it to pursue this diagnosis?” and “How will the results change what you do?”
Q: In your book, you talk about how a doctor-patient relationship can be sidelined when someone goes to the hospital. Instead, hospitalists provide care. How should people respond?
A: It’s really important to give that doctor a sense of the patient and who they are. Say your 88-year-old mother is in the hospital and she’s become profoundly confused. The doctor doesn’t know what she was like a week or a month ago. He may assume she has dementia unless he hears otherwise. He won’t understand it might be delirium.
You or a caregiver want to come across as someone who can make it easier for the doctor to do his or her job — vs. someone who’s a nuisance. You want to build trust, not annoyance.
Q: What about skilled nursing facilities?
A: These are settings that people go to after the hospital, to get rehabilitation. Typically, the contact with doctors is minimal after an initial evaluation, though there’s a spectrum as to how much medical care there is.
Many older patients come to skilled nursing facilities, or SNFs, after having had one complication after another in the hospital. These patients can be very fragile, with many medical problems. They’re at risk of getting some new problem in the SNF — perhaps an infection — or an exacerbation of one of the problems they already have that hasn’t resolved.
SNFs are required within the first week or so to have a care planning meeting with the team. They’re supposed to invite patients and their representatives to the meeting. This is a good place to say something along the lines of “My mother has been through a lot, and now that we’ve met you and seen what you can do, we’d like you to do your best to treat her here and not send her back to the hospital.”
You have to have trust to make that happen. The family has to trust the medical team. And the team has to trust that the family isn’t going to get upset and sue them. A meeting of this kind has the potential to allow everyone to figure out what’s important and what the plan will be going forward.