SENIOR CARE
Treating Underserved Aging Patients Never make presumptions LAURA PATTISON, MD AND MORGAN WEINERT, RN, MSN, AGPCNP
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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.
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OCTOBER 2020 MINNESOTA PHYSICIAN
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. 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-ofAged-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
