It doesn't take very much for things to go very wrong in the health of an older person. While we all must be grateful for the better health and longer lifespan than ever before for older Americans, these are often precarious states and dependent upon health care providers who may lack the skills needed to preserve that health and independence. An example from my own life makes this fact and the limitations of the current health care workforce and system very clear to me.
Last Fall, right before Thanksgiving, while at the Gerontological Society of America meeting in San Francisco, I crossed the Bay to visit my parents in the Oakland hills. After dinner, I noticed that my 73-year-old father's ankles were quite swollen. He said that they didn't hurt and that he hadn't really noticed, but he thought that they might have been swollen for a while.
(My dad is a fairly typical "well" older adult, maintaining an active and independent life--albeit quite overweight, with hypertension managed by three medicines, and increasingly severe arthritis and pain in his hips and knees. While perhaps generally healthier, my mother's macular degeneration made it difficult for her to notice such things as dad's swollen ankles.)
Being something of a worrywart and knowing of his long history of hypertension, I was quite concerned about the possibility that this swelling was a sign of congestive heart failure (CHF), and I persuaded my father to visit his physician at Kaiser-Permanente down the hill as soon as possible. I was quite relieved a few days later to hear that the physician diagnosed venous insufficiency (not enough veins?) and doubled the dose of my dad's diuretic. While not sounding like a particularly thoughtful or useful diagnosis, at least it wasn't CHF or something more serious, and I put the issue out of my mind.
Unfortunately, over the next week my mom and dad began to report strange incidents of dad falling. Often right after dinner, my dad would report that he suddenly found himself on the kitchen floor. He would deny that he passed out, but even I knew that often one doesn't realize one has lost consciousness when one has. Calls to the doctor's office produced vigorous assertions that this could not possibly be due to the new dosage. After the fact, we came to suspect that the physician was attributing the new symptom to excessive drinking over the holidays.
Finally, one Saturday afternoon before Christmas, while I was out with my family and my sister and her kids at the holiday train show at the New York Botanical Garden, my dad called on my cell phone very concerned about a recent fall and blackout that led to a mild head injury. Knowing that med changes should always be the number one suspect, I suggested that he just return to his prior dose until he could insist on a full exam and check up for orthostatic hypotension and/or a potassium-sodium imbalance due to the increase in the diuretic. My sister, a family nurse practitioner, agreed with me (a rare event), and yet my dad continued to rely on his physician.
Over the next few days, however, the falling increased in frequency, and the periods of altered consciousness became more evident. Finally, just before Christmas, my dad drove himself and my mother to the urgent care center, where his BP was found to be life-threateningly low, and he was transferred to the hospital and admitted. At first, the drug dosage change continued to be ignored in favor of more esoteric possible diagnoses such as liver disease, but soon cooler heads prevailed and after two nights in the hospital over Christmas, the culprit was identified and the dose was changed.
This story ends quite well. Perhaps motivated by the fear and anxiety of a hospitalization, my dad has lost over 40 lbs and needs fewer medications for his hypertension. As good, he "fired" his physician, who had missed the obvious relationship of the postprandial orthostatic hypotension to the increased diuretic dosage and was assigned a new primary care physician--still not a geriatrician but someone seemingly with better skills. A planned trip to Europe was merely postponed until later in the Spring (the first use of a wheel chair in the Louvre, might be another posting).
However, it is really only luck that this rolling "incident" didn't end very badly. The possibility of multiple falls leading to a serious injury is very real. Broken hips, broken bones, and brain injury are all very real and serious risks. I still get the shakes when I think of my father nearly unconscious driving with my mother to the medical center--there are some things that not even air bags can overcome.
The John A. Hartford Foundation has worked specifically on the problems of medication use in older adults for more than 25 years. One of its earliest efforts in aging and health supported the development of the Beers Criteria, a list of drugs that should not be used in older people. At the beginning of my career at Hartford, I served as the program officer on a major study of adverse effects of medications and how they can be prevented. Given the success of that trial, the Foundation has supported two efforts to disseminate the intervention model into routine practice with our grantee, The Partners in Care Foundation. For more information about this ongoing initiative, please click here.