Sunday, September 15, 2013

Managing progressive disability in older adults

- Kenny Lin, MD, MPH

One in seven Americans suffer from disability, which an article by Dr. Cathleen Colon-Emeric and colleagues in the September 15th issue of AFP defines as "limitation in the ability to carry out basic functional activities." Progressive disability, or functional decline, commonly affects older adults with multiple chronic health conditions. First steps in the evaluation of an older adult with a new or progressive disability include characterizing the time course, associated symptoms, effects on specific tasks (including activities of daily living), and compensatory strategies. The authors then recommend that clinicians identify potentially modifiable health conditions, comorbid impairments, and contextual factors. All of this information should be considered and integrated into a treatment plan that enhances the patient's capacity and/or reduces task demands.

A Close Ups in the same issue of the journal provides insight on the perspective of a patient and family member who benefited from a comprehensive evaluation for functional decline. C.W. writes about her late mother's positive experience:

Twenty-minute visits were inadequate to address all of the diagnoses and medications, let alone her falls, constipation, insomnia, and cognitive decline. It seemed no one was appreciating the big picture. ... With full support from her family physician at home, we arranged for her to undergo a comprehensive assessment [that] focused on mom's primary goal—the ability to continue the activities she loved. She was evaluated by a geriatrician, a nurse, and a social worker. My family was also interviewed, and the appointment concluded with a meeting involving the whole team. We were given recommendations to consolidate and simplify her regimens for pain, insomnia, and constipation; initiate medication for depression; and make sure she exercised and socialized regularly, with concrete recommendations for overcoming barriers to these goals, such as transportation. Additionally, we received referrals for physical therapy and low vision rehabilitation.

In a related editorial, Dr. V.S. Periyakoil observes that progressive frailty that does not respond to optimal management of reversible conditions is in fact a terminal illness, even if it is often not recognized as such. He criticizes a recent decision by the Centers for Medicare and Medicaid Services to stop accepting the ICD codes for "debility not otherwise specified" and "adult failure to thrive" as principal hospice diagnoses, arguing that "these older adults may be subjected to ineffective interventions, including repeated emergency department visits and hospitalizations that are burdensome and expensive, and erode their quality of life."

Do you have the time and resources to evaluate functional decline in older adults in your practice, or do you refer these patients to other health professionals? How do you recognize when a patient is transitioning from a reversible state of frailty to a potentially terminal one? Will the information in these articles change your approaches to disability and end-of-life care, and if so, how?