Author Archives: Dianne Savastano

Managing Along the Health Continuum

We have many older adult clients (defined as those over the age of 80) who began working with us 10-15 years ago. At this point, we have taught them and their family members to pay close attention to subtle changes in health status and to notify us immediately so that we can take quick and appropriate action. Overall, our goal is to prevent a crisis (e.g., becoming seriously ill, having an accident/fall for which hospitalization is required).

For example, just last month, two different clients called to report what appeared to be mild symptoms — but that were indicative of greater problems had they gone untreated. Read further to learn more about managing similar situations should they occur in your life.

“I can’t hear very well. I’m a little bit dizzy and my balance is off.”

John is 87. He called on a Friday afternoon and described his symptoms. Considering that one in four older adults in the United States fall each year, resulting in more than 32,000 deaths, preventing falls is something we constantly emphasize.

Our actions involved a call to his primary care physician, a trip to an urgent care center for an evaluation of his ears, wax removal, and a plan for irrigating his ears over the weekend. We agreed to alter his weekend schedule to keep him close to home/not driving and to make sure he was not alone.

By Monday, he was still not back to normal. So, we called his primary care physician who scheduled a same-day appointment, conducted a thorough examination, and removed more wax. John then saw his audiologist who found his hearing aids were malfunctioning due to wax debris (that’s why his hearing was off).

Fortunately, after a couple of days, he was back to normal. Further, we now have a plan in place for him to visit his audiologist every 3-6 months. This will prevent an alteration in his balance and keep his hearing aids functioning properly.

Phew! Crisis averted. But notice that we didn’t just solve today’s emergency… we took clear, proactive steps, based on John’s diagnosis and health, to minimize the likelihood of reoccurrence in the future.

“I think I have symptoms of a urinary tract infection.”

“Danger Will Robinson!” Yes, I am old enough to have been a fan of the TV program, “Lost in Space.”

And there is, indeed, danger. Urinary tract infectionsoccur in about 20 percent of women over age 80, and 25-50 percent of women living in nursing facilities. If left untreated, a urinary tract infection may lead to a form of sepsis called urosepsis, a condition with a mortality rate of 20%-40%.

And so, when we received this call from our client Maureen, who was experiencing pain when going to the bathroom, we acted immediately. Our goal was to treat appropriately and prevent progression that can lead to hospitalization and suffering.

We called Maureen’s primary care physician, obtained an order for two different urine tests, started her on an antibiotic, increased her daily fluid intake, and began checking in daily. After two days, with symptoms not resolving, we used her patient portal to check the result of the urine test. Next, we contacted the on-call physician covering over the weekend who changed the antibiotic to one that was more appropriate for the bacteria identified.

We watched closely over the next several days for any signs of side effects from the more potent antibiotic and had a follow-up urine test done once the drug was finished. Fortunately, Maureen tolerated everything nicely and was soon doing just fine.

Crisis averted again!

Steps to Take

Here are some recommendations for managing changes in health care status — no matter how benign they may seem and regardless of a person’s age:

  • Pay close attention to subtle changes in your body. If a change is noted, don’t wait — talk it over with your care partner (if you have one) and develop a plan of action.
  • Check in frequently. For older adults in particular, frequently ask how they are doing or if they have noticed any changes.
  • Start with your primary care physician. This person knows you and knows your medical history. He or she can help determine whether further action is needed and work with you to plan next steps.
  • Monitor progress. If the outlined plan does not result in improvements, reach out to your primary care physician with a request for modification. Our physicians rely on us for observation, data collection, and reporting. We need to take that responsibility seriously.
  • If a specialist is needed. Ask your primary care physician for assistance in obtaining an urgent appointment and be sure all the information the primary care physician has about the situation is relayed to the specialist.
  • Use your patient portal. This is the best way to track test results and obtain visit summaries.

Watchful Waiting

In the client examples noted above, fast action was taken, resulting in positive outcomes. However, there are many situations in which things are not resolved as quickly or in which immediate intervention is not required.

Instead, “watchful waiting” is recommended. This refers to an approach in which time is allowed to pass before medical intervention or therapy is used. If your physician recommends this approach, it is important that you continue to gather data and remain in close contact with your medical team, so that intervention can occur if necessary.

If you remain concerned and would feel reassured by an intervention (especially an in-person appointment), be open and honest about your worries. Be sure you feel heard and ask to be seen if that is what you desire.

Summary

Each of us has a responsibility to pay close attention to our bodies and to reach out for assistance when things don’t seem quite right.

For the older adults in our lives, some of whom may no longer have the self-awareness or who prefer to ignore symptoms (thinking that things well get better on their own), we need to be especially diligent with our observations and, if necessary, insist upon acting.

Overall, having an established relationship with a primary care physician well in advance of having to call upon them, will facilitate working together, prevent future crises, and reduce suffering in ourselves and in those we love.

Recommended Reading and Resources: Bills

When we help clients enroll in insurance products, our overarching goal is for them to fully understand the requirements of their health insurance products so that they can follow the rules set out in their contractual relationship with their insurer. Still, bills sometimes arrive that are questionable and that require investigation and troubleshooting. This service, which uses crowdsourced investigation by Kaiser Health News and NPR, dissects and explains medical bills, shedding light on U.S. health care prices so that patients can be more active in managing costs.


Hereis a fabulous summary of resources available to assist older adults in becoming more technologically savvy.


I loved this piece about “deprescribing” as a means of reducing prescription overload.

Managing Cognitive Impairment in Our Loved Ones

I recently began working with a client family of a woman in her 90s who had been living independently. Following a health care crisis, she had to move in with her daughter and son-in-law. Although the couple cared very deeply for this woman, living together in the same home and addressing all her physical and psychological needs was not a tenable long-term solution.

In this case — and it’s something we experience often with our client families — while the signs of cognitive impairment had been evident for quite some time, they had never before been addressed head-on. The crisis forced the family to quickly develop both short- and long-term plans, as well as learn how to communicate differently with her and manage her problematic behaviors.

What is “Cognitive Impairment?”

Cognitive impairment is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life. When defined as “mild,” it is considered an intermediate clinical state —between normal cognition and Dementia.

Many people immediately label all types of cognitive impairment as Alzheimer’s Disease. That is sometimes the case, but certainly not always.

Alzheimer’s Disease is the most common form of Dementia, accounting for 60-80% of cases. But Dementia is a more global term, one that describes a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life. It isn’t a specific disease; several different diseases may cause Dementia.

In all situations, an appropriate diagnosis — and an appreciation of the differences among them — is helpful with overall management and with preparation for continued decline. Depending on the cause, some Dementia-like symptoms may be reversible.

Managing Behavior

Whatever the specifics, the day-to-day interactions with someone experiencing cognitive impairment can be incredibly frustrating, particularly when a loved one resists doing something that they never had a problem with before. In these cases, we encourage our caregiver clients to focus on the one thing they have control over — their approach to managing behavior.

For example, many of those with cognitive impairment resist taking their prescribed medications. This can be very serious, leading to a medical crisis such as a fall, an event that may in turn lead to hospitalization, surgery, confusion, additional medication, and a downward spiral from which a loved one may never fully recover.

Here are some recommendations for managing problematic behaviors you may experience…

#1. Simplify everything.

In the case of medications, are all of them necessary? A review of the medication panel with your loved one’s primary care physician can help with this assessment.

Would prearranging medications in a daily AM/PM pill box help, so that taking them out of individual bottles every day is not necessary?

Would a reminder system, such as leaving the medications on the dining room table or a daily call, be helpful?

#2. Develop purposeful activities and participate together in social engagements.

A loved one who previously enjoyed cooking may have stopped because alterations in their executive function skills now prohibit the planning and sequencing necessary. You can help by participating in the planning and using simple questions to limit decision making.

For example:

“Let’s have pasta and meatballs tonight for dinner. I’ll get the recipe to see what we need. Let’s go to the market together to get the items on the list. It looks like we have all we need, let’s get started. How about if you open the packages of meat and I’ll crush the garlic.”

#3. Validate the emotions you hear.

Individuals with cognitive impairment often retain memories of life events that resulted in powerful emotions. They may perseverate on an experience and bring it up repeatedly.

Instead of saying that you know all about it and have heard the story many times before, validate the emotion: provide reassurance while distracting them toward a more positive conversation.

For example:

“I know it hurt when your sister stopped talking to you for a while and that it continues to make you sad. You also have lots of fun stories about when you and your sister were little. Tell me about the mischief you used to get into.”

#4. Create predictable routines and offer choices (but only two at a time).

Establishing routines, even ones that are new, can be incredibly helpful for those with cognitive impairment.

For example, if your loved one needs assistance with dressing, he/she may be overwhelmed by the available choices in their closet. So, try selecting two outfits that are clearly segregated from the rest and suggesting that they chose between them. Ask, never command:

“We need to get going so we can get to the market before it’s too crowded. You look great in both this red and this blue outfit. Which would you like to wear?”

In all cases, remember that the way you communicate can be as important as the words themselves. For example, instead of saying, “Why didn’t you take your medication today?”, you could say, “I see your medications are still in the box for this morning. Let’s take them now. I’ll get a cup of your favorite juice.”

Summary

The journey of caring for a loved one with cognitive impairment is not an easy one. If you notice subtle changes in behavior and mood, share your observations with them. Beginning a dialogue about the topic can lead to an appropriate evaluation, diagnosis, and treatment.

Simultaneously, focus on day-to-day management and practice changing how you react and interact with your loved one. Most important, remember to laugh — often and together.

Recommended Listening and Reading

For those of us who are health care professionals, it’s challenging to understand — let alone influence — those who remain vaccine hesitant. I sometimes wonder if it’s worth the effort.

This podcast, featuring Dr. Daniel Lewis of Greenville, Tennessee, with two of his patients, provided great examples of how to address concerns, giving me optimism and energy to continue to try!

On the same topic, this interactive article is based on the principles of motivational interviewing, a research-backed approach for encouraging people to get vaccinated. It’s used by health care professionals to harness people’s innate drive for change.

Recommended Reading: Unwinding Anxiety

I am a huge fan of Ezra Klein and his podcasts. In this recent one, “That Anxiety You’re Feeling? It’s a Habit You Can Unlearn,” he interviews Jud Brewer, an associate professor of psychiatry at Brown University and the Director of Research and Innovation at the Mindfulness Center. His new book, “Unwinding Anxiety: New Science Shows How to Break the Cycles of Worry and Fear to Heal Your Mind,” applies that research to anxiety, which he understands as a kind of addiction. As with any addiction, you must understand its rewards in order to begin addressing it.