Caroline Mayer, 97, lives with her husband Edward in an independent living community on Cape Cod, Massachusetts. The couple has been isolated because of COVID-19, and Caroline looks forward to returning to her normal routines, which include playing canasta with friends and practicing tai chi. She has enjoyed a long and happy life. When asked to account for her blessings, she points to her husband. “I loved him in the beginning, I loved him in the middle, and I love him still,” she said. “I can write that in gold.”
But Caroline has also benefited from the care of expert clinicians. In her 90s, she was treated for breast cancer and non-Hodgkin’s lymphoma—recovering fully with a minimum of pain and discomfort. In addition, she has participated in a 20-year study, the Yale Precipitating Events Project (PEP), which helped keep her on a healthy path. She has reported on her health and well-being during regular visits from a clinician and monthly calls, and she has gotten advice on how to live with arthritis and avoid stressors and falls.
PEP, a National Institute of Health-funded cohort study of 754 people, has greatly expanded the understanding of functional independence and disability among older adults. The study is directed by Thomas M. Gill, MD, the Humana Foundation Professor of Medicine and head of the Yale Program on Aging. His work related to the NIH study and other research has demonstrated that functional decline can be slowed through care that helps to prevent falls and enables older people to live more resiliently.
Gill is among a number of faculty members at Yale School of Medicine who focus on keeping people healthier longer. They study the mechanisms underlying functional decline and disability, and develop strategies to forestall the onset and progression of disabilities. Other faculty members who are producing notable research and care advances in this area are Mary Tinetti, MD, the Gladys Phillips Crofoot Professor of Medicine and the geriatrics section chief, who focuses on including the patient in care decisions; and Sarwat Chaudhry, MD, associate professor of general medicine, who looks at ways to improve recovery among older patients hospitalized for cardiac conditions. Much of their work is carried out at the intersections of medicine, psychology, and sociology.
Their work challenges some of the conventional wisdom within the medical profession, which is organized around specialists treating disease states in isolation rather than treating patients holistically and putting their wishes at the center of care. “The management of almost all conditions needs to be done in the context of the totality of an older patient’s health and priorities,” said Gill. “The medical system hasn’t been set up to deal with this.”
The treatment of older adults is rapidly growing in importance. By 2030, one-fifth of the United States population will be 65 or older; and the group that is 85 or older is the fastest-growing segment of the population, according to the Federal Interagency Forum on Aging-Related Statistics. As the general population ages, the pressure is on society and the health care system to respond by helping older people to live healthier lives and delay disability.
It turns out that some of the most important strategies for forestalling disability are also the simplest. Each year, one-third of adults aged 65 and older fall; and one-third of those falls result in injuries that lead to further declines in health and loss of independence. A national study that Gill co-leads is called STRIDE: Strategies To Reduce Injuries and Develop confidence in Elders. The study has shown that fall-avoidance techniques and physical conditioning can help elders lower the severity of injuries caused by falls. “Physical activity is the single best strategy for restoring or maintaining function, and walking is the best exercise,” says Gill. He also stresses the importance of hydration. The STRIDE study built relationships with patients and their caregivers to ensure that patients were heard and heeded.
Tinetti is a national leader in the move to patient-centric medicine—the shift from treating diseases to treating people, and letting patients set their health priorities. This shift is nothing less than a revolution in medicine. In 2004, Tinetti worked with Terri Fried, MD, to co-author an article published in the American Journal of Medicine titled “The End of the Disease Era.” The authors argued that traditional specialty-oriented medicine led to much overtreatment, undertreatment, and mistreatment. They were met with harsh criticism from some in the medical community. “An editorial in the same issue basically called me a quack. I was very proud of that,” Tinetti says. “Today the approach is broadly accepted, but it’s still early days in terms of doctors acting on it.”
The patient-centric coordinated care approach is particularly relevant to older adults. They frequently have multiple diseases, each treated by a different specialist. A pharmaceutical therapy prescribed for one disease or condition might interact negatively with one prescribed for another disease—a phenomenon that Tinetti calls “therapeutic competition.” In addition, a drug might make a patient drowsy or lightheaded, which could lead to falls or interfere with the person’s enjoyment of life. “We should be talking to patients about their important health goals,” says Tinetti. “Then you align the care with their priorities.” She cautions that there will inevitably be trade-offs between length of life and quality of life.
In order to treat patients this way, primary care physicians and specialists must see themselves as part of a collaborative team. Tinetti has developed a coordination method that she calls “patient priorities care.” The approach was piloted in 2016 at the ProHealth Physicians’ primary care practice in Bristol, Connecticut. Facilitators kicked off the process by meeting with patients in person to “capture the patient’s voice,” says Kizzy Hernandez-Bigos, who was one of the facilitators.
The facilitators handed narrative reports to primary care physicians, who worked with cardiologists to develop holistic and personalized care strategies. Jonathan Rosen, MD, who at the time led ProHealth’s research arm, said that after the pilot was concluded, his group briefed hundreds of clinicians at the practice’s 80 locations in Connecticut. “We have to help patients get off the therapeutic treadmill,” he says. “It made us take two steps back and broaden our thinking to put more focus on patients’ concerns.”
Tinetti foresees a time when primary care physicians caring for older adults will operate like orchestra conductors coordinating teams of specialists on behalf of patients. She and her Yale School of Medicine associates have designed a self-directed method for patients to prepare a report for their physicians. In addition, they’re helping health care systems train physicians and other care providers to use the techniques pioneered at ProHealth. You can learn more about the method on their website, https://patientprioritiescare.org.
Chaudhry’s work in geriatrics focuses on some of the softer elements of medicine as well. Her SILVER-AMI study of patients 75 and older at nearly 100 cardiology practices around the country demonstrated the importance of social support in improving older adults’ recovery from heart attacks. The researchers studied five key social factors. They found that people who don’t have somebody to turn to for advice were readmitted to the hospital at a higher rate; and there was also a higher death rate among those with low emotional support. “Emotional support is critical, and it underscores the importance of providing services that enable seniors to live socially well-connected lives,” says Chaudhry.
That would be no surprise to Caroline Mayer, the 97-year-old lover of life whose story led off this article, but it’s a useful reminder to primary care physicians and specialists alike to always make the patient’s feelings a priority in health care.