Over and above
An unsuitable old age: the paradoxes of elder care
Kenneth Rockwood

http://www.cmaj.ca/cgi/reprint/173/12/1500

Division of Geriatric Medicine, Dalhousie University, Halifax, NS

There is a spectre haunting Canadians. Will we be able to get the
health care we need when we need it? Many Canadian baby-boomers first
encounter a system gone wrong when a parent becomes ill: they become
caught in the emergency department crisis, the waits on hallway
stretchers, the palpable frustration of all. The problem is often
portrayed as government inefficiency, but this incomplete diagnosis
leads to wrong prescriptions. To sharpen the diagnosis, consider the
following paradoxes about ageing and health care.

1. Unless they double up and triple up on their illnesses, there won't
be enough old people to go around. This may seem ludicrous, but let's
do the math. The heart society advocates for more heart doctors and
heart nurses, and for the latest heart diagnostic devices to allow for
the latest heart treatments. It's a neat syllogism: heart disease is
highly age-related; the population is ageing; therefore, there will be
more heart disease, and we must act now. The lung society tells us the
same about lung disease, the kidney society about kidney disease ...
But when many of these old people show up in facilities ostensibly
built in their name, they are sent away as "unsuitable." Why? Because
they arrive for their procedure not just with one problem but with a
host of other ailments, too. In a word, their multiple, interacting
medical and social problems make them frail. Geared to the
sophisticated treatment of single problems, our system doesn't
accommodate the complexity of caring for frail elderly patients, even
though that is where much of our demand comes from.

2. The ideal patient is otherwise healthy. The unsuitability of frail
older people for the patient role is well known: many cannot give a
proper history; their temperatures go down in the face of infection;
they are hyponatremic for no good reason; and their medication list is
endless. Not to mention the "unsuitable" demands made by their
families, who naturally focus on outcomes: "I need Dad to walk again if
I am to take him home," versus "We have treated his pneumonia and now
it's time for him to go." In such a case, families can be forgiven for
thinking that it is the care that is unsuitable, not the patient. Not
recognizing the cognitive impairment that makes for the "poor
historian," or sending home a patient who newly cannot walk are common
examples of how "the system" fails because we don't know better. The
reasons that we don't are complex, but they are an educational, not a
moral, failing: simply blaming doctors won't do. Not admitting our
ignorance won't, either.

3. It's more rewarding to do things to people than for them. When
people have just a few things wrong with them, it's perfectly
reasonable to focus on those few things, especially when "to do to"
(say, replace a painful hip) equates with "to do for" (relieve
suffering, increase mobility). In such cases, we can ignore a few days
of discomfort and focus on (and pay for) the skilled procedure. But
this might not take into account the vulnerability of the patient who
is frail. To replace a hip in someone who never recovers from an
unrecognized and untreated postoperative delirium means that the link
between the procedure and the preferred patient outcome has been lost.
Yet our present accounting of what goes on and what goes wrong is often
silent on patient function. We pay more to perform a complex procedure
with a bad outcome than to achieve a better outcome with less
technology.

4. We're willing to pay less, not more, for comprehensive care. The
experiment of the last 20 years shows that underpaying family doctors
for nursing-home care does not enhance care there, and paying
geriatricians badly means that few people want to become geriatricians.
Just as the hardest-working doctors are not always the highest-earning
ones, the skills essential to good care of the frail are little prized
in our remuneration systems. This is a tricky area for doctors: in a
single-payer system, physicians' salaries are a zero-sum game. Hence,
there is a strong temptation to view private care as a "win-win"
solution that injects more cash into the system and allows us all to be
better paid.

5. We let perverse incentives persist. Fee-schedule oddities are not
the only perverse incentives that undermine the care of frail elderly
patients. In Halifax, for example, we now annually admit to acute care
about 125 people for every 100 nursing-home beds. A local group has
reckoned that these costs are at least twice as high as they need to be
and that we could improve care at less cost if even just the money now
put into unnecessary ambulance transfers were used to provide better
on-site care. So, why don't we? History and silos aside, health care
organizations are both the recipients of funds and the auditors of
quality: we rely on ourselves to say whether we are doing a good job,
and it is often easier to say that we are than to undertake fundamental
reform. If we are to save medicare, we must discuss, not deny, perverse
incentives. (We could start by recognizing that length of hospital stay
is a system input, not a health outcome.) Without such a discussion,
private providers, doing what they know best, will skim. They will
efficiently treat single-problem patients and attribute their success
not to careful patient selection but to the inherent virtues of
privatization. The other, "unsuitable" patients will be left to the
public system, which is why medicare has no choice but to face up to
frailty.

6. Physicians are their own worst enemies. We have to find a way to
engage debate about "the system" that recognizes how we contribute to
its ills as well as how we might make things better. For example, how
much of the "wait-list crisis" persists not just because of the obvious
inefficiencies in the ways that lists are assembled and maintained, but
because we have done little to prioritize by likelihood of benefit? How
many people await high-tech, physician-driven solutions for which they
have little hope of benefit while being denied low-tech services that
might mitigate their suffering? In 2002 I worked with the Canadian
Cardiovascular Society to discuss the management of heart disease in
elderly people.1 One of the most impassioned presentations we heard
advocated for implantable cardiac defibrillators, from an evidence base
that included virtually no patient that I would recognize from my
geriatric medicine practice. But the momentum was unstoppable, and
within a short time a cardiologist colleague asked my opinion about a
patient who had been referred for an implantable cardiac defibrillator
but whose multiple medical problems and cognitive impairment had led to
the patient being designated as "no code." If we lack the wherewithal
to rationally discuss outcomes, how can we rationally advocate inputs?
Our most passionate advocacy might go down well with the public, but it
will be viewed sceptically by colleagues unless we can share a better
sense of ends and their achievement.

Canada's dilemma of providing care for an ageing population is of
course a privilege denied to many countries. Those of us who are
baby-boomers face the challenge of growing old as a group. Think of it
as a bequest from our parents, who faced challenges of depression and
war that must have sometimes seemed overwhelming to them, too.

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Acknowledgements: Kenneth Rockwood is supported by the Canadian
Institutes of Health Research through an Investigator Award. He also
receives career support from the Dalhousie Medical Research Foundation
as the Kathryn Allen Weldon Professor of Alzheimer Research.

Competing interests: Kenneth Rockwood is a geriatrician; this paper
advocates for (among other things) more geriatricians and better pay
for them.

1.    Fitchett D, Rockwood K, Chan BT, et al. Canadian Cardiovascular
Society Consensus Conference 2002: management of heart disease in the
elderly patient. Can J Cardiol 2004;20(Suppl A):7A-16A.