Keeping Up With Senior Evolution: Meeting the Changing Needs of an Aging Population
February 2016 Issue
What it means to be a senior citizen is changing, and approaches to seniors' O&P care are changing too-but still have far to go, some O&P experts say.
Intellectually, physically, and psychologically, what defines senior citizens has evolved significantly over the last decade or two, including their expectations to continue in the workforce or pursue new careers after retirement.
The first step toward improving healthcare services for today's elders is, perhaps, understanding that changed patient profile-and anticipating the direction in which it may continue to evolve. Mary Ann Miknevich, MD, clinical assistant professor and associate residency director, Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, observes that according to World Health Organization estimates, "the older are getting older. By 2050, one-fifth of older persons will be 80 years or older. In developed countries, those living beyond 80 will live an average of nine additional years compared to current statistics.
"Projections show that by 2050, for the first time in history there will be more elderly people than young people in the world, impacting the support ratio. The number of people under 65 who would be available to provide care for the older people is dropping from a current 12:1 ratio to 4:1."
Health trends in the elderly population are a major concern for our future. Miknevich points to findings published in United Health Foundation's America's Health Rankings© report that identify 9.5 percent of the U.S. population as having diabetes, and predicts a rise in that figure to 33 percent by 2050.
"We're seeing a bad trend with obesity and diabetes that is likely to have dramatic consequences," she says. "The Limb Loss Task Force of the Amputee Coalition predicted in their 2012 study that by 2050, the incidence of amputation will double largely due to the diabetes epidemic."
Factoring those predictions together, we can reasonably anticipate a significant increase not only in the number of people with amputations, but especially in the number of older people with amputations.
The Older Population Is Different-But Faces Similar Challenges
Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics for Hanger Clinic, Austin, Texas, observes that the older population is getting stronger, healthier, and more active and socially involved than ever. "Every week now, I'll see someone over 90 years old who is very alert and well-informed. Ninety is the new 80-really, it's the new 70."
The physical changes of aging may be inevitable, he admits, but healthcare professionals are now able to compensate for more of them.
"The body changes and the elasticity of your skin changes, but today we have some great protective materials that we can put over the skin before we apply the prosthesis," Carroll says. "As a result, the residual limbs are not nearly as at risk as they were several years back-so we can get people up and going even if their body is changing and aging.
"There are ways of recovering from the body wearing down," he adds, noting surgical interventions like total knee replacements. "We can reenergize the body and build up the muscle tone and strength. As the bony structure starts to weaken, we can recommend bone density tests and bone-strengthening exercises; medications are also available."
If the elderly can compensate in some way for declines and losses, Miknevich points out, it allows them to retain potential to engage with life, be successful in aging, and not be a burden to society.
"Studies have shown that physical activity is medicine for older people," she says. "There is a positive association between increased levels of physical activity and improved health. Recommendations for exercise for the elderly are moderate to vigorous, five days a week-both strengthening and aerobic activities."
Studies have shown that keeping the elderly active and exercising not only improves their quality of life, but also improves their cardiac output, hemoglobin levels, blood oxygenation, and muscle mass. Additionally, exercise can offer the bonus of improving seniors' functional levels and helping them qualify for higher-activity-level prostheses.
Age alone shouldn't define what's appropriate for an elderly patient, Miknevich says, recalling a 100-year-old patient who was recently discharged from a nursing care facility to go home alone. "It depends on the support systems that they have, the patients' resilience, and their desire and willingness to try to stay active and independent. On one hand we have those people-but on the other, I have 50 year olds coming in and asking for power scooters."
Carroll stresses the importance of providing emotional and psychological support and encouragement to inspire and motivate older patients to maintain independence through improved functionality.
"Our elderly population is doing better than they've ever done when it comes to utilizing prosthetic and orthotic devices, partly because they're educated-they can access all the knowledge they need on their smart phones. So they're asking me, as a clinician, the tough questions about why they're not a candidate for a specific technology.
"I tell them what they're not doing, and they have a goal to shoot for. 'I'll be back in a month,' they vow, 'and I will measure up!'" Carroll says, adding that they often do meet those goals, taking responsibility and ownership of their future care.
"We as clinicians can help create those levels of expectation," Carroll says. Phil Stevens, MEd, CPO, FAAOP, immediate past president of the American Academy of Orthotists and Prosthetists and a practitioner at the Hanger Clinic in Salt Lake City, points out that patient responsibility works both ways.
In cases where patients may have admirable determination to succeed but their expectations of mobility may not be realistic, given comorbidities of type 2 diabetes or the etiology of an amputation that resulted from peripheral arterial disease, Stevens defines the challenge. "I try not to say no. Instead, I set goals. I tell patients that when they meet a given functions standard, then we can consider certain technologies. So if they ultimately fail to reach a given standard, it's not because the system wouldn't allow them to pursue it, but because they were unable to get there."
Patient ownership of healthcare also extends to participation in the documentation process, Carroll says. "These better-informed individuals now realize that they have to play an active role in talking to their physicians about what they need as an orthotic or prosthetic user-because if it's not in the physician's notes, I'm not able to provide what may be the most clinically appropriate device."
The Elephant in the Room
Perhaps the primary obstacle to improving senior care, however, is understanding the greater potential for reimbursement problems and the threat of audits.
Gerald Stark, MSEM, CPO/L, FAAOP, senior upper limb clinical specialist for Ottobock, Austin, points out that part of the problem faced by providers and suppliers is that successful reimbursement requires different skillsets than have ever been needed before, which may be why Medicare reimbursement issues are becoming more acute.
O&P comprises conceptual (business management), technical (fabrication and design), and human-centered (clinical management) people, but all are focused on relationships to deal well with patients and each other, he explains. "We have difficulty dealing with bureaucracies like Medicare or third-party payers because we must overcome those abstractions of relationships that do not share our patient-centered focus."
For his doctoral dissertation, Stark is currently engaged in a study that examines workplace anxiety and its effect on adaptation to change, including the O&P industry's sometimes adversarial relationship with those responsible for reimbursement-which can result in biased thinking.
"Whenever there's a sense of threat, there's an increase in individual and group anxiety," he says. "That anxiety can be systemic-anxiety can be felt by the profession as well as by the individual."
And when that threat level increases-when claims are denied or questioned, or audits occur, for example-it influences our actual intelligence, he notes. "Our instant response is survival. Our IQ actually goes down as the cortisol levels rise, and sometimes we sabotage ourselves by reacting emotionally rather than thoughtfully.
"When someone is faced with a reimbursement denial and they are instantly feeling like their company is going down the tubes, that is some very palpable stress there. No longer are they thinking creatively in how to manage the situation or thinking critically as to how their process may have played a part; they're thinking in terms of fight or flight."
Stark advises employing various anxiety-relieving and stress management techniques and a conscious effort to employ System 2 thinking, as described by Daniel Kahneman in his book, Thinking, Fast and Slow. The keys for O&P, he says, are (a) a capacity for risk tolerance, (b) removing uncertainty by measuring something, and (c) removing your own bias so you can respond less emotionally.
Stark's study, projected for publication in 2016, is well on its way to confirming that people who are able to think more slowly are technologically more optimistic and more innovative.
"The converse is true, as well," he adds. "People who challenge themselves with innovation and generally have an optimistic attitude become less emotionally involved and reactive. It's a two-way street. If your group is very emotional, you can challenge them with new innovations and processes; take a few of the outcomes studies that people have found that work really well and challenge [your group], and gradually they'll become more optimistic about the use of them."
How does this relate to the challenge of taking better care of today's "new" older patients?
Since the range of activities which older patients are participating in is dramatically increasing, Stark says, we have to approach older patients without predetermined ideas based on age. O&P professionals are very good at evaluating factors to recognize functional potential, he believes, but insurance companies are less progressive in their thinking in this respect. "They have an inherent bias regarding the activity level that a geriatric patient has after age 65. Being inherently optimistic, we think of the patient in terms of what they could achieve; we need to help insurance companies with their bias in thinking older people are all classified in one category."
Stark continues, "Helping them [third-party payers] with their anxiety about that means providing outcomes for them and increasing our communication. So in a way, we have to become their mentors.
"When we talk about outcomes, it's a language we can share with insurance companies that's less anxious and more objective in our assessments. They are recognizing some of this scientific and statistical work, and I think we're getting better about providing that," he says.
While some may find researching and applying outcomes intimidating, it doesn't need to be a complex process, Stark notes. There are a number of outcomes that are easy and inexpensive to incorporate. "You don't need a six-camera Vicon force plate sensor gait lab to do outcomes-it could be a stopwatch and a pylon," he says. "[The patient] gets up from a chair, walks around a pylon ten feet away, and sits down. That's an outcome."
Stevens agrees. "We don't need statisticians, but we do need practitioners with a working knowledge of outcome measures. We're at an interesting place. A number of practitioners now appreciate the changing trends in healthcare and the needs for outcomes assessment, but they're overwhelmed by the prospect. They turn to the research community and ask what measure they should use. The research community responds by saying, 'It's not that simple; it depends on what and who you want to measure.'
"But in doing so, they've misunderstood the proposition from the field at large," he explains. "The profession, our clinicians, are not interested in becoming specialists in outcome measures. But they're willing to start using a few of them. I think we're at a point where the field needs to coalesce on three to five outcome measures and start using them." He adds that the expanded variety of outcome measures may be appropriate for the research community to assess nuanced hypotheses, but that the choice of outcome measures needs to be kept simpler if practitioners are expected to adopt them on a routine basis.
Another consideration regarding older patients, Stevens notes, are the Medicare audit trends, which have had a negative impact on Medicare beneficiaries in a way in which they may not be aware.
"The use of advanced technologies within the Medicare population, such as certain dynamic response feet and microprocessor knees, has dropped substantially-not because they are inappropriate for this population, but because some providers are genuinely afraid that they won't get reimbursed for providing these services even when they constitute the most appropriate care. The challenge is that new patients don't know what they're missing.
"Given their advanced safety features, microprocessor knees really should be considered the standard of care for Medicare beneficiaries that are active in their communities, irrespective of their age, but certain studies have shown that until a patient has used a microprocessor knee, they aren't very critical of their conventional knee," Stevens says.
"So if a practitioner decides not to provide advanced technology because of reimbursement fears, their patients may simply receive suboptimal care with no real understanding of what they're missing out on."
In balance, however, Miknevich points out there are newer prosthetic options available to help active seniors transition from a K2 into a low K3 level-less expensive and lighter weight options with a little more motion- which don't require the provider and patient to risk Medicare denial of an overambitious claim.
"The industry is starting to respond; we're seeing some newer, more moveable devices coming out. People are at least hearing that there's a need for prosthetic feet that allow patients with the potential to get more active," she notes.
Miknevich also mentions the trend toward lighter weight materials can make a huge difference for elderly patients, whose metabolic costs of walking are higher. Newer orthotic technology, such as the Smart Moore Balance Brace, an Internet of Things orthosis promoted for use by seniors with balance issues, is also becoming available.
As more outcomes studies become available, however, Stevens adds a warning. "A lot of new technologies are initially validated in younger patients with non-dysvascular amputation etiologies. The majority of the studies on microprocessor knees and powered lower-limb prosthetics were conducted with patients that really don't represent the Medicare population. The benefits realized by a patient in their early 40s with no comorbid illness are a little different than those experienced by someone in their late 60s with comorbid diabetes. As new technologies continue to come to market, they will need to be evaluated in the Medicare population to really support the argument that this population benefits from the technologies as well."
Change may indeed be the only true constant, as is the case with the changing patient profile of older patients. But on the bright side, one of Stark's major findings-of abundant interest to all of us who plan to age-is the news that innovation is not related to age. "Most people think the older you are, the harder it is to adapt to innovation, and that's just not seen statistically with the behavioral studies. In fact, people who are innovators are always innovators-they constantly are challenging themselves, unrelated to age."
Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.