AGS

Multicomplexity

Multicomplexity

History

  • Consider the psychosocial needs of each older adult and their caregiver(s) and their experience with structural and social determinants of health, including experiences of racism, sexism and ageism.
  • Assess living setting and conditions, support system, and financial security.
  • Life changes, stressors or concerns about abuse or neglect? Recent weight loss?
  • Which symptoms and/or medical conditions affect life the most?

Exam

  • Be alert to warning signs of elder mistreatment (see Elder Abuse and Neglect, below).
  • Look for signs of difficulties with self-care such as poor dentition, weight loss or long toenails.32,33
  • Use a Trauma-Informed Care approach to the exam that creates safety and empowers each older adult34

Frailty: defined as either accumulation of deficits or biologic syndrome of decreased resilience and reserve resulting from cumulative declines across multiple physiologic systems.35 Frailty predicts adverse outcomes better than age alone. 

Fatigued?
Resistance: walk up one flight of stairs?
Ambulation: walk 1 block?
Illnesses: >5?
Loss of weight: >5% in past 6 months?
≥3 = frail, at risk of decline in health and mortality

Nutrition

  • Recommend high-quality protein (1 g/kg of ideal body weight per day), evenly distributed throughout day to maintain muscle mass37
  • Screen for vitamin B12 and vitamin D deficiency (more common in older adults)
  • Screen for weight loss (e.g. – “Stop Weight Loss” mnemonic)32

Social Isolation

  • Associated with high rates of depression, anxiety, disability, and self-rated poor health.34
  • Hearing loss is associated with social isolation.
  • Screen for social isolation and connect patients to Area Agencies on Aging (eldercare.acl.gov/Public/Index.aspx) or religious organization if appropriate.

Elder Abuse and Neglect

  • National Center: https://ncea.acl.gov/Resources/State.aspx
  • Screening questions
    • Do you feel safe where you live?
    • Who prepares your meals?
    • Who handles your checkbook?38
  • Notice warning signs, such as poor hygiene, skin tears, burns, fractures (spiral fractures of long bones), malnutrition, pressure ulcers, vaginal or rectal bleeding.
  • If there is concern, report to state Adult Protective Services: napsa-now.org)

“CARE” for Caregivers3,39

  • Caregiver Well-Being
    • Explore caregiver well-being
    • Identify ADLs and IADLs not being met
    • Social work consult
  • Advance Care Plan
    • Start discussion on goals of care and wishes
    • Health care proxy, POLST
    • Long-term care?
  • Respite
    • Identify opportunities for caregiver respite (e.g., others to care for patient, time away, adult day health program)
  • Education
    • Resources
      • Case manager Counseling and 1:1 CBT
      • Non-medical home services
    • Caregiver support groups
      • Council on Aging
    • Disease-specific
      • Symptom-focused skills

Best Support / Setting?40,41

Skilled Nursing Facility

  • Inpatient rehab: 3 hours/day of PT/OT, Medicare pays
  • Long term care: inability to perform ADLs or ongoing nursing care, Medicaid pays
  • Long-term acute care, eg, recent ventilator or status post prolonged ICU stay
  • Hospice: ≤6 months prognosis, can also be delivered at home

Other Settings/ Supports

  • Adult day health: Some have medical/nursing, eg, PACE
  • Assisted living: individual units, minimal regulation and hire help as needed, meals and activities available
  • Independent living facility: individual units, hire help as needed, often opt in to meals, activities
  • Home care: visiting nurse, PT, OT for skilled needs; home health aides for ADLs
  • Local elder services/Area Agencies on Aging (eg, Meals on Wheels, Homemakers)

Interprofessional Team Involvement: Consider social work, nursing/care manager, nutrition, dental, mental health.

Tools for Multicomplexity

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