Optimal Management of an Older Patient With Multiple Comorbidities and a Complex Psychosocial History

This department in Annals of Long-Term Care focuses on real-world difficult cases that clinicians have encountered in their practice. A case presentation will be followed by a discussion about the case that includes teaching points and clinical pearls from clinicians at collaborating medical schools. The case presentation in this article was written by the geriatrics fellows and faculty from the University of Texas Southwestern Medical Center at Dallas, and the discussion that follows was compiled from a transcript of a monthly telephone conference hosted by Aurora Health Care.
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Case Presentation

 An 87-year-old white man with several underlying medical conditions, including Parkinson’s disease, visited the VA geriatric fellows’ clinic frequently over the previous 2 to 3 years for depression and repeated falls. At a regularly scheduled clinic visit in April 2009, he said life “isn’t worth living” and admitted contemplating taking an overdose of sleeping pills. He was evaluated in the emergency department (ED) and received close follow-up for mental health issues. During a follow-up examination, he was referred for an occupational therapy assessment, which found him independent in his activities of daily living (ADL) but in need of assistance with instrumental activities of daily living (IADL); he typically uses a walker to ambulate. 

At geriatric clinic visits and mental health appointments, he continues to acknowledge depression but denies suicidal ideation. In addition to medications he takes to address physical health problems (Table), he was started on various psychiatric medications, including multiple selective serotonin reuptake inhibitors, bupropion, and mirtazapine. The possibility of poor adherence makes it questionable as to whether he received an adequate trial of medical therapy. He lives with his daughter, who recently stopped all her father’s psychiatric medications, stating she did not “believe” in those types of medications and that they were generally overprescribed.

Relevant Social and Family History
The patient is a World War II veteran, has 2 years of postsecondary education, and ran his own company before retiring 15 years ago. His wife of 60 years died in 2001, and he attributes his depression primarily to social isolation. The patient had five children with his wife; he lives with one daughter and maintains telephone contact with his other four children, who live out-of-state. His retirement income is approximately $1300 monthly, part of which he uses to pay utility bills. His savings were used to add living quarters for himself onto his daughter’s home.

He moved in with his daughter shortly after his wife’s death to “help” her and describes it as the worst mistake he’s ever made. His daughter, who works from home, does the cooking, most of the grocery shopping, and manages his medications. He says their infrequent interactions are typically hostile and he spends most of the time alone in his room. He and his wife were active at their senior center, but after her death, he found it too painful to continue going. His only social activity is a weekly widows-widowers luncheon. He met a woman at these luncheons with whom he has sex on occasion but no ongoing romantic relationship.

The patient quit smoking 40 years ago and acknowledges moderate to heavy alcohol consumption until 2007, which is when he claims to have stopped drinking. Approximately 2 years ago, the patient briefly befriended a prostitute. He said he began using crack cocaine with the prostitute to “feel better,” but vehemently denies recent crack cocaine use. Of note, his daughter’s husband committed suicide by drug overdose approximately 1 year ago. The patient says his daughter also has a history of using illegal drugs, but he does not know if she is still using them.

The patient’s daughter accompanied him to the clinic only once. During the visit, she verbally degraded him and rarely allowed him to speak. When the patient was out of the room, she told the physician her father had a history of pedophilia and could not be trusted around children and that this had led to his estrangement from multiple family members. She also said he was not monogamous during his marriage, had prior episodes of drug use, and still used drugs periodically.

The patient was involved in an automobile collision in August 2009, which totaled his vehicle and for which he claims the other driver was found to be at fault. After the accident, he missed several appointments; his daughter said she was too busy with her business to drive him. He purchased a new car, which he uses to drive himself to doctor appointments and the weekly widows-widowers meetings. He denies having any recent accidents or near-misses.

Medical History
The patient’s medical history is significant for multiple comorbid conditions. These include hypertension; hypothyroidism; cerebrovascular disease, including a stroke in August 2009 that left no residual neurological deficits; hyperlipidemia; sinus tachycardia of unknown origin (rate controlled); Parkinson’s disease; restless legs syndrome; benign prostatic hypertrophy; gastroesophageal reflux disease; hiatal hernia; iron deficiency anemia (declined workup for etiology); posttraumatic stress disorder (PTSD); depression; laryngeal carcinoma (in remission since 1987); seborrheic dermatitis; mild vitamin B12 deficiency, with no sensory deficit; hyperhomocysteinemia; moderate sensorineural hearing loss (uses hearing aids); cataracts; degenerative joint disease; erectile dysfunction; diverticulosis; and vitamin D deficiency. His surgical history includes cataract removal, cholecystectomy, bilateral knee replacements, inguinal hernia repair, and excision of the laryngeal carcinoma. His significant family history includes a father who had heart disease and a son with “heart problems.”

The patient has at least a 5-year history of chronic falling, but no related fractures or major injuries. A thorough workup, which included neuroimaging, was unremarkable. His falls have been ascribed to multifactorial etiologies, such as medications, chronic knee pain, and deconditioning related to a sedentary lifestyle. He once received a diagnosis of benign positional vertigo, which responded to treatment with meclizine.

The patient was referred for physical therapy and gait training, which he completed but demonstrated no significant improvement. He says he no longer experiences vertigo or orthostatic symptoms and has not fallen in the past 9 months because he moves more slowly and diligently uses his walker.

Physical Examination
The patient weighed 182.1 lb and had a body mass index of 25. The patient’s mucous membranes were moist and his pupils were equal, round, and reactive. Examination of his neck found no thyromegaly, jugular venous distension, or lymphadenopathy. Examinations of his lungs and abdominal region were unremarkable.

His blood pressure while seated was measured 106/66 mm Hg and his pulse measured 85 beats per minute. While standing, his blood pressure was 110/55 mm Hg and his pulse was 80 bpm. His heart rate was regularly regular, with a soft II/VI systolic murmur loudest at the right upper sternal border. He had a respiration rate of 18 breaths per minute.

A neurological examination found cranial nerves II to XII intact. The patient had normal sensation and no tremor. His extremities were warm and well-perfused, with no edema. His knees and hands demonstrated arthritic changes. Strength measured 5/5 in all extremities, with left and right symmetry, normal tone, and no evidence of bradykinesia. Rapid finger tapping quickly elicited breakdown in both arms, however, which was more pronounced with his left arm. His gait was stable overall, but notable for mildly stooped posture and decreased stride length. He ambulated well with his rolling walker.

Cognitive/Behavioral Assessment
The patient was well-groomed, pleasant, and behaved appropriately throughout the examination. He was oriented to person, place, and date, but he appeared to lack insight on some matters, such as his ability to live alone without assistance. He expressed a desire to move into an independent living apartment.

The patient scored 19 of 30 on a Montreal Cognitive Assessment (MoCA), demonstrating deficits in clock drawing, an inability to repeat three digits backwards, and problems attempting to tap the letter A. He scored poorly on serial 7’s subtraction (0/3) and language (0/3).

On the geriatric depression scale, he scored 6 of 15, with positive answers for activity/interests and social interaction. He denied feeling depressed, suicidal, or homicidal.

Laboratory and Imaging Results
Abnormal laboratory findings included a hematocrit of 32.1% (normal, 41%-50%), serum iron level of 19 µg/dL (normal, 60-150 µg/dL), iron saturation of 4% (normal, 20%-50%), and a ferritin level of 7 ng/mL (normal, 15-200 ng/mL). Renal and liver function tests, platelet counts, and levels of electrolytes, protein albumin, thyroid-stimulating hormone, hemoglobin, mean corpuscular volume, and mean corpuscular hemoglobin were within normal limits. His vitamin B₁₂ was also in the normal range, but on the lower side of normal at 393 pg/mL (normal, 160-950 pg/mL). His total cholesterol level was 130 mg/dL (desirable, <200 mg/dL), with levels of low-density lipoprotein at 72.8 mg/dL (high, >160 mg/dL) and high-density lipoprotein at 46 mg/dL (low, <40 mg/dL); triglyceride level was 56 mg/dL (normal, <160 mg/dL).

Test results for hepatitis B, hepatitis C, syphilis, human immunodeficiency virus, gonorrhea, and chlamydia were negative. The patient’s urine tested positive for cocaine.

In March 2009, the patient underwent magnetic resonance imaging of the brain without contrast, which showed chronic ischemic changes involving the deep white matter and pons. No acute infarcts were observed.

Case Summary Multiple factors make this a very challenging case. Like many geriatric patients, he has a complex medical history and takes multiple medications, placing him at high risk of drug-drug interactions and drug-disease interactions. His impaired cognition and judgment make it difficult for him to negotiate reasonable solutions, particularly regarding housing options. His drug abuse further complicates his medical and social situations. Perhaps most challenging is the patient’s relationship with his daughter, which appears to contribute to his depression and sense of social isolation. His daughter’s personal beliefs about psychoactive medications interfere with his ability to get effective treatment for his comorbid psychiatric illness. In addition, the patient has distant relationships with other family members and receives little social support. He would likely benefit from a change in his current living situation, but this is complicated due to his limited financial resources.

Multiple interventions have been attempted, including referrals to the mental health clinic to address his psychosocial wellbeing and to social workers to discuss housing options. He was also referred for a driving evaluation. In addition to his monthly clinic appointments, the patient attends neurology and urology clinics. He has refused referrals to get treatment for his substance abuse. Several attempts to get his daughter more involved in his care have been unsuccessful.

What strategies should we consider to improve the patient’s current situation?

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The case discussion that follows is based around the Wisconsin Star Method (see below for more on this method), which guides clinicians in addressing the five realms of this patient’s complex, interconnected problems: (1) medication use; (2) medical problems; (3) behavioral health issues; (4) personality traits and personal values; and (5) social issues. Assessing these then allows us to approach the most difficult aspects of the case.

Case Discussion

Lilly: Do we know when the dopamine agonist was started?

Arnouville: It was started approximately 18 months ago during an admission to an outside hospital. His outpatient neurologist at the VA was skeptical about the diagnosis of Parkinson’s disease and tried to wean him off these medications.

The patient experienced worsening of symptoms and was admitted to an outside hospital ED, and the medications were restarted by the attending neurologist. He prefers the neurologist outside the VA, but he cannot afford to follow with him. It has been difficult to determine the optimal treatment for his probable Parkinson’s disease. A trial of carbidopa-levodopa without ropinirole resulted in a lot of “crazy legs” sensations. A trial of ropinirole alone, without carbidopa-levodopa, resulted in increased tremor, and on return he reported using it up to four or five times a day to treat this.

Lilly: Does his cocaine use with the prostitute predate ropinirole?

Arnouville: Yes.

Lilly: Is there any link between his increased impulsivity and taking ropinirole?

Arnouville: That’s a good question. He appears to have had some of these personality traits prior to this; however, we think his recent drug use may be related to the dopamine effects of these medicines.

Oakes: We question the use of finasteride and tamsulosin in a patient who is 87 years old. The blood pressure, while not orthostatic, is low, especially in somebody with high-risk behaviors. There may also be occasions where he overmedicates himself. Have you considered stopping some of his medications?

Arnouville: I agree his medications likely contribute to his multiple falls. In the past couple of months, I have focused on his polypharmacy and decreased tamsulosin by half. He has not experienced increased urgency, although he has some mild, ongoing urgency symptoms.

His beta-blocker contributed to his low blood pressure. It was started by cardiology for sinus tachycardia of unknown etiology. His recent periodic cocaine use is a potential etiology of the tachycardia; beta-blockers are contraindicated with cocaine use. The beta-blocker was tapered off at his last visit, and I plan to reevaluate his blood pressure control when he returns.

Malone: Are there questions about the social or functional aspects of the case?

Mehr: The daughter indicated that she didn’t think antidepressants were helpful and that they were overprescribed. Does she think he’s depressed?

Arnouville: I met her once and I’ve tried to talk to her on the phone since, but she’s been very distant. When I spoke with her, I had the impression she may also have depression and additional personality issues. She did recognize that he was depressed when I met with her; however, she was somewhat dismissive about it. She suggested it was his own fault and that he could get out more and be more social if he wished.

Mehr: I understand why he’s reluctant to go back to the senior center where he used to go with his wife. Have other efforts been made to try to get him out of his house and be more socially active?

Arnouville: Yes. His daughter brought him to the widows-widowers luncheon every Saturday. He has continued to do that, but it’s just one outing a week.

Lodhi: Did his history of pedophilia impact the relationship with his daughter? Is he safe to live independently?

Arnouville: Regarding the pedophilia, there are no young children in the home and they seldom visit. When I spoke to his daughter, she appeared suspicious that she might have been subjected to sexual abuse that she wasn’t able to remember. It definitely has impacted their relationship.

Regarding living alone safely, he performs his ADLs independently; however, he cannot administer his own medications appropriately, shop, schedule or show up for appointments, or cook without assistance. I think he needs a supervised living situation.

Malone: Are there questions in regards to the patient’s social arm of the “star” or the patient’s behavioral health needs?

Duthie: One, is he a registered sex offender? Two, has adult protective services been called, given his complaints that this is “the worst move he’s ever made” and the question of abuse in the family. At least in the office situation, the family seemed to be verbally abusive.

Arnouville: Adult protective services has not been involved to date; however, one of my major goals was to try to get him into a situation that would be healthier both for him and his daughter. Maybe they could get a break from each other.

Duthie: Was social work able to help you as to whether you could verify this pedophilia issue? Is he a registered sex offender?

Arnouville: I didn’t explore that further because the patient doesn’t live in a situation where he might be a threat to children. To my knowledge, he is not.

Alhumaid: Have you discussed appointing a healthcare agent with him. Does he want his daughter to be his healthcare agent despite their strained relationship, or does he just have nobody else to turn to?

Arnouville: Yes, she is his medical and durable power of attorney. She is really the only person available, but not really who he might choose otherwise. One consideration is whether he should appoint someone else, such as an attorney.

Malone: Was he ever incarcerated?

Arnouville: Not to my knowledge. As I said, he’s been a long-time patient of the VA, so there are a lot of records to review. I have never asked him that question.

Malone: We’re going to move to the next part of the case. If you were to see this patient this afternoon, how would you handle such a complex case? How would you address the key one or two issues, including the difficult relationship with the patient’s daughter, which is exacerbating the patient’s depression and isolation, and the daughter’s personal beliefs about the medications?

Moylan: One of the key components is recognizing that the number one determinant of quality of life in a Parkinson’s patient is depression, not the movement disorder. Approximately 50% of these patients are affected by depression. It’s something I would emphasize with the daughter—how important treatment of depression is for his quality of life. Depression is part of the biology of the disease, rather than something he can influence by what he does every day. She’s the gatekeeper to his medications, so we need her agreement to ensure he receives an adequate trial of antidepressant therapy.

In addition, I recommend utilizing your community resources to try to get him socialized more and out of the home. A day program, for example, may be optimal for him so he can spend less time with his daughter.

Arnouville: I agree. I did discuss this with his daughter. I am particularly concerned about his high risk for suicide.

Moylan: One treatable cause of restless leg syndrome is iron deficiency, and his ferritin level is 7.0 ng/mL. Some older patients never get adequate iron, either because they don’t take it or they can’t take enough to offset their ongoing loss. It may cut down on his dopamine agonist use. Our experience is that older patients rarely tolerate dopamine agonists well and the drugs tend to cause side effects such as hypersexuality, gambling, other compulsive behaviors, weepiness, and delirium. Carbidopa-levodopa is usually better tolerated. We avoid using ropinirole or pramipexole-type drugs.

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Lilly: I think we’ve established that he has a cognitive deficit of some type, and while it might be potentially academic to work up the etiology, it may prove useful. Do we have a previous MoCA or MMSE [Mini-Mental State Examination] to compare, to get a sense of a timeline; and secondly, have you considered neuropsychiatric testing for him? Looking specifically at the MoCA, receiving 3/5 on recall is quite good because the recall portion of the MoCA is more rigorous compared with the MMSE recall section. So Alzheimer’s disease may be less likely than vascular dementia, especially considering his executive function. If he has vascular dementia, future management may focus on optimal stroke prevention for him.

Lodhi: In addition to neuropsychiatric testing, is there a history of hallucinations, as Lewy body dementia should be considered with his parkinsonian features? The social worker may help with assessing the safety of his home, and she may also be helpful with the relationship between the patient and the daughter.

Garcia: Home safety is a major concern, and I would evaluate his environment. I also recommend neuropsychiatric evaluation to further assess his cognitive impairment. We also would focus on advanced directives.

Oakes: Has the patient ever had a home health nurse or other healthcare providers visit the home?

Duthie: I think the move-in with the daughter sounds like a lose-lose situation. I would pursue whatever could be done to relocate him to an environment that is safe. I think he might be more comfortable, and he will need some oversight due to the cognitive issues and the medications. Does your VA have adult day care? This VA program encourages socialization and may help while relocation is being considered.

Arnouville: No, unfortunately our VA does not have an adult day center.

Teaching Comments

Before the case conference, Dr. Danto-Nocton was asked to prepare some general teaching points, and Dr. Goveas was asked to prepare teaching points regarding the behavioral health aspects of this case.

Danto-Nocton: What is the best way to approach this case? To avoid getting totally overwhelmed, the first thing I would do is make a problem list using the Wisconsin Star Method (Figure) and look for some relatively easy things to tackle, such as repleting vitamin D, which may decrease his risk of falls. His vitamin B₁₂ level was also relatively low, so you may decide to check his methylmalonic acid level.

I would set priorities. Be aware of your patient’s goals; you and your patient may have different goals and agendas. Use your interdisciplinary team members, as you will not be able to manage this patient’s case alone. The social worker may be key. Be aware of additional community resources, such as your mental health providers, and work with neurology and psychiatry. An assisted living-type setting may be indicated if independent living is not appropriate. He should continue to have routine driving assessments to ensure he stays safe.

Building trust and a rapport with this patient is very important. Frequent clinic visits, for example at monthly intervals, would be helpful. Discuss a stepwise management plan with him and explain that it may take some time to see improvement.

Review his medications. Consider stopping labetalol because his blood pressure does not need to be so low. He is not orthostatic by his systolic readings, but his diastolic blood pressure fell by more than 10 mm Hg. Tamsulosin use has already been addressed.

Does he have any pain? While he has had no recent falls, he may have chronic pain from osteoarthritis in his knees. I don’t see analgesics on his drug regimen apart from the low-dose aspirin that he takes as part of an antithrombotic regimen. Consider whether he is self-medicating with cocaine to treat depression and pain.

We discussed advance directives earlier—maybe completing a living will is also advisable so he can ensure his wishes are taken into account. I would like to adequately treat his depression. The system being used to improve his compliance may be confusing if he has executive dysfunction. Could you get the medications prepackaged by a pharmacy? This would make it harder for his daughter to remove the antidepressant.

Regarding sensory deprivation, he has hearing aids. Does he wear them? Assess his vision, as sensory deprivation will add to his sense of isolation. He’s an incredibly difficult case and it sounds like you’re doing a great job.

Goveas: Some of my key points have already been mentioned, so I will focus on managing this patient from the psychiatric perspective. He has a depressed mood; evaluate for additional depressive symptoms including energy level, sleep, appetite, and anhedonia.

Does he meet criteria for major depression or is this a chronic adjustment disorder from several stressors? This is important because the treatments are different. An antidepressant may not be indicated if he has an adjustment disorder, but it is likely indicated if he has major depression or a dysthymic disorder.

Are his symptoms related to periodic losses in his life? Did the onset of this episode begin with the death of his wife? Consider bereavement that has evolved into a major depressive disorder. Approximately 20% of elderly individuals with bereavement develop major depression during the first year post-loss. Consider depression secondary to a medical neurological disorder. There is a strong association between depression and Parkinson’s disease, approaching 50%. Anxiety disorders also may be found in patients with Parkinson’s disease. Does he have an anxiety syndrome? Male patients may be reluctant to volunteer information about depression and anxiety unless probed.

Comorbid panic disorder, agoraphobia, or a mood disorder associated with cognitive impairment need to be considered. These disorders will amplify the difficult relationship he has with his daughter. Knowing more about the onset of his cognitive impairment relative to the development of depression is key to his diagnosis and management. Which came first?

Depressed elderly patients often present with executive dysfunction, slower information processing, attention difficulties, and short-term memory loss. This was previously described as pseudodementia. I would like to know the progression of his cognitive impairment. His ADLs are intact, but he has some IADL impairment. Is this mild cognitive impairment or has he developed dementia? His cognitive performance is atypical for Alzheimer’s disease. He presents with more pronounced nonamnestic cognitive deficits than amnestic impairments. His cognitive disorder may be due to vascular disease, depression, Parkinson’s disease, or a combination of these conditions. Has his alcohol abuse contributed to his cognitive impairment?

What is the relationship between his depression and his cocaine use? During cocaine intoxication, patients may present with hypomania, poor impulse control, or manic behavior. During withdrawal, they may develop suicidality with or without a substance-induced depressive syndrome. Was there a link between his suicidal ideation and his son-in-law’s suicide? What was their relationship like?

From the medical standpoint, the majority of issues have been covered. I would get a serum methylmalonic acid level in this gentleman. It is also important to keep in mind the relationship between Parkinson’s medications and impulse control disorder. Poor impulse control—specifically hypersexuality, pathological gambling, and hyperspending behaviors—have been associated with dopamine agonists, particularly when adding dopamine agonists to carbidopa-levodopa.

What were his premorbid personality traits and what did he use for support when he returned from World War II? Were specific interventions or resources helpful when he had PTSD symptoms? He succeeded, he owned a company. What coping mechanisms did he use? What were his strengths when he was socially very active? Identify them, and then help him find ways to use them now.

I want to reiterate some key aspects about the treatment plan. Confirming the diagnosis is very important, both his cognitive impairment and his mood disorder. I agree with the structured, time-limited visits. I want to emphasize that you have had successes with your care: he has had fewer falls, he is no longer suicidal, and he is coming to his appointments.

I agree that short-term goals should be assessed and treatment planned accordingly. His and your goals may be completely different, so it is important to outline them together. Make a problem list and a list of the short-term goals. Identify what is important in his life now and incorporate this into the care plan. Keep his cognitive impairment and functional deficits in mind. An alternate family member or an acquaintance from this adult group may be helpful with this process, if the patient agrees. Activity programs and increasing his social contacts would also be helpful, as mentioned earlier.

Addressing advance directives is very important. You play a vital role, and you may choose to integrate a nonphysician case manager who can liaise between you and the behavioral health providers.

Malone: We appreciate your expertise and your wisdom. Dr. Arnouville, can you provide any follow-up comments?

Arnouville: Yes, thank you, everyone. I think this conference will definitely help me develop future goals with this patient. Since I prepared this presentation 2 months ago, there have been some changes. We brought him in for respite care at the VA and, at that time, our social worker evaluated housing options that would be financially viable for him. For some reason, possibly due to his respite stay and testing done by occupational therapy on his IADLs, he seemed to gain some insight. He decided independently to stop driving. This freed up some additional funds so he could move into assisted living, which he has done in the past month. However, all is not perfect; since his move there, he has fallen 15 times. We are working on that now and trying to make his home environment as safe and supportive as possible.

Malone: We appreciate the chance to collaborate with your group at UT-Southwestern and thank you for your contribution to our education.

Moderator, Discussant, and Attendee Affiliations: Johns Hopkins University School of Medicine, Baltimore, MD (Alia Alhumaid, MD); Madison VA Hospital, Madison, WI (Timothy Howell, MD); Mayo Clinic, Rochester, MN (Aimee Yu Ballard, MD, Matthew Lilly, MD); Medical College of Wisconsin, Milwaukee (Edmund Duthie, MD, Joseph Goveas, MD); Metro Clinic, Cleveland, OH (Wajahat Lodhi, MD); University of Missouri-Columbia (David Mehr, MD, Kyle Moylan, MD); University of Texas Health Science Center, San Antonio (Liliana Oakes, MD, Cesar Garcia, MD); University of Texas Southwestern Medical Center, Dallas (Vivyenne ML Roche, MD, Jennifer Arnouville, DO, Roopali Gupta, MD); University of Wisconsin School of Medicine and Public Health, Milwaukee (Michael Malone, MD, Ellen Danto-Nocton, MD).

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The Wisconsin Star Method

The Wisconsin Star Method (WSM) was developed over several years, with input from clinicians, medical educators, and patients. It is a simple concrete tool for addressing the problem of complexity in geriatrics. The high frequency of multiple interacting patient and systems issues in clinical practice has long called for the development of a user-friendly method that allows clinicians to get a better handle on difficult situations more quickly and provide effective care with greater clinical integrity.^1,2

The value of the WSM is supported by the principles of heuristics,^3-5 cognitive science,^4-7 information visualization,⁸ ecological interface design,⁹ team functioning,⁴ and network theory.^10,11 The method involves a low-tech graphic user interface—drawing a small five-pointed star on a surface such as paper or whiteboard and mapping out clinical data about a patient’s situation in list form at the appropriate field or domain. Each datum is an element in a network of potentially interacting variables, with the links between them ranging from very weak (ie, negligible) to very strong (ie, directly causal). The primary identifiable clinical challenge (eg, ability to live safely at home) is written in the center of the star. In some cases, the primary challenge may not be entirely clear at the outset, but emerges gradually as the situation is reviewed.

Each arm of the star represents one domain: medications, medical, behavioral, personal, and social. The medication arm includes all of an individual’s current medications (ie, prescribed, over-the-counter, and “borrowed”) and other relevant substances (eg, dietary). The medical and behavioral arms list known diagnoses, functional status (eg, abilities regarding IADLs), and symptoms. The personal arm highlights a person’s individual traits, values, and usual ways of coping. These include the rules of thumb individuals use to guide their assessment of situations, their learning and communication styles, and their general approaches in dealing with stressful experiences. The social arm covers interpersonal problems, environmental problems, assets (eg, family support, finances, housing, transportation, legal issues), and access to needed resources.

Each arm of the star also represents a different ecological aspect at which problems may occur. The medication arm is considered the biochemical or molecular interface; the medical arm, the area of organ systems; the behavioral, the interface mediating between the brain, the body, and the environment; the personal arm, the interface of the “mind and heart”; and the social arm, the interaction of the interpersonal and the environmental.

Per the WSM, it is essential that the data be written down, as effective implementation is simply not possible in complex cases if the data is kept in the user’s head, because the carrying capacity of the conscious human brain is on the order of 7+/- simultaneous interacting variables.^5,9 The WSM serves as a two-dimensional map that becomes an extension of the users’ working memory⁸ and, whether used by individuals or a team, enhances executive functioning for situation awareness and problem solving. Writing the elements down creates a small but significant distance between the user(s) and the problems, thus providing cognitive and affective perspectives.

The WSM also facilitates the ability to attend simultaneously to multiple interacting variables and to identify those data that are most relevant. One simply travels around the star, assessing and highlighting those elements in each arm that appear to connect significantly with, and thus contribute to, the challenge in the middle of the star. This process allows the user to identify any potentially relevant data that is missing (eg, is the person able to manage all the required steps to refill a prescription?) and reconsider whether data initially considered irrelevant might have some bearing on matters after all.

Using the WSM in this manner helps ascertain which problems have multifactorial origins and thus avoid the common hazard in complex situations of coming to premature closure.^6,12 It can ease shifting sets when considering pairs of problems at different levels that might have linear-causal relationships (eg, poor blood pressure control despite three antihypertensive medications and an inability to afford medication or an unrecognized problem with alcohol abuse). It can also be applied holistically to identify how multiple problems may be interconnected, such as parkinsonian gait instability, falls, loss of usual means for coping, depression (low mood and motivation), and social isolation. The resulting map provides a big picture of the case, with strong and weak ties highlighted, and can be viewed as the person’s unique ecosystem.

By integrating holistic and linear-causal perspectives into an ecological approach, the WSM can enhance the recognition of diagnostic patterns within domains and the identification of vicious cycles between domains (eg, falls + embarrassment about using a walker→decreased activity→physical deconditioning→falls). It also facilitates novel problem-solving: generating hypotheses, prioritizing and sequencing interventions, integrating clinical pearls¹³ with evidence-based guidelines,¹⁴ and transforming vicious cycles into virtuous ones (eg, arranging for a friendly visitor—someone who also needs a walker—to visit and walk with the person regularly).

Likewise, the WSM can be used to help identify traits, values, and usual ways of coping and thus promote better appreciation of the anxieties that may underlie puzzling behaviors, such as recurrent falls and worry about being seen in public as being dependent on a walker.^15-17 When the user attends to these issues and assesses how he or she feels when confronted with a challenging clinical situation, it can enhance the user’s emotional effectiveness and reduce the likelihood of affective errors. Thus, the WSM can help in cultivating collaborative relationships with older persons rather than confrontational ones, such as blaming them for refusing to use a walker. Often, the personal arm of the star points the way to a good clinical outcome, helping the user acquire a sound appreciation for a patient’s understanding of the issues and preferences for addressing them.¹⁸

Using the WSM has the potential not only to enhance proficiency at providing comprehensive care, but also to reduce cognitive and emotional burdens and errors.^6,19 The WSM can help individuals and teams become more confident and mindful²⁰ in addressing the complicated interacting physical, emotional, and social issues of older adults with greater sensitivity and specificity to each one’s uniqueness.

References

1. Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med. 2004;351(27):2870-2874.

2. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294(6):716-724.

3. Michalewicz Z, Fogel DB. How to Solve It: Modern Heuristics. 2nd ed. Berlin: Springer-Verlag; 2004.

4. Page SE. The Difference. Princeton, NJ: Princeton University Press; 2007.

5. Gigerenzer G. Gut Feelings. New York, NY: Penguin; 2007.

6. Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med .2005:142(2):115-120.

7. Heath C, Heath D. Made to Stick. New York, NY: Random House; 2007.

8. Ware C. Information Visualization. San Francisco, CA: Morgan Kaufmann Publishers; 2004.

9. Endsley MR, Bolté B, Jones DG. Designing for Situation Awareness: An Approach to User-Centered Design. Boca Raton, FL: Taylor & Francis; 2003.

10. Barabasi AL. Linked. New York, NY: Plume; 2003.

11. Csermely P. Weak Links. Berlin: Springer-Verlag; 2006.

12. Groopman J. How Doctors Think. Boston, MA: Houghton Mifflin; 2007.

13. Mangrulkar RS, Saint S, Chu S, Tierney LM. What is the role of the clinical “pearl”? Am J Med. 2002;113(7):617-624.

14. Hunink MGM, Glasziou PP, Siegel JE, et al. Decision Making in Health and Medicine: Integrating Values and Evidence. Cambridge, UK: Cambridge University Press; 2005.

15. McCrae RR, Costa Jr PT. Personality in Adulthood. New York, NY: Guilford Press; 2006.

16. Agronin ME, Maletta G. Personality disorders in late life: understanding and overcoming the gap in research. Am J Geriatr Psych. 2000;8(1):4-18.

17. Agronin ME. Personality is as personality does. Am J Geriatr Psych. 2007;15(9):729-733.

18. Epstein RM, Peters E. Beyond information: exploring patients’ preferences. JAMA. 2009;302(2):195-197.

19. Graber ML, Franklin N, Gordon R. Diagnostic errors in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.

20. Epstein RM. Mindful practice. JAMA. 1999;282(9):833-839.