Physician Obligations to Older Adult Patients With Declining Cognition, Mobility

When the health and cognition of older adults declines over time, family members and physicians must determine the proper balance of providing assistance while also attempting to preserve whatever independence the older individual can handle safely. Deteriorating cognition can make it especially difficult to ascertain how older adults should be assisted, as they may have trouble communicating discomfort or pain. Loss of insight may limit them from admitting or explaining physical or mental problems. The articles in this issue of Annals of Long-Term Care: Clinical Care and Aging (ALTC) touch on a few areas of geriatric care related to this delicate balance of recognizing when to step in—sometimes firmly—and when to allow greater independence.    

Research has shown a confirmed lack of documented driving advice in discharge summaries for patients who had an inpatient procedure or who had sustained a transient ischemic attack or stroke. Adding to the complexity of these situations, physicians disagree regarding who should make the final decision about driving cessation for an older patient whose driving abilities are under scrutiny. Sina Aghaie, MD, and colleagues sought to better understand the variables at play in these situations. Older adults’ attitudes on resuming driving after hospital discharge were studied in 3 subacute rehabilitation (SAR) facilities. A survey was administered to alert and oriented residents measuring their perceptions about their driving efficacy. The objective of this study was to determine patients’ attitudes and beliefs regarding their driving abilities during their SAR, after a recent hospitalization, and before discharge to the community. 

Behavioral symptoms are quite common in older adults with dementia. When these behaviors occur in dementia patients, such as psychomotor agitation or retardation, the cause may be an unmet need, such as pain or discomfort. Pre-exisiting medical devices implanted in patients with dementia may be a source of discomfort that could be overlooked during care. Over the past few decades, surgical advances in treatment of erectile dysfunction (ED), such as penile implants, have resulted in patients who are both outliving their devices’ shelf lives and who are experiencing cognitive impairments. While the popularity of such implants has declined, prior popularity in men with ED may result in a growing number of older men living with both a penile prosthesis (PP) implant and dementia. Raza Haque, MD, and coauthors present the case of a community-dwelling, 79-year-old man with a history of moderate dementia who presented to a clinic with his spouse to establish care. His spouse reported increased physical agitation, worsening at night, for the last several months. He had a PP implanted 10 years prior. An intervention solution was then devised to improve the patient’s quality of life. 

Taking a different angle on the question of physician responsibility, Richard G Stefanacci, DO discusses the provider’s challenge in balancing obligations to patients, families and the skilled nursing facilities (SNFs) administration. He points out that the role and responsibilities of SNF attending physicians is shifting due to increasingly regulated facility environments and the advent of value-based reimbursement and care models. He explains how these new circumstances require attending physicians to work more closely with SNFs to reduce readmissions and legal liability while adhering to the growing number of regulations. 

These articles, covering both common and less common clinical situations, provide clinicians with guidance on how to approach driving cessation conversations, unique medical devices in older individuals, and changes in LTC reimbursement.

To read more ALTC expert commentary and news, visit the homepage