Donald Jurivich: Do we need better health care for older adults?

For the first time, the Centers for Disease Control reported a decline in the U.S. average life expectancy. As reported, the decline – 77.0 to 76.1 years – sent U.S. life expectancy at birth to its lowest level since the 1990s.

Alarmingly, the U.S. life expectancy decline has unearthed significant health disparities. The drop represents 6.6 years for the American Indian/Alaska Native population, 4.2 years for Hispanic Americans, 4 years for Black Americans 2.4 years for white Americans, and 2.1 years for Asian Americans.

Furthermore, the U.S., on average, has a lower life expectancy at birth than most European countries and Japan. For a health care system that boasts of being the best in the world, our metrics in healthy longevity do not look so good when compared to other developed nations.

What’s the deal?

Several explanations can be floated as reasons for the U.S. lagging in healthy longevity.

The obesity and opioid, not to mention COVID-19, epidemics might be cited as drags on average life expectancy. We know that sedentariness accelerates biological aging, as noted by a rapid decline in chromosomal telomere length.

Smoking has the same effect. Chronic diseases are on the rise in the U.S. Six in 10 adults have a chronic disease, with two-thirds of these individuals having two or more conditions.

In North Dakota, the prevalence of cardiovascular and chronic lung disease has not changed much; however, diabetes, type II, has increased from 7.7% to 9.4%. Diabetes accelerates aging and dementia.

Another chronic condition, Alzheimer's Disease, is highly prevalent in the area, with North Dakota ranking third among states as a percent of the population with the diagnosis of dementia. Some providers speculate that North Dakota has one of the highest percentages of 85-plus-year-olds in the U.S. and thus accounts for the high rate of Alzheimer's Disease. Yet, Minnesota ranks right up there with one of the highest numbers of the oldest old and yet the prevalence of Alzheimer's Disease is more toward the national average. Also notable, older adults in Minnesota average 6% fewer multiple chronic conditions than North Dakotans.

Whatever the driving force behind the high prevalence of dementia in North Dakota, any level of cognitive impairment is unacceptable and potentially avoidable if we apply evidence-based Geriatric health care.

What is evidence-based Geriatric health care? The Hartford Foundation, in collaboration with the Institute for Healthcare Improvement, asked this very question a few years ago. They set out to conduct a comprehensive analysis of all Geriatric-focused interventions and see if they could distill the evidence into fundamental basics.

They asked, “What should every health care system consistently do to provide better care for older adults?" The evaluation of best practices in Geriatrics was challenged by several factors such as the question whether the Geriatric interventions were applicable in non-university settings or other geographic locations, such as rural and tribal areas.

While recognizing these caveats, the Geriatric content experts and work group discovered that best practices in Geriatrics could be described in four major categories.

These categories were dubbed the Geriatric 4Ms and included:

• What matters.
• Medications.
• Mentation.
• Mobility.

Our Canadian friends were quick to revise the nomenclature and came up with the term “Geriatric 5Ms” by adding a fifth “M” called Medical Complexity. While the 4M framework sounds simple enough, its consistent application has proven to be quite the challenge for health care systems, especially those hospitals and clinics that do not have Geriatric specialists.
Under the aegis of Age Friendly Health Care, the Geriatric 4Ms are to be practiced each time a health care provider meets an older adult in the clinic setting, whether that setting is in the hospital, clinic or skilled nursing facility. Each of the 4Ms has an evidenced-based “assessment” associated with it. The health care provider either interviews the older adult patient or conducts a quick screening test to complete each 4M assessment.

For example, the provider may ask the patient whether they completed their advance care directives when they address the 4M of "What Matters." On the other hand, the health care provider may conduct a special test for gait and balance, thus providing information about the 4M of mobility. Through a combination of interview questions and performance-based tests, the health care provider can consider various action plans to address issues unearthed by the 4M assessments.

If your health care provider is not routinely practicing Age Friendly Health Care and the 4Ms, you still can do a self assessment of your own 4Ms and share this information with your health care provider.

The UND Department of Geriatrics has self-assessment forms and they can be obtained by contacting dakotageriatrics@und.edu. Additional information about the 4Ms — such as videos and power point slides — are available on the Dakota Geriatrics website, www.dakotageriatrics.org.

Following this article will be additional reports and a deeper dive into the elements of the 4Ms that can lead to healthier lifespans. Health care systems are eligible for Age Friendly Health Care certification by enrolling in the program through the Institute for Healthcare Improvement. UND Geriatrics provides no-fee consultations to health care programs wishing to become certified as an Age Friendly Healthcare.

Here in Grand Forks, Home Therapy Solutions became one of the first health care programs in North Dakota to be recognized by the Institute for Healthcare Improvement as a level II Age Friendly Health Care program.

Dr. Donald Jurivich is professor and chairman of Geriatrics at the UND School of Medicine and Health Sciences.  He holds the endowed chair established by Eva Gilbertson, M.D., who was the first woman graduate of UND Medical School.  Jurivich is the principal investigator for the HRSA funded Dakota Geriatrics Workforce Enhancement Project that supports Age Friendly and Dementia Friendly Health Care.  Any opinions expressed in this article are strictly those of the author and do not reflect the opinion of UND or HRSA.