It was a lazy Sunday afternoon when I heard a knock at the door. My neighbor stood there, asking us for help after finding an elderly woman had fallen in her driveway across the street. My husband and I ran over to find her lying on the ground next to her rollator. She cried out in pain as we tried to move her and said she had hit her head on the concrete. She did not want us to call 911 since her husband would return shortly, but she could not get up. The neighbor, my husband, and I sat with the woman until the paramedics came to take her to the hospital. We never saw her again. A few weeks later, her husband posted an estate sale on the neighborhood Facebook group. We learned they were moving to live with their son.
I had seen my elderly neighbor before this incident. Shortly after we moved in, we found her sitting on the grass in our front yard as we sat down to eat dinner. We walked outside to help her up. She didn’t cry out in pain that time, but she asked for a ride to the bank. Another time, she came to our door at 9:00 p.m. asking for a ride to the pharmacy. These incidents — and her eventual fall — highlight the critical gaps in the elderly care system.
As a doctor, this incident stirred up a long-dormant frustration, one I had felt during residency when admitting older adults to the hospital for observation. These two-to-three day stays often felt like temporary fixes for deeply rooted problems affecting geriatric patients and their families. While in the hospital, many of these patients developed delirium from disruptions to their circadian rhythm due to frequent vital sign checks and bed alarms. Some fell while in the hospital – an unfamiliar environment with slick floors and confining bed rails. I quickly understood that hospital admissions were not the solution to addressing the broader gaps in care for older adults.
The health care system’s emphasis on crisis-driven care instead of prevention creates a domino effect of challenges. ER visits and ICU decisions force difficult conversations with families about their loved ones when they are at their most vulnerable. These crises strain adult children and spouses emotionally, physically, and financially. Older adult patients are discharged home, but their families are often unprepared to provide the necessary care, leading to another 911 call. The cycle of repeat admissions and ER visits misses key opportunities for preventative care and continuity in outpatient settings.
By focusing on prevention, continuity, and support, we can address the root causes of these crises and improve the quality of life for our aging population. My proposed areas of reform include multiple discussions of end-of-life care involving families in the primary care setting to establish clear goals of aging and dying for the patient, integration of community organizations, dementia prevention strategies, and products designed and prescribed by doctors for the geriatric population.
Turning Values Into Action: Clearer Medical Preferences for End-of-Life Care
Advanced care planning often includes complex topics that can be difficult to comprehend and may require multiple conversations to address comprehensively. Elderly patients frequently express preferences in vague terms, such as, “I don’t want to be dependent on a machine,” or, “If there’s no way to save me, don’t try.” While these statements reflect their values, they are too imprecise to translate into actionable medical orders. To address this, physicians must develop patient-centered preferences during these discussions so that they are actionable during a medical emergency. Adult children or designated health care powers of attorney should be actively involved in these discussions.
The Power of Family Conversations: A Unified Front During Aging
By involving family members in conversations about end-of-life care, clinicians can ensure a patient's values and wishes are understood, documented, and respected. This allows for complex and difficult conversations to take place in the outpatient setting, which tends to be calmer, rather than in an emergency room or intensive care unit. These conversations also focus on the values and goals of the patient. Families can learn what is important to the patient – maintaining independence, spending time with grandchildren, living near close friends, or attending church every Sunday. These specific, functional goals can help lead the direction of the treatment plan, which depends heavily on community support outside of the doctor’s office.
Community Support in Action
Relationships between physicians and community organizations are needed to support an aging population, particularly related to social determinants of health. For example, where I live, the Athens Community Council on Aging (ACCA) in Athens, Georgia offers a range of programs, including Meals on Wheels, dementia resources, a center providing a variety of wellness, creative, social, and travel offerings, and a senior employment program. With a recent AARP grant, the ACCA plans to work with both local health care systems to assess the community’s needs as seen by health care professionals, educate these professionals on the resources offered by ACCA, and create a system for sending and receiving referrals.
The organization wants to close the loop by sending back a report to the health care team on what the patient achieved or received based on the referral. Physicians should do their best to be aware of and partner with local elder support organizations like this one to minimize repeated ER visits and decomposition of independence in their elderly patients.
Dementia Prevention: Strategies Besides a Pill
Dementia plays a large role in older adults losing autonomy and depending on caregivers, and doctors can help patients develop strategies to build up cognitive reserves. The Whitehall II Cohort Study demonstrated the protective effect of social contact at age 60 lowering the risk of dementia. The Kungsholmen Project found dementia incidence was inversely related to social activities. Playing games, doing puzzles, and physical activity can lower dementia risk for older adults. Limiting alcohol consumption, maintaining a healthy weight, and avoiding smoking can help with overall brain health. Doctors can also address any hearing issues associated with an increased risk of developing dementia. A visit to the audiologist and hearing aid can be vital to avoid memory loss.
The Power of a DME Prescription: Safe and Stylish
Proactive care can extend into our prescriptions for durable medical equipment. DME can be a powerful tool to prevent falls such as rollators, grab bars, and shower chairs. Products specifically designed for older adults can be functional and visually appealing. One of my patients was ashamed to use her cane until we upgraded her to an electric blue rollator. Color and style are important features for older adults in their everyday lives, and it can make a difference to acknowledge and encourage that for patients.
Designing a Future Health Care for Aging
Families and adult children often face overwhelming responsibilities when caring for an elderly loved one. A proactive, patient-centered, and community-integrated approach is essential to achieving the best outcomes for our aging population.
How do you think physicians can enact more preventative care for elderly and aging patients? Share in the comments!
Dr. Kathleen Grant is a primary care physician in Athens, Georgia. She enjoys hiking, yoga, and playing ukulele with her husband. Interests in general internal medicine include rural populations, medical education, and cancer prevention. Dr. Grant is a 2024–2025 Doximity Op-Med Fellow.
Illustration by Diana Connolly
