Older Adults

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In 2013, 23% of dually eligible beneficiaries aged 65 and older had Alzheimer’s Disease and Related Dementias (ADRD).⁴ The risk of dKloping ADRD increases with age, and the prevalence of dementia is the highest among those 85 and older.⁵ Common causes of dementia include vascular disease and Lewy body dementia, with Alzheimer’s disease being the most common cause of late-life progressive cognitive decline. Primary care providers can, in most cases, accurately assess cognitive changes. However, the care of these individuals presents unique challenges for health plans and providers.

⁴ Medicare Payment Advisory Commission and the Medicaid and CHIP Payment and Access Commission. (2018). Data Book. Beneficiaries Dually Eligible for Medicare and Medicaid. Retrieved from: http://medpac.gov/docs/default-source/data-book/jan18_medpac_macpac_dualsdatabook_sec.pdf?sfvrsn=0. Note: This figure was identified using fee-for-service claims data.

⁵ Alzheimer’s Association. (2017). Alzheimer’s Disease Facts and Figures. Alzheimers Dement,13:325-373.

Care transitions are defined as moves from one provider or setting to another as conditions or care needs change.⁶ A change in care plan usually accompanies this transition. This transition can take place within provider organizations (e.g., change in home care team), between settings (e.g., hospital and home), and across health states (e.g., curative and palliative care). High-quality transitional care is particularly important for older adults as well as for their family and friend caregivers. Evidence demonstrates that older adults may be particularly vulnerable to breakdowns in care due to frequent moves within health care settings. Poor care transitions from hospital to home are linked to adverse events, low satisfaction with care, and high rehospitalization rates.⁷

⁶ Coleman, E. A., Boult, C., & American Geriatrics Society Health Care Systems Committee (2003). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51(4), 556–557. https://doi.org/10.1046/j.1532-5415.2003.51186.x.

⁷ Naylor, M., & Keating, S. A. (2008). Transitional care. The American journal of nursing, 108(9 Suppl), 58–63. https://doi.org/10.1097/01.NAJ.0000336420.34946.3a.

Approximately two out of five adults over the age of 65 have a disability, and older adults with major chronic diseases have higher rates of disability.⁸,⁹ However, current models of care delivery are frequently not suited to address the functional limitations of older adults. Older adults with disability may face barriers to accessing quality health care. Disability-competent care is a person-centered approach that recognizes and treats each individual as a whole person. It responds to an individual’s physical and clinical needs while considering their emotional, social, intellectual, and spiritual needs.

⁸ Okoro, C. A., Hollis, N. D., Cyrus, A. C., & Griffin-Blake, S. (2018). Prevalence of disabilities and health care access by disability status and type among adults—United States, 2016. Morbidity and Mortality Weekly Report, 67(32), 882.

⁹ Fong, J. H. (2019). Disability incidence and functional decline among older adults with major chronic diseases. BMC geriatrics, 19(1), 323.

Yearly, up to one-third of adults over the age of 65 living at home experience a fall. Almost two-thirds of older adults who suffer a fall will fall again within the same year.¹⁰ Older adults with chronic conditions are at higher risk of falls,¹¹ making older adults dually eligible for Medicare and Medicaid particularly vulnerable.¹² Falls and their related complications are the leading cause of both fatal and non-fatal injuries among adults over the age of 65, particularly brain injuries.¹³,¹⁴

¹⁰ Barton, A. (2009). Patient safety and quality: An evidence‐based handbook for nurses. Aorn Journal, 90(4), 601-602.

¹¹ Centers for Disease Control and Prevention National Center for Injury Prevention and Control. (2017). Fact sheet risk factors for falls. Retrieved from https://www.cdc.gov/steadi/pdf/STEADI-FactSheet-RiskFactors-508.pdf.

¹² Centers for Medicare & Medicaid Services. (2014). Physical and mental health condition prevalence and comorbidity among fee-for-service medicare-medicaid enrollees. Retrieved from https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/Dual_Condition_Prevalence_Comorbidity_2014.pdf.

¹³ Barton, A. (2009). Patient safety and quality: An evidence‐based handbook for nurses. Aorn Journal, 90(4), 601-602.

¹⁴ Aging & Health A to Z. (n.d.). Retrieved from https://www.healthinaging.org/a-z-topic/falls-prevention.

More than half of adults over the age of 65 report taking four or more prescription medications to address complex health needs.¹⁵ Dually eligible beneficiaries tend to have higher Medicare Part D prescription drug costs than Medicare-only beneficiaries.¹⁶ Inappropriate use of multiple medications can lead to an increased risk of adverse drug reactions, particularly among older adults.¹⁷ Therefore, it is important to address medication management, medication misuse, and adverse drug effects among dually eligible beneficiaries.

¹⁵ Kirzinger, A., Neuman, T., Cubanski, J., Brodie, M. (2019). Data Note: Prescription Drugs and Older Adults. Retrieved from https://www.kff.org/health-reform/issue-brief/data-note-prescription-drugs-and-older-adults/.

¹⁶ Medicare Payment Advisory Commission (2018). Medicare fee-for-service and managed care enrollment, CY 2013. https://www.macpac.gov/wp-content/uploads/2017/01/Jan18_MedPAC_MACPAC_DualsDataBook.pdf#page=57.

¹⁷ Mangoni, A. A., & Jarmuzewska, E. A. (2020). Medication management in older adults. Clinics in Integrated Care, 1, 100002.

Older adults in the advanced stage of an illness or nearing the end of life may experience physical and emotional distress, fragmented care delivery, and barriers to effective communication. Family caregivers and other individuals providing support may also experience related challenges.¹⁸ In particular, dually eligible older adults are more likely to experience frequent hospitalizations and facility-based long-term care at the end of life than other beneficiary groups.¹⁹ Palliative care provides comfort and relief to individuals with chronic or terminal illnesses and their caregivers. It addresses physical, spiritual, social, and emotional needs; coordinates care delivery; improves quality of life; optimizes function; and assists with decision-making for individuals living with a serious illness and their families. Palliative care may also reduce hospital readmissions and facility-based long-term care by offering community-based services tailored to the individual.²⁰

¹⁸ Morrison, R. S. (2013). Research priorities in geriatric palliative care: An introduction to a new series. Journal of palliative medicine, 16(7), 726-729.

¹⁹ Bynum, J. P., Austin, A., Carmichael, D., & Meara, E. (2017). High-cost dual eligibles’ service use demonstrates the need for supportive and palliative models of care. Health Affairs, 36(7), 1309-1317.

²⁰ Ibid.

Parkinson’s disease (PD) is a progressive degenerative disorder of the central nervous system that mainly affects movement. Early in the disease course, the most obvious symptoms are movement-related, including shaking, rigidity, slowness of movement, difficulty walking, and gait. Thinking and behavioral problems may arise later, with dementia commonly occurring in the disease's advanced stages. Depression is the most common psychiatric symptom associated with PD. Other symptoms may include sensory, sleep, and emotional problems. The incidence and prevalence of PD increase with age. Data suggests that PD is more prevalent among dually eligible individuals – 3% of dually eligible beneficiaries have PD compared to 1.6% of other Medicare beneficiaries.²¹

²¹ Kasper, J., O’Malley Watts, M., & Lyons, B. (2010). Chronic Disease and Co‐Morbidity Among Dual Eligibles: Implications for Patterns of Medicaid and Medicare Service Use and Spending. Retrieved from https://www.kff.org/wp-content/uploads/2013/01/8081.pdf.

Person-centered care is consistent with individuals' values, needs, and desires and is achieved when providers and health plans involve individuals in healthcare discussions and decisions.²² Individualized person-centered planning and collaborative partnerships are shown to improve the quality and accessibility of care for older dually eligible beneficiaries.²³ The strengths-based focus of person-centered approaches is especially helpful for managing chronic conditions and identifying long-term support needs.

²² American Geriatrics Society Expert Panel on Person‐Centered Care, Brummel‐Smith, K., Butler, D., Frieder, M., Gibbs, N., Henry, M., ... & Saliba, D. (2016). Person‐centered care: A definition and essential elements. Journal of the American Geriatrics Society, 64(1), 15-18.

²³ Office of the Assistant Secretary for Planning and Evaluation. (2016). Report to Congress: Social Risk Factors and Performance under Medicare’s Value Based Purchasing Programs, 61-65.

Substance use disorders (SUD) are an emerging public health concern for the growing population of older adults. Some older adults may take substances as a coping mechanism for big life changes such as declining health, grief and loss, retirement, or a change in living situation. As of 2018, nearly 1 million adults aged 65 and older live with a SUD. Furthermore, older adults may be more susceptible to the effects of different substances, as their bodies cannot absorb and break down drugs and alcohol as easily as when they are younger. ²⁴ Older adults with SUD face unique challenges in receiving appropriate care. Historically, they are less likely to be screened for SUD.²⁵ Older adults with SUD benefit from treatment approaches that are age and generationally appropriate and designed to address common co-occurring conditions, mobility limitations, and social factors.²⁶

²⁴ National Institute on Drug Abuse. (2020). Substance Use in Older Adults DrugFacts. Retrieved from https://www.drugabuse.gov/publications/substance-use-in-older-adults-drugfacts.

²⁵ Han, B. H., & Moore, A. A. (2018). Prevention and Screening of Unhealthy Substance Use by Older Adults. Clinics in geriatric medicine, 34(1), 117–129. https://doi.org/10.1016/j.cger.2017.08.005.

²⁶ Kuehn, B. (2016). Substance Use Treatment for Older Adults. Retrieved from https://www.samhsa.gov/homelessness-programs-resources/hpr-resources/substance-use-treatment-older-adults.