Driving to her next housecall, a family physician* sees which house contains her new patients—a 1950s bungalow set among perfectly maintained rancher homes with sparkling renovations. The house has peeling paint, missing roof shingles, and a disheveled front yard. Picking her way up the broken sidewalk, she notices the curled, wavy outer layer of the plywood front door and the rubber-backed curtains, clothespinned shut, on all the front windows.
Ethel eventually answers the door. She is a game, determined, upbeat 70-year-old; her clothes are not clean and are a bit ragged. She does not appear to remember the appointment. Ethel shows the doctor to her husband’s room. Bill, a 75-year-old military Veteran, lies on a single bed in a bathrobe watching television. He is wearing nasal prongs from an oxygen concentrator. Parkinson disease, osteoarthritis, and chronic obstructive pulmonary disease keep Bill nearly confined to a chair. Clearly, Ethel is the legs and Bill is the brains. Bill remembers everything, including his Korean War service. Ethel is unable to remember much of anything (for which she takes a medication that appears to have made no difference), but has no other health problems. Ethel and Bill fear that they are wearing out their family caregivers. He is interested in some “help from the government” to maintain their home, because he realizes that he and his wife are barely able to remain independent. Bill scores 6 out of 7 (moderately frail) on the Canadian Study on Health and Aging frailty scale.1 The family physician develops a treatment plan for Bill’s pain and stiffness, and consults provincial home care. She calls Veterans Affairs Canada (VAC) with Bill’s permission, and he is found to be eligible for the Veterans Independence Program (VIP).
Maintaining independence at home
Frail elderly people generally value independence and wish to avoid institutions. Frailty is a useful term with no widely accepted definition.2 There is agreement that it has 3 qualities: vulnerability, precarious balance between demands and coping, and impending or current disability.3,4
Much geriatric care is directed toward reducing disability by maximizing independence.3 Lack of independence is a fundamental characteristic of frailty.3,4 Dependence on others and the extent of independence loss are strong predictors of institutionalization.4 Illness, especially chronic illness, results in loss of capability such that frail elderly need help with activities of daily living (ADLs) (Box 1).
Activities of daily living (ADLs)
Examples of basic ADLs
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Feeding
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Bathing
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Toileting
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Dressing
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Grooming
Examples of instrumental ADLs
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Housekeeping
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Meal preparation
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Errands
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Banking
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Laundry
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Grounds maintenance
There is evidence that supported care at home might be more cost-effective than institutional care.5–7 Interventions supporting ADLs reduce dependence, reduce cost, address elderly people’s desires and needs, support caregivers, and tend to be effective in preventing institutionalization.5,6 This article outlines strategies for helping frail elderly people remain independent and explains how family physicians can work with VAC to support aging Veterans at home.
Risk factors for loss of independence
Success in avoiding hospitalization is associated with access to support services and home visits by professionals, including physicians. Identifying frail elderly is key to mitigating loss of independence.4,8–11 Previous hospital admission, substance abuse, morbidity, care-giver burden, depression, weight loss, poor mobility, cognitive impairment, and proximity to hospital are all associated with greater likelihood of hospital admission. The best predictors of admission to nursing homes are cognitive impairment, lower-extremity dysfunction, and absent or dysfunctional caregivers.
Strategies to support independence
Family physicians should consider the following strategies when providing care to elderly people to help them continue living at home by improving independence and minimizing unnecessary hospitalization.
1. Make home visits
In addition to providing information about living circumstances, physician home visits improve the likelihood that people who need medical evaluation and treatment will get it in a timely way. Traveling to a physician’s office might be difficult for people with mild frailty, extremely difficult for people with moderate frailty, and nearly impossible when someone is confined to bed. Admission to nursing homes might occur because medical care is unavailable at home. Trips to the hospital might occur when there is no access to assessment at home during crises.
2. Make sure medical care is available 24 hours a day, 7 days a week
Crises that trigger transfer to hospital do not respect office hours. Crises among frail elderly people are often crises of function, resulting from relatively unimportant changes in health status. Physicians making home visits can make tentative diagnoses, start empiric treatment, and plan for follow-up, in many cases preventing unnecessary trips to hospital. Let patients and family caregivers know that necessary visits are available outside office hours so they do not develop the habit of calling 911.
3. Connect and work with other disciplines
Although availability differs among communities, resources such as home care nursing, home support, and home rehabilitation are often available. Nonmedical professionals can provide physicians with valuable information about patients and can encourage patient activity to maintain function. Collaboration is more likely to ensure that information will be shared, treatment strategies will be understood, and advance directives will be developed. Informal team-building is critical in primary care geriatrics.
4. Support the supporters
Caregiver burnout is a common cause of unnecessary transfer to hospital or nursing home.4,12 Keeping caregivers informed, respecting their priorities, encouraging respite, avoiding onerous interventions, and supporting caregiver health can make all the difference.
5. Encourage adequate and flexible home support of ADLs
Independence can fluctuate with small changes in health status. If the people doing the shopping, banking, food preparation, transportation, home cleaning, and gardening are only available on a fixed basis, a sudden change in independence might overwhelm an otherwise stable home support situation.
6. Organize and respect reasonable, practical advance directives
Directives do not need to be formal. Some elderly people want to go to the hospital, but most are happy to authorize medical care at home, despite its shortcomings. It is important to identify a substitute decision maker who can be contacted if the patient suffers mental incapacity. If a health care team member knows that the elderly patient favours comfort over prolonging life, wants to remain at home, and trusts her daughter, decision making is much easier.
Assisting patients to access support services to maintain independence and “age in place” is an important challenge for family physicians, requiring considerable coordination among an extended team. Coordinating patients, families, and various professionals to manage physical and mental health problems, support care-givers, and support ADLs requires teamwork.
Veterans Affairs Canada
Veterans Affairs Canada can collaborate with family physicians to meet the needs of Veterans who are eligible for VAC services. Veterans Affairs Canada offers a range of services and benefits to qualified Veterans, Canadian Forces members, serving and discharged members of the Royal Canadian Mounted Police, certain civilians, and the families of such individuals.13
To deliver services and benefits, VAC follows a client-centred service approach. District office area counselors provide case management to coordinate services for clients when required, in consultation with interdisciplinary client service teams. This includes screening clients at all points of entry to detect problems or life changes that might otherwise be overlooked; performing needs assessments as required, including nursing, occupational therapy, and case management assessments; and providing clients with information about VAC services and benefits.13
Veterans Independence Program
Together with other VAC programs, the VIP provides continuing care support services to help eligible young and elderly clients remain healthy and independent in their own homes or communities.14 When clients qualify for the VIP, the services they receive depend on eligibility, circumstances, and health needs. Services can include grounds maintenance, like lawn mowing or snow shoveling; housekeeping support, like doing the laundry or cleaning the home; personal care services, like assistance with bathing, dressing, and eating; access to nutrition or food services (eg, Meals on Wheels); home adaptations; caregiver respite; treatment benefits; and services provided by health professionals.15
The VIP was a pioneering national long-term continuing care program when it was established in 1981.14 The program anticipated key barriers later identified by Inouye et al16 to improving quality of life for seniors living at home. Established at the time largely on the strength of expert opinion, new research evidence supports the clinical and economic effectiveness of VAC’s VIP support for frail elderly at home.5,6
To best meet the needs of eligible clients, VAC services such as the VIP complement but do not replace other federal, provincial, or municipal programs. If a patient is not eligible for the VIP, VAC staff might be able to put the patient or family physician in touch with other home support programs and services in provinces and communities across Canada.
Veterans Affairs Canada welcomes family physician collaboration in helping Veteran clients to continue living at home. Veterans Affairs Canada might request information from a client’s family physician to help determine eligibility and identify service needs. Family physicians can contact area counselors or client service agents at the district offices in their areas when the care of their Veteran patients requires coordination in order for those patients to remain at home.
Resources
Resources for physicians
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Veterans Affairs Canada (VAC) website: www.vac-acc.gc.ca
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Senior District Medical Officer or Area Counselor in a VAC District Office: Telephone the VAC National Contact Centre at 866 522–2122 (English) or 866 522–2022 (French). If your patient is a VAC client, it helps to provide the patient’s VAC client number
Resources for Veterans
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VAC telephone: 866 522–2122 (English)
866 522–2022 (French)
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VAC website: www.vac.gc.ca; click on “Veterans Services” and then “Veterans Independence Program”
Notes
BOTTOM LINE
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Frail elderly people are vulnerable because they must finely balance the demands of independent life with the ability to cope.
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Physician home visits improve the ability of frail elderly people to remain at home.
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Veterans Affairs Canada can collaborate with family physicians to help frail elderly clients remain independent at home.
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Veterans Affairs Canada’s Veterans Independence Program allows eligible clients to remain at home by providing essential supports for activities of daily living.
POINTS SAILLANTS
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Les personnes âgées de santé précaire sont vulnérables parce qu’elles doivent être en mesure d’établir un équilibre judicieux entre leur capacité de vivre de façon autonome et leur capacité de s’adapter.
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Des visites à domicile effectuées par des médecins améliorent l’aptitude des personnes âgées de santé précaire à demeurer chez elles.
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Anciens Combattants Canada peut collaborer avec les médecins de famille en vue d’aider les clients âgés de santé précaire à demeurer autonomes chez eux.
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Le Programme pour l’autonomie des anciens combattants d’Anciens Combattants Canada permet aux anciens combattants admissibles de demeurer chez eux en leur fournissant une aide essentielle pour les activités de la vie quotidienne.
Footnotes
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Competing interests
None declared
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The opinions expressed are those of the authors and not necessarily those of Veterans Affairs Canada.
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Veteran Health Files is a quarterly series in Canadian Family Physician coordinated by Veterans Affairs Canada. The series explores situations experienced by family physicians caring for Veterans of military service. For further information on this series, contact Dr Jim Thompson, Veterans Affairs Canada Head Office, Charlottetown, PEI; e-mail research-recherche{at}vac-acc.gc.ca
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↵* The case presented is fictitious.
- Copyright© the College of Family Physicians of Canada
