Optimizing better health and care for older adults and their family caregivers: A review of geriatric approaches

Abstract

Addressing the care needs, health, and well-being of family caregivers (e.g., spouses, partners, siblings, friends, neighbors, kin, and others) in the United States is a public health priority. According to a national survey, 24.4% of adults aged 45–64 and 18.8% of adults aged 65 and older provide care or assistance to a family or friend.1 One-third of these caregivers provide care for at least 20 h per week and most have provided care for 2 years or longer. Reinhard et al. reported that the estimated economic value of caregiving increased from $470 to $600 billion from 2017 to 2021.2 Survey data reveal an increase in the number of caregivers over time and demand for caregiver labor and the value of their services is estimated to grow exponentially as the population ages.1 Compared with non-caregivers, family caregivers face substantial threats to their health and well-being. Caregivers experience increased risk for depression and anxiety, poor physical health, and compromised immune function.3 However, there are also benefits and positive aspects of caregiving, such as a sense of fulfillment, expansion of social networks, and relationship gains with the care recipient.4 As caregivers strive to provide optimal care to their family members or friends, they often encounter barriers to inclusion within healthcare processes which can compromise patient health and, in turn, the caregiver's health and well-being. “Caregivers experience increased risk for depression and anxiety, poor physical health, and compromised immune function. However, there are also benefits and positive aspects of caregiving, such as a sense of fulfillment, expansion of social networks, and relationship gains.” Too frequently, caregivers and the essential assistance they provide go unrecognized by clinicians and healthcare systems. Previous studies have found that several factors (including a lack of access to appropriate information via electronic health records and patient portals,5 limited clinician time and communication, insufficient clinic and hospital resource availability, and low health and digital literacy) negatively impact caregivers' ability to provide care and assistance.6 To rectify this problem, the federal government released the first-ever National Strategy to Support Family Caregivers, and the Department of Health and Human Services7, 8 distributed $20 million to begin implementation of the strategy. Two major goals of this policy are to build partnerships and engagement with caregivers and to strengthen services and supports for caregivers. However, healthcare systems and clinicians are frequently challenged by competing extrinsic and intrinsic demands for providing safe, effective, and efficient care. Drawing attention to the evolution of various geriatric care approaches may help healthcare systems and clinicians conceptualize strategies for achieving these goals. See Figure 1 for a summary of geriatric care approaches across time. Coined by prominent psychologist Carl Rogers in the mid-twentieth century, the person-centered care approach places the focus of intervention on problems relevant to the patient, rather than on a specific diagnosis, and emphasizes satisfaction with care as a key outcome.9, 10 Within a person-centered care approach, clinicians attempt to work collaboratively and align their service delivery with the goals, values, and needs of the patient.11 This approach concentrates on the patient to achieve optimal health and service utilization outcomes. Although most healthcare systems aim to execute person-centered care, this approach places less value on interpersonal factors (e.g., relationships and social network of the patient), which can limit the ability to achieve goal-concordant care. As the population of older adults enjoys longer lifespans, but not necessarily longer health spans (i.e. older adults live longer with disability), health systems and researchers have begun to recognize the critical influence of interpersonal factors on patient health and experiences. Interpersonal factors include the relationship between patients and clinicians.12 In the early 1990s, relationship-centered care was conceived to create a more integrated view of health care13 where “…people form relationships…to maintain their functioning and grow in the face of changes within themselves and their environments” (p. 24). Under relationship-centered care, clinicians focus on building and maintaining relationships to favorably influence patient health and experiences.14 Although this approach emphasizes the reciprocal influence of the patient and clinician relationship, it minimizes the role of caregivers in the planning and delivery of services and supports. Considering the key importance of caregivers for older patients, the next evolution in care approaches is person (or patient)-and family-centered care.15 Key elements of this approach include respecting the perspectives and choices of the patient and family, integrating caregivers as partners in care, assessing and addressing both the patient and caregiver support needs and promoting shared decision-making and communication across care settings. Caregiver-centered care16 extends beyond person-and family-centered care by recognizing and treating the caregiver's health and well-being. This approach is grounded in decades of caregiving research that has revealed unmet needs of the caregiver, combining the goal of supporting the caregiver while also consistently and meaningfully involving them in patient care. With current policy changes embracing this approach to optimize not only patient outcomes but caregiver outcomes as well, caregiver-centered care provides a framework for clinicians to help caregivers care for themselves. Mr. X is a 72-year-old male with a history of atrial fibrillation, hypertension, and Type 2 diabetes who was admitted to the hospital following a fall at home. He was diagnosed with a urinary tract infection and was prescribed an antibiotic, improving his strength and healing of minor injuries. However, his nurse is concerned that his functional status is below his baseline and asks the hospitalist to place a therapy consult. Before his hospitalization, Mr. X was living independently with his wife who receives weekly outpatient infusion therapy. Mr. X typically provides transportation to these appointments as his wife no longer drives. In this example, there are a number of ways that the clinical team could potentially integrate person-centered, relationship-centered, person- and family-centered, or caregiver-centered approaches into their evaluation and treatment plan. We stress again that these are not mutually exclusive approaches. Building on decades of work to assure safety and quality of care, geriatric approaches to care continue to evolve. These approaches demonstrate the evolution of geriatric care and provide a roadmap for moving forward. Over the next few decades, an increasing amount of research, public, and policy attention will be devoted to preparing the healthcare workforce to provide optimal care to patients and families and refining best practices to identify and address unmet needs for caregivers. To provide the highest quality of care possible, healthcare systems and clinicians should immediately initiate the adoption of these innovations in caregiving education, practice, and research. Beth Fields took the lead drafting the article and conceptualizing the ideas. Blair P. Golden, Kate Perepezko, Mary Wyman, and Joan M. Griffin provided guidance in conception of ideas and supported drafting the article. We have no known conflicts of interest to disclose. No sponsor had a role in our commentary.

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