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LEARNING OBJECTIVES

Learning Objectives

  • Conceptualize the ideal model of palliative care provision for the aging population facing multimorbidity and progressive functional impairment across care settings.

  • Identify existing deficiencies and barriers to the adequate delivery of palliative care for older adults across the care continuum.

  • Illustrate how effective collaboration between geriatrics and palliative care services with integration of palliative care interventions into existing models of care can help bridge these gaps.

Key Clinical Points

  1. The palliative care needs of older adults differ from younger populations due to differences in illness trajectories, treatment preferences, and patterns of health care utilization.

  2. Although the highest proportion of palliative care needs for older adults exists in the community setting, access to palliative care is concentrated in acute care settings and through hospice utilization.

  3. Older adults often experience advancing frailty and multiple complex conditions, necessitating an integrated approach between geriatrics and palliative care specialties to meet the needs of this population across their trajectory of functional decline and increasing needs for care and support.

INTRODUCTION

Consider Mrs. M, an 85-year old woman with congestive heart failure, mild cognitive impairment, and multijoint osteoarthritis, who lives alone in a second-floor, walk-up apartment. Mrs. M retired from her part-time secretarial work at the age of 70 to care for her husband with Lewy body dementia and has been widowed for the past 5 years. Mrs. M recently agreed to try ambulating with a walker after her third trip to the emergency room for falls but frequently forgets to use it. Her daughter, an only child, lives in the same city and helps her mother shop and clean. In the past, she accompanied her mother to medical appointments but has been unable to do so regularly in the past 2 years due to her work schedule and helping care for her grandchildren. Although Mrs. M never missed medical appointments in the past, she now has “no-showed” to most visits including for follow-up after being evaluated in the emergency room. Her daughter receives a call from a concerned neighbor who reports that her mother only rarely comes out of her apartment, and when she does, seems confused and unsteady. Her daughter has had similar concerns, and additionally worries that her mom appears to be in pain most days, depressed, and losing weight. She takes a day off from work to bring her mom to see her primary care doctor; but, prior to the appointment, she gets a call from the emergency room that her mother fell again resulting in a broken hip requiring surgery. Mrs. M’s postoperative course is complicated by delirium and pain. She is transferred to a skilled nursing facility for rehabilitation where the team raises the concern that Mrs. M now has moderate dementia, frailty, and significant gait impairment. They recommend a more supportive living environment. Mrs. M moves in with her daughter and enrolls in a home-based primary ...

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