|Proceedings of a Workshop—in Brief|
Advancing Diagnostic Excellence for Older Adults
Proceedings of a Workshop—in Brief
To examine the current state of the science and research opportunities for improving diagnosis in older adults within the U.S. health care system, the Board on Health Care Services of the National Academies of Sciences, Engineering, and Medicine hosted a hybrid workshop on July 21, 2022.1 The workshop highlighted unique challenges faced in achieving diagnostic excellence for older adults, opportunities and obstacles to improving diagnosis, and strategies and interventions to promote diagnostic excellence across the care continuum. This workshop was the fifth in a series on diagnostic excellence funded by the Gordon and Betty Moore Foundation, with additional funding provided for this specific workshop by The John A. Hartford Foundation.2 This Proceedings of a Workshop—in Brief highlights the presentations and discussions that occurred at the workshop.3
Daniel Yang of the Gordon and Betty Moore Foundation highlighted how the workshop on older adults takes a different approach by examining the opportunities and challenges of achieving diagnostic excellence in a specific population compared to the previous workshops that explored specific diseases. He described the Foundation’s framework of diagnostic excellence that embraces the six domains of health care quality as defined by the Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001). The diagnosis “must be safe, timely, effective, efficient, patient-centered, and equitable across populations,” he said. While all six domains are important, he noted that they can often be in tension with one another, which may require trade-offs to achieve the overall goal. Terry Fulmer of The John A. Hartford Foundation underscored the importance of recognizing that medical complexity increases as people age, which makes diagnosis even more difficult. Similarly, she said, ageist stereotypes can be a very serious pitfall in diagnostic excellence. Rani Snyder, also of The John A. Hartford Foundation, highlighted the age-friendly health system movement
1 The workshop agenda and presentations are available at https://www.nationalacademies.org/event/07-21-2022/workshop-on-advancing-diagnostic-excellence-for-older-adults (accessed August 29, 2022).
2 Past workshops in this series have explored improving diagnosis for sepsis, acute cardiovascular events, and cancer, as well as diagnostic lessons learned from the COVID-19 pandemic. More information about the workshop series is available at https://www.nationalacademies.org/our-work/advancing-diagnostic-excellence-a-workshop-series (accessed August 29, 2022).
3 This Proceedings of a Workshop—in Brief is not intended to provide a comprehensive summary of information shared during the workshop. The information summarized here reflects the knowledge and opinions of individual workshop participants and should not be seen as a consensus of the workshop participants, the planning committee, or the National Academies of Sciences, Engineering, and Medicine.
to break down siloes in all care settings to more reliably deliver evidence-based care, reduce harm, and focus on what truly matters to older people and their families. The vulnerability of older adults due to isolation, challenges related to hearing, cognition, and mobility limitations, as well as complications from medications, combined with a well-developed sense of individual identity, creates challenges in caring for this population within the health care system, and highlights the need for whole-person care, said Andrew Bindman of Kaiser Permanente.
KEY CHALLENGES AND CONSIDERATIONS FOR DIAGNOSTIC EXCELLENCE
David Reuben, professor at the University of California, Los Angeles, noted commonly cited examples of atypical medical presentations among older adults, such as those with acute myocardial infarction presenting with shortness of breath (instead of chest pain) or hyperthyroidism presenting as weight loss (instead of other common symptoms), and discussed how these types of atypical presentations contribute to difficulties in diagnosis. Reuben also said that many diseases can share common symptoms and a physiological pathway. Conversely, there are many possible causes of common symptoms such as fatigue or apathy, and many older adults such as those with cognitive impairments or hearing or vision problems may have difficulty in articulating symptoms. Additionally, he said, tests are often unavailable or inaccessible due to lack of insurance coverage. Some tests are interpreted in the context of age-adjusted normal values (e.g., D-dimer tests used to check for blood clotting problems), and age-related physiological changes may cause false positives if using normal ranges based on younger persons. Finally, he highlighted the role of attitudes contributing to the challenge of diagnostic excellence, both for clinicians who may have an implicit bias toward older adults and for patients who are resistant to being labeled by a specific diagnosis. Reuben also noted recent efforts in health care generally to make earlier diagnoses of asymptomatic diseases and the trend in labeling of “pre-disease,” even if no effective treatments exist to modify the disease trajectory. Diagnostic excellence in older adults is an “imprecise science due to patient factors that are intrinsic to aging, comorbidity, atypical presentations, inaccuracy of diagnostic tests, clinician and patient attitudes, and prioritization,” concluded Reuben.
Nicholas S. Reed, audiologist at Johns Hopkins School of Medicine, discussed assessing hearing loss as a risk factor for diagnostic errors. While imprecise terms such as “mild” or “moderate” hearing loss are used, he said, everyone has some level of hearing loss over time. Most of the loss occurs at higher frequencies, he explained, so hearing loss is a clarity issue, not a volume issue, and simply shouting at people will not help. The brain can often put things together with context and keep up with a conversation, but in unfamiliar situations—as with patient-clinician communication—it can be harder to do so, especially when situations are stressful or there is background noise. Reed also highlighted the higher rates and risks of social isolation and access barriers to health care faced by older adults with hearing loss. Although very few studies have even considered hearing loss in patient-clinician communication (Cohen et al., 2017), Reed said that a systematic review found that hearing loss was directly associated with longer time to diagnosis (Shukla et al., 2018). Looking at health care outcomes over time, he shared data comparing adults with and without hearing loss and found that over 10 years, adults with hearing loss incur $22,000 more in health care costs, even after removing hearing loss–related costs (see Figure 1) (Reed et al., 2019). Additionally, those adults spend an average of 2.5 days longer in the hospital, with a 44 percent increased risk of 30-day readmission (Reed et al., 2019). Furthermore, adults with hearing loss have a higher risk of avoiding clinicians and delaying health care visits, but do not have any changes in how they care about their own health. “It is our health care system that is the barrier for older adults to seek care,” he said, “We lack sustainable accommodation programs for hearing loss.” Reed emphasized technological tools (e.g., speech-to-text software, handheld devices), environmental modifications (e.g., removing background noise, improving room lighting), and intentional training in communication for clinicians (e.g., speaking more slowly and at a lower frequency, allowing for visualization of the mouth when possible) to address hearing loss.
Beverly Canin, co-chair at SCOREboard Patient Advocate Board, said that she has seen progress toward improvement in diagnosis of older adults but there is still a long way to go to achieve excellence in care. She said the hardest part of being a patient is when you are treated like just a number or a body part. This is further exacerbated in older adults, who often already feel marginalized. She highlighted the difference between focusing on the disease itself and focusing on the patient. Patients often report that clinicians are interested in symptoms and clinical data instead of their story, she said, but studies have shown that more than 80 percent of diagnoses can be made just by listening (Wen and Kosowsky, 2014). She also said a study found that it takes a clinician an average of 18 seconds to interrupt a patient as they are describing symptoms (Beckman and Frankel, 1984). Time constraints and the use of electronic medical records can hinder patient-clinician interactions even further, potentially promoting more frequent interruptions (Singh Ospina et al., 2019). While these are issues faced by all patients, they are amplified for older adults, said Canin. Unless clinicians consider the whole patient and listen to their story, she said, clinicians will be unable to refer them to the supportive services that may assist in addressing their concerns. While clinicians need to make a conscious effort to listen instead of talking during visits, she also encouraged patients to tell their whole story, write down a timeline of symptoms and medical history, and foster communication among all clinicians to support a team approach.
Speakers discussed opportunities to focus diagnosis on health issues of importance to the patient, and what diagnostic excellence means to older adults. The first obligation of clinicians is to address patients’ symptoms and concerns, said Reuben, but secondly, “we should be trying to help them maintain as high a state of functioning as possible.” Canin reiterated the importance of effective communication, which includes keeping patients informed at every step of the diagnostic process and being transparent about uncertainties.
STRATEGIES TO IMPROVE DIAGNOSIS
The number of older adults with complex needs is growing quickly, said Sonja Rosen, chief of geriatrics at Cedars-Sinai, and because a large gap remains in delivering safe, effective care, older adults will be at the greatest risk for preventable harms and death. Researchers and health system leaders have refined evidence-based geriatric care models with four core features known as the 4Ms, which form the framework for an age-friendly health system (see Box 1). With this framework as a background, this section discusses shared decision making, assessing cognitive function, improving medication use and recognizing adverse drug events, and the impact of frequent and safe mobility in improving diagnosis.
Mary Tinetti, professor at Yale School of Medicine, shared a story of a 78-year-old patient presenting with fatigue, shortness of breath, urinary frequency, and pain. In addition, she explained how the context of specific social care concerns (e.g., transportation barriers, medication affordability) is an important consideration in diagnosis and shared decision making with older adults. More than 80 percent of older adults have multiple chronic conditions and variable life circumstances, she said, resulting in uncertainty and conflict. Addressing one condition can worsen another, she added. In the diagnostic process, clinicians often assume that the condition is discrete and can be managed in isolation, that there is a discrete set of symptoms, and that the diagnosis would lead to beneficial treatment with little
harm. But this is not always the case with older adults, she said. Tinetti offered a different framing of diagnostic excellence for older adults to include the recognition of specific health priorities or health outcome goals most desired by an individual and identification of various types of life factors, such as medical, psychological, environmental, and socioeconomic factors, that might impede a patient’s ability to achieve those goals. She emphasized that shared decision making needs to shift from being disease focused to being more aligned with patient priorities. For example, the 78-year-old patient who presented with multiple issues may prioritize fatigue. For her, diagnostic excellence might be more focused on identifying the issues that contribute to her fatigue and based on that information, interventions can be appropriately designed.
Sharon K. Inouye, professor at Harvard Medical School, discussed assessing cognitive function to improve diagnosis in older adults. She reviewed three leading conditions related to cognitive impairment in older adults: dementia, mild cognitive impairment, and delirium. Dementia (such as Alzheimer’s disease) is a chronic progressive deterioration of cognitive function, and 11 percent of adults age 65 and older in the United States have dementia, she reported, but 60 percent of cases are unrecognized. Mild cognitive impairment is present in 12 to 18 percent of adults over age 60, but this is also often unrecognized in over 50 percent of cases. Lastly, delirium is an acute confusional state associated with cognitive dysfunction, she explained. It can occur in up to 50 percent of hospitalized older adults and is also unrecognized approximately two-thirds of the time. Inouye pointed out that cognitive impairment of any kind can affect each stage of the diagnostic process, and patients with cognitive impairment may underreport or misreport their initial symptoms, resulting in a delay in seeking care or an accurate diagnosis. The lack of inclusion of older adults in clinical trials, especially those with cognitive impairment, may impact diagnostic testing, and appropriate referral and consultation may be affected by the lack of geriatric expertise and lack of awareness of atypical presentations. Inouye emphasized the importance of involving family members or caregivers in the communication process to ensure the patient understands the diagnosis. Once a diagnosis is made and a treatment is prescribed, she said there is a very high rate of adverse drug reactions in older adults with cognitive impairment, and multimorbidity is often not fully considered. Together, all of this adds up to very high rates of diagnostic errors and worse clinical outcomes for these populations. She suggested that cognitive assessments should be done routinely in health care settings, using the many available screening tests, such as the Montreal Cognitive Assessment test, the Mini-Cog, and Ultra-Brief Confusion Assessment Method. “Addressing cognitive function in older adults is key to achieving diagnostic excellence in this population,” concluded Inouye.
Michael Steinman, professor at the University of California, San Francisco reviewed medication use, deprescribing, and adverse drug events, and the relationship of each to diagnosis. When the cause of a patient’s symptoms is difficult to pinpoint, some clinicians will use a response to drug therapy as a form of a diagnostic test. This method may be useful, but also has downsides. For example, it falsely presumes a direct and specific effect between a specific drug and a diagnosis—but often this is not the case because it does not account for placebo effect or the natural history of disease, in which chronic illnesses may wax and wane over time. Furthermore, Steinman noted that while approximately one-third of older adults experience an adverse drug reaction each year, they may be misdiagnosed because those reactions do not always present classically as expected, and because they are often similar to signs and symptoms associated with a wide variety of conditions. Aging also amplifies the risk of misinterpreting these symptoms, he added, especially if an individual already has other conditions and is taking multiple medications. This situation can lead to prescribing cascades, which occur when one medication is prescribed and causes adverse effects, but instead of removing it, another medication is prescribed to address those new symptoms, which may lead to initiation of a third medication, and so on. To address this, he suggested smarter integration of medication data into electronic health records (EHRs), structured monitoring and follow-up when a patient starts a new medication, and enhanced awareness by clinicians and patients.
Cynthia J. Brown, chair of medicine at Louisiana State University, discussed ways to improve assessment and treatment of mobility issues in older adults. Brown reviewed various changes associated with aging, such as decreased muscle strength and more fragile skin. Once combined with bed rest and low mobility, these age-related changes can lead to adverse outcomes including falls, delirium, and pressure ulcers. Furthermore, numerous factors in the hospital environment limit mobility for older adults. Brown suggested a universal assessment of mobility issues for older adults at the start of a hospital stay, using quick, simple tests. But barriers to keeping patients mobile also exist within the hospital, such as the hospital culture and environment encouraging bed rest; patient-related factors such as illness severity and altered mental status; and treatment-related factors such as needing a urinary catheter or an intravenous therapy. Additionally, specific hospital policies may affect mobility; for example, the threat of falls (and resulting nonpayment by Medicare and other insurers) may encourage health care providers to keep patients as sedentary as possible. While these policies are well intended to keep patients safe, Brown said, this limitation of mobility contributes to unintended consequences, such as 30 percent of older adults having a decline in their ability to perform activities of daily living following a hospital stay (Loyd et al., 2020). Low mobility has also been linked to functional decline, longer length of hospital stay, and need for new nursing home placement (Brown et al., 2004). Health systems have an opportunity to reimagine how health care is delivered to improve diagnostic quality, said Brown, including the assessment and targeting of mobility.
Speakers highlighted the fundamental changes needed in the health care system to improve the diagnostic process for older adults. Tinetti reinforced the idea of talking with patients to learn what matters most to them, and then building a diagnosis from there. Steinman added that some problems are so vast and span so many areas that it will take dedicated effort to change the culture of how medicine is taught and how the health system is structured. Inouye advocated for all health professional education and training to include assessing cognition and mobility, atypical presentation in older adults, and combating ageism. Some participants also noted that many of these types of modifications for older adults would be helpful for people across the age spectrum. Barriers to implementation include the lack of resources to incorporate practices such as mobility assistance and the culture of seeking diagnoses for individual diseases. Tinetti and Steinman added that there will not be much progress in this area until the system changes how care is structured and financed.
EQUITY IN DIAGNOSIS AND STRATEGIES TO MITIGATE DISPARITIES
Charlie P. Hoy-Ellis, assistant professor at the University of Utah, described support for person-centered
diagnosis of lesbian, gay, bisexual, transgender, and queer (LGBTQ) older adults. Hoy-Ellis shared statistics showing significant differences in rates of chronic health conditions between lesbian and bisexual women and heterosexual women, as well as between gay and bisexual men and heterosexual men. Studies clearly demonstrate that LGBTQ older adults experience significant health disparities compared to their heterosexual counterparts (Fredriksen-Goldsen et al., 2017), he said. Although physical and mental health are often approached separately, Hoy-Ellis described them as interdependent. Clinicians often discuss physical and mental health conditions, and ask about health-promoting pathways, but not many will discuss allostatic load4 of chronic stressors for a person, or the various structural and individual levels of discrimination and victimization for a person (Fredriksen-Goldsen et al., 2014). From a perspective of health equity promotion, Hoy-Ellis stressed the importance of examining all of these levels and dimensions and looking at the entire context of a person’s life. Social positions over the life course determine a variety of contexts for a person, and can result in profound influences in health and well-being, he said. As an example, queer people experience stressors—acute or chronic— associated with being a minoritized population, which can be implicated in chronic health conditions such as asthma, diabetes, or depression. He said that two-thirds of LGBTQ adults over age 50 have experienced at least three instances of discrimination and victimization (Fredrikson-Goldsen et al., 2011). All of these experiences contribute to a person’s health status and can be compounded as the person ages.
Peggye Dilworth-Anderson, professor at the University of North Carolina at Chapel Hill, discussed potential ways to improve dementia diagnosis in older adults of color. She described two theoretical approaches to conceptualizing the problem. First, she described the critical constructionist view, which seeks to understand how humans interpret knowledge, or construct what they are seeing among loved ones. The second approach, the intersectionality framework, explains that who you are matters when making these interpretations, and that can give meaning to a condition such as dementia when it is co-constructed in racial and cultural contexts. This also informs whether the family and patient normalize the condition, seek a diagnosis, or even consider it a problem that requires taking action. Both approaches inform and shape the notion of timeliness of diagnosis, said Dilworth-Anderson. Minority caregivers with less formal education have been found to invoke folk beliefs into their understanding and knowledge of dementia, she noted. Dilworth-Anderson also highlighted that cultural beliefs can intersect with a sense of power and knowledge and can influence the lack of trust in the power dynamic of a system for certain racial or ethnic groups because of historical missteps, so those groups may not even seek care. Dilworth-Anderson concluded by emphasizing that improving diagnosis of dementia among older adults of color includes understanding that the perception and meaning of dementia is constructed in cultural contexts; providing diverse communities with more culturally relevant education on dementia symptoms and diagnosis; providing clinicians with training on how best to integrate cultural factors into the diagnosis of dementia; and providing additional training to researchers on the importance of the interplay between a clinical diagnosis and the culture and lived experiences of diverse racial and ethnic groups.
Sarah Szanton, dean of the Johns Hopkins School of Nursing, described consideration of aging in community-based settings to improve health equity and diagnosis for older adults. The United States has more people who receive care at home than all residents of nursing homes combined, she said. Working with people in their home to understand their concerns is a great way to shift the power dynamic, making it more convenient for patients while also giving a nuanced view to what their life is like. Szanton described assessments that are provided in the Community Aging in Place—Advancing Better Living for Elders (CAPABLE)5 program and focus on the priorities of the patient instead of the clinician or system. The assessments help to understand an older adult’s daily life
4 Allostatic load refers to the long-term wear and tear on the body and the brain and the mind due to chronic stressors throughout the lifetime.
5 CAPABLE is a “person-directed, home-based program that addresses both function and healthcare expenses. The four- to five-month program integrates services from an occupational therapist, a registered nurse, and a handy worker who work together with the older adult to set goals and direct action plans that change behaviors to improve health, independence, and safety.” See https://nursing.jhu.edu/faculty_research/research/projects/capable/ (accessed September 21, 2022).
including what food they eat, how they get around, and how they sleep as well as functional activity to improve health and independence. When talking about diagnostic excellence, Szanton said, it is important to enhance the person’s voice in their care to provide a full picture, and to improve trust, communication, and reduce barriers to access by providing home visits.
With a lens of equity and understanding, speakers discussed the importance of listening to patients and the community to learn the cultural aspects of knowledge and meaning of terms. Highlighting the trust factor for many minorities, Dilworth-Anderson said it is important to educate and train health professionals to improve health by looking at the whole person to consider social and medical factors and to consider a person’s or group’s experiences. Szanton added that a lot of progress has been made in thinking about the importance of intersections in multiple identities, and the more progress that is made into those intersections, the closer the system gets to person-centered care. Speakers also reviewed the first steps to improving diagnosis, including humility within the medical system, better understanding cultures, listening to the patient, and rethinking and retooling approaches to be more inclusive and equitable.
NEW DIAGNOSTIC TECHNOLOGIES AND INNOVATIONS
Marjorie Skubic, professor at the University of Missouri, described potential ways to improve diagnosis for older adults through in-home sensors. She discussed a framework for clinical decision support, which sends health and fall alerts to the clinical staff at a senior housing facility when certain changes have been detected. The idea behind this is that a clinician could recognize the beginning of health or functional decline for a resident and be able to offer early intervention. Residents in the facility with early alert sensors were able to stay 1.7 years longer on average at the facility than those without early alert sensors (Rantz et al., 2015). The depth sensor captures gait and falls and tracks walking speed, stride time and length, and several other parameters. If walking speed decreases by 5 centimeters per second over 1 week, there is an 86 percent probability of a fall occurring within the next 3 weeks (Phillips et al., 2016). Additionally, a noninvasive bed sensor can capture pulse, respiration, restlessness, and overall sleep patterns. Family members were also interested in home sensors for older adults in independent housing but were not always sure how to interpret the data. For future directions, she highlighted the need for a care coordination team working with older adults and family caregivers, the potential for prevention and improvement using these alerts and predictions that come from various sensors, and the decentralization of the care model from the traditional hospital setting to care in place.
Gary Weissman, assistant professor at the University of Pennsylvania, discussed the potential for using artificial intelligence (AI) and predictive analytics to promote diagnostic excellence for older adults. He said billions of dollars have been invested in developing AI tools for health care, with thousands of publications, but there are only a handful of randomized clinical trials, and not all show a benefit. Weissman emphasized that developing an AI system to identify one particular disease is likely not the right way to improve diagnostic excellence for older adults, but that is currently what the vast majority of systems aim to do. The majority of existing clinical decision support systems for older adults are rules based, he said, applying guidelines to data from an EHR. The challenges in this area are numerous and are different for older adults than other populations. For instance, there is a broad diagnostic scope for older adults, who have higher rates of comorbidity, greater complexity of needs, and variation in functional status. High-quality data also do not exist for older adults who are routinely excluded from randomized clinical trials and observational studies, he said. These challenges influence the development of clinical AI systems—from both the analytic side and the human factor side in integrating the delivery of predictive information at the bedside. Lastly, he shared a diagram (see Figure 2) emphasizing the iterative nature of the diagnostic process, taking place over time and space but also in partnership with the patient, caregiver, and clinician (Adler-Milstein et al., 2021).
Shabnam FakhrHosseini, research scientist at the Massachusetts Institute of Technology AgeLab, discussed the future of technologies for diagnostics, emphasizing that aging in place is a challenge. Older adults spend
most of their time in their homes, and most of that time they are alone, she said. She reported that the United States will need nearly one million new senior living units by 2040. She emphasized that the home can be more than a place to live; it can be a platform to engage with new technologies and enable a better life. FakhrHosseini’s work at the AgeLab is focused on building a common language for researchers within the domain of smart homes. Although there are questions about whether older adults will want to engage with that type of technology, one study in Boston found that many would want to talk with social robots about health topics (FakhrHosseini et al., 2020). Similarly, a survey found that older adults believe implementing AI in health care is beneficial, similar to results in younger generations. In conclusion, when designing age-friendly homes, FakhrHosseini shared six characteristics that were found to be important to older adults: identity,6 safety, duality,7 connection, control, and comfort (FakhrHosseini, n.d.).
This technology discussion highlighted barriers to wider adoption of AI and smart technologies in older adult populations. Weissman reiterated the lack of high-quality evidence to support the use of any system. Technologies may also exacerbate health inequities, especially when AI approaches focus on efficiencies. Skubic and FakhrHosseini agreed that cost has been a big issue with these newer technologies. When discussing alerts and sensors, Skubic highlighted the importance of having skilled people who can interpret and act on the results and stressed the need to connect patients with a care coordination team if they are in a home setting. Speakers also discussed privacy concerns with data generated by smart home tools. Skubic said older adults own the data and while there are methods of controlling access to data, policies may be needed to ensure that it happens appropriately at scale.
ENVISIONING THE FUTURE OF DIAGNOSTIC EXCELLENCE
In a final session, workshop panelists reflected on their visions for diagnostic excellence in older adults. Arlene Bierman, director of the Center for Evidence and Practice Improvement at the Agency for Healthcare Research and Quality, said, “We need a system that cares for people who are living with illness or multiple conditions in the context of their lives aligned with their goals and preferences, as opposed to our current disease focused system.” She emphasized the need to change how care is delivered by listening to patients and their stories, improving education and training in geriatric care, and improving evidence for new models of care and implementation strategies. John B. Wong, professor at Tufts Medical Center, suggested thinking of health care in the context of a complex adaptive system,8 with a first step in prioritizing what matters to the patient. This helps to clarify what the person seeks for their health and avoid ageist pitfalls, underdiagnosis, and overdiagnosis. “One of the biggest challenges in primary care is assessing whether a patient’s symptoms and potential diagnoses are acute versus chronic,” said Gordon Schiff, associate director of the Center for Patient Safety Research at Brigham and Women’s Hospital. Knowing the patient and having that continuity of care is extremely important, yet not always possible, he said (Schiff et al., 2018). Schiff suggested the need for more reliable systems for patient follow-up and monitoring.
6 Identity refers to residents looking for their home to reflect their identity, including their personal history, their memories, their family dynamics, and their aesthetic preferences (FakhrHosseini, n.d.).
Reuben had previously noted that 20 percent of primary care physicians are considering retirement in the next 5 years, which would leave a tremendous deficit in the workforce and needs to be addressed. Clara Berridge, associate professor at the University of Washington, highlighted concerns that older adults may have about being constantly monitored, reporting one’s daily activities, and the lack of data protections and security for some devices. “Ethical implementation does not follow a one-size-fits-all approach for monitoring,” she said, “it is critical that we allow for diverse preferences and enable refusal because context matters and people differ.” Finally, Jennie Chin Hansen, chair of The SCAN Foundation, discussed the importance of partnering with community organizations to help assess needs of the older adult population and provide high-quality care.
Suggestions from workshop speakers for improving diagnostic excellence in older adults are outlined in Box 2.
Adler-Milstein, J., J. H. Chen, and G. Dhaliwal. 2021. Next-generation artificial intelligence for diagnosis: From predicting diagnostic labels to “wayfinding.” Journal of the American Medical Association 326(24):2467-2468.
Beckman, H. B., and R. M. Frankel. 1984. The effect of physician behavior on the collection of data. Annals of Internal Medicine 101(5):692-696.
Brown, C. J., R. J. Friedkin, and S. K. Inouye. 2004. Prevalence and outcomes of low mobility in hospitalized older patients. Journal of the American Geriatrics Society 52(8):1263-1270.
Cohen, J. M., J. Blustein, B. E. Weinstein, H. Dischinger, S. Sherman, C. Grudzen, and J. Chodosh. 2017. Studies of physician-patient communication with older patients: How often is hearing loss considered? A systematic literature review. Journal of the American Geriatrics Society 65(8):1642-1649.
FakhrHosseini, M., C. Lee, J. Miller, T. Patskanick, and J. Coughlin. 2020. Older adults’ opinion on social robot as companion. Paper presented at 29th IEEE International Conference on Robot and Human Interactive Communication (RO-MAN), August 31–September 4, 2020.
FakhrHosseini, M. n.d. Some principles for designing age-friendly homes. https://agelab.mit.edu/blog/some-principles-designing-age-friendly-homes/ (accessed September 20, 2022).
Fredriksen-Goldsen, K. I., Kim, H.-J., Emlet, C. A., A. Muraco, E. A. Erosheva, C. P. Hoy-Ellis, J. Goldsen, and H. Petry. 2011. The Aging and Health Report: Disparities and Resilience Among Lesbian, Gay, Bisexual, and Transgender Older Adults. Seattle, WA: Institute for Multigenerational Health. https://www.lgbtagingcenter.org/resources/pdfs/LGBT%20Aging%20and%20Health%20Report_final.pdf (accessed September 14, 2022).
Fredriksen-Goldsen, K. I., J. M. Simoni, H. J. Kim, K. Lehavot, K. L. Walters, J. Yang, C. P. Hoy-Ellis, and A. Muraco. 2014. The health equity promotion model: Reconceptualization of lesbian, gay, bisexual, and transgender (LGBT) health disparities. American Journal of Orthopsychiatry 84(6):653-663.
Fredriksen-Goldsen, K. I., H. J. Kim, C. Shui, and A. E. B. Bryan. 2017. Chronic health conditions and key health indicators among lesbian, gay, and bisexual older US adults, 2013-2014. American Journal of Public Health 107(8):1332-1338.
IHI (Institute for Healthcare Improvement). 2019. What is an age-friendly health system? https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx (accessed September 14, 2022).
IOM (Institute of Medicine). 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press.
Loyd, C., A. D. Markland, Y. Zhang, M. Fowler, S. Harper, N. C. Wright, C. S. Carter, T. W. Buford, C. H. Smith, R. Kennedy, and C. J. Brown. 2020. Prevalence of hospital-associated disability in older adults: A meta-analysis. Journal of the American Medical Directors Association 21(4):455-461.e455.
Phillips, L. J., C. B. DeRoche, M. Rantz, G. L. Alexander, M. Skubic, L. Despins, C. Abbott, B. H. Harris, C. Galambos, and R. J. Koopman. 2016. Using embedded sensors in independent living to predict gait changes and falls. Western Journal of Nursing Research 39(1):78-94.
Pype, P., F. Mertens, F. Helewaut, and D. Krystallidou. 2018. Healthcare teams as complex adaptive systems: Understanding team behaviour through team members’ perception of interpersonal interaction. BMC Health Services Research 18(1):570.
Rantz, M., K. Lane, L. J. Phillips, L. A. Despins, C. Galambos, G. L. Alexander, R. J. Koopman, L. Hicks, M. Skubic, and S. J. Miller. 2015. Enhanced registered nurse care coordination with sensor technology: Impact on length of stay and cost in aging in place housing. Nursing Outlook 63(6):650-655.
Reed, N. S., A. Altan, J. A. Deal, C. Yeh, A. D. Kravetz, M. Wallhagen, and F. R. Lin. 2019. Trends in health care costs and utilization associated with untreated hearing loss over 10 years. Journal of the American Medical Association Otolaryngology-Head and Neck Surgery 145(1):27-34.
Schiff, G. D., S. A. Martin, D. H. Eidelman, L. A. Volk, E. Ruan, C. Cassel, W. Galanter, M. Johnson, A. Jutel, K. Kroenke, B. L. Lambert, J. Lexchin, S. Myers, A. Miller, S. Mushlin, L. Sanders, and A. Sheikh. 2018. Ten principles for more conservative, care-full diagnosis. Annals of Internal Medicine 169(9):643-645.
Shukla, A., C. Nieman, C. Price, M. Harper, F. Lin, and N. Reed. 2018. Impact of hearing loss on patient–provider communication among hospitalized patients: A systematic review. American Journal of Medical Quality 34(3): 284-292.
Singh Ospina, N., K. A. Phillips, R. Rodriguez-Gutierrez, A. Castaneda-Guarderas, M. R. Gionfriddo, M. E. Branda, and V. M. Montori. 2019. Eliciting the patient’s agenda—Secondary analysis of recorded clinical encounters. Journal of General Internal Medicine 34(1):36-40.
Wen, L., and J. Kosowsky. 2014. When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests. Macmillan.
DISCLAIMER This Proceedings of a Workshop—in Brief has been prepared by JENNIFER LALITHA FLAUBERT, TRACY LUSTIG, and MEGAN SNAIR as a factual summary of what occurred at the meeting. The statements made are those of the rapporteurs or individual workshop participants and do not necessarily represent the views of all workshop participants, the planning committee, or the National Academies of Sciences, Engineering, and Medicine.
The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the workshop rapporteurs and the institution. The planning committee comprises ANDREW BINDMAN (Chair), Kaiser Permanente; CHRISTINE K. CASSEL, University of California, San Francisco; GEORGE DEMIRIS, University of Pennsylvania; KEDAR MATE, Institute for Healthcare Improvement; KATHRYN MCDONALD, Johns Hopkins University; SUPRIYA GUPTA MOHILE, University of Rochester Medical Center; SONJA ROSEN, Cedars-Sinai; GORDON SCHIFF, Brigham and Women’s Hospital; and SAUL WEINGART, Rhode Island Hospital and Brown University.
REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by BEVERLY CANIN, SCOREboard Patient Advocate Board, SHARON INOUYE, Harvard Medical School, and MICHAEL STEINMAN, University of California, San Francisco. LESLIE J. SIM, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.
STAFF JENNIFER LALITHA FLAUBERT, TRACY LUSTIG, RUTH COOPER, ANESIA WILKS, ADRIENNE FORMENTOS, and SHARYL NASS, Board on Health Care Services, Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine
SPONSORS This workshop was supported by the Gordon and Betty Moore Foundation and The John A. Hartford Foundation.
For additional information regarding the workshop, visit https://www.nationalacademies.org/event/07-21-2022/workshop-on-advancing-diagnostic-excellence-for-older-adults.
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2022. Advancing diagnostic excellence for older adults: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/26789.
Health and Medicine Division
Copyright 2022 by the National Academy of Sciences. All rights reserved.