Family members have long been important yet underrecognized participants in medical encounters between older adults and their physicians. The recognition of family caregivers as "hidden patients" in geriatric care encounters first arose in the published literature about 30 years ago, which led to the emergence of the concept of the "healthcare triad" in gerontology and geriatrics to describe encounters and interactions among older patients, family caregivers, and physicians, including in the context of dementia care.[1–4] In the early 1990s, the American Medical Association (AMA) officially recognized the pivotal role primary care physicians could play in helping to alleviate the adverse effects of family caregiving. The AMA called for healthcare partnerships between family caregivers and primary care physicians and recommended medical education and healthcare reimbursement initiatives to encourage physicians to use the partnership model.
More recent studies have reaffirmed the critical role of family caregivers as participants in medical visits with older adults generally and for persons living with dementia in particular.[6–9] Older adults report being more satisfied with outpatient medical visits when they are accompanied by family members or other companions than when they are not. Older adults also report that physicians engage in more communication about their conditions when they are accompanied to medical visits, and these trends are the strongest for older adults in the poorest health, including those with cognitive impairment. According to a recent study, the vast majority of primary care practitioners recognizes the value of family caregivers as participants in older patients' outpatient visits. Given this enduring theme of involving family caregivers in medical encounters with older adults, it is tempting to conclude that, in the year 2020, primary care physicians, including geriatricians, routinely determine the needs of family caregivers when caregivers accompany older adults to office visits.
In this issue of the Journal, Riffin and colleagues report results from a recent national survey of primary care physicians, the majority of whom were in private practice, suggesting that positive strides have been made but that considerable improvement is needed in how physicians support family caregivers of their older patients. Although the response rate in this study was disappointingly low (22%), and the sample size in this study was quite modest (62 geriatricians and 44 general internists), the authors made the most of the data they gathered and cast their findings and recommendations nicely within current practice and policy trends regarding ongoing barriers and facilitators to assessing the needs of family members of older patients. Their study revealed that physicians most often engaged in unstructured discussions with caregivers about their needs and concerns, lack of time was by far the most common barrier to assessing caregiver needs, and access to easier and better referral mechanisms to community resources were the most sought after facilitators to help caregivers. It would be useful to know how respondents from private practice settings compared to those practicing in academic and community health center settings as those in the former settings are less likely to have clinical or administrative support staff available to provide patient or family education regarding community support services.
A particularly surprising study finding was few differences between geriatricians and general internists in their responses to survey questions. Because geriatricians treat older adults exclusively, this unexpected study finding prompts the question of why geriatricians perform no better than internists in their caregiver-related practice behaviors. The incorporation of caregivers into the longitudinal clinical experience of care for older patients is embodied in geriatric fellowship curricular milestones. Training expectations include managing psychosocial aspects of care, including interpersonal and family relationships (Milestone 23), and assessing and incorporating caregiver needs and limitations, including caregiver stress, into care management plans (Milestone 24). Clinical practice guidelines that embody these training expectations, both for trainees and practicing geriatricians, could lead to protocols for incorporating more structured discussions with family caregivers into office visits.
Assessment of caregiver needs and referral practices in primary care have received the most attention in the dementia care literature, but frailty, more broadly, and multiple chronic conditions among older patients in the absence of dementia bring caregivers to physician encounters; much less is known about caregiver involvement in these medical encounters. Evidence from previous surveys of primary care physicians regarding their dementia care referral practices demonstrates persistently low rates of referral to community resources.[12,13] These results, coupled with physicians in the current study reporting that easier referral mechanisms would facilitate greater attention to caregiver needs, strongly suggest that the growing list of efficacious interventions offering meaningful benefits that cannot be easily offered in the outpatient medical setting to caregivers of older adults, especially those living with dementia, would be attractive to physicians and other office-based practitioners if a link could be made between interventions and these types of healthcare settings.
The COVID-19 pandemic offers unique and highly salient opportunities for primary care physicians to inquire about the well-being of family caregivers of older patients during office visits, whether these visits are conducted in person or via telehealth arrangements. Riffin and colleagues reported that their study recruited physicians from March 2019 to November 2020, and it would be informative to compare physician responses to their survey questions depending on whether responses were provided before or during the COVID-19 pandemic. Recent publications, principally commentaries and recommendations, have focused on the need to address caregivers of community-dwelling older adults in the midst of the COVID-19 pandemic. Caregivers of older adults are at risk of increased physical and mental health problems due to loneliness and social isolation, especially if they experience unavailability of community-based services such as respite care and if they assume greater care responsibilities due to a shortage of in-home workers. Health-related consequences of living amidst the pandemic place primary care physicians in uncharted territory when interacting with older patients and families, suggesting the need for new assessment tools that tap impacts on health and well-being related more specifically to pandemic-related circumstances. Moreover, the caregiver population in the United States is increasingly ethnically and racially diverse, so disparities associated with social determinants of health will likely exacerbate challenges already facing the caregiver population in the COVID-19 era. Caregiver assessments, therefore, should include inquiring about the adequacy of financial resources to purchase food supplies, medications, and other essential needs for daily living. Recommendations have been offered regarding the potential benefits of healthcare providers using technology creatively to reach caregivers at home to train them about how to avoid unnecessary hospital visits and to address accumulating needs among caregivers of older adults at home in the COVID-19 pandemic, including remote assistance using technology.[17,18]
Compilations of caregiver assessment tools have been developed and disseminated for use by healthcare practitioners, but evidence is lacking regarding the degree to which such tools have been adopted in outpatient medical care encounters with older adults. Riffin and colleagues point out that Medicare reimbursement policies have facilitated the potential use of caregiver assessment tools, but for these opportunities to be realized, mechanisms must be put in place to routinely embed and capture caregiver assessment tools and data into electronic medical records in outpatient settings. Two key elements needed to achieve this potential are physician champions within healthcare systems and willingness of information technology decision makers within care settings to configure electronic health record systems to easily capture, store, and report back to physicians the results of caregiver assessment data.
Finally, lack of time was overwhelmingly the most common barrier reported by physicians to assessing family caregiver needs and risks in the study by Riffin and colleagues. How can physicians make the most of their limited time with older patients and families yet provide tailored education, support, and referrals? Caregivers vary widely in their need for support depending on circumstances at any point in time, and their needs change over time based on new sources of stress and need for skills-based training.[20,21] Precision gerontology, with its focus on the better understanding of sources of heterogeneity in aging, can be expanded to include variation in caregivers and caregiving circumstances to offer a novel framework for helping physicians determine which older patients and caregivers require the most attention for referral to community-based services and supports during any given outpatient encounter. Figure 1 summarizes the sources of heterogeneity among each individual in the healthcare triad—older patient, caregiver, and physician—that could be taken into account and measured to determine how much support caregivers might need. Geriatricians and other physicians practicing in the primary care setting can take stock of which characteristics within this panoply of heterogeneity best fit an older patient and caregiver in the healthcare triad in a given medical encounter and can tailor assessments and referrals to meet these characteristics. This approach, along with other strategies suggested by Riffin and colleagues, as well as in this editorial, could go a long way toward strengthening the healthcare triad in geriatric primary care.
J Am Geriatr Soc. 2021;69(2):286-288. © 2021 Blackwell Publishing