1. Home and community-based healthcare are definitely coming to the forefront
Most care of frail older adults happens in the home and community. Up to now, the healthcare system has not acknowledged this reality. Healthcare has been based in the clinic, hospital, and nursing facilities. The result has been intense care in those settings and few services in the home. Caregivers receive little support. We are now at a turning point. The importance of home and community-based services is finally being recognized. Providing more healthcare in the home setting is good news for frail older adults. Hospital at Home is an example of this.
In 2023, a push for more home and community-based services came from multiple sectors. The White House ordered increased support for caregivers. The American Rescue Plan allocated $37 billion for home and community-based care services. Medicare/Medicaid/insurers are all investing in home and community-based healthcare. Some Medicare Advantage plans are including more support in the home. Long term services and support is a strategic initiative at AARP. The National Alliance for Caregiving is promoting a National Strategy to Support Family Caregivers.
What does all this mean for caregivers? Caregivers are the backbone of home and community-based care. My role as a geriatrician went far beyond diagnosing and treating a disease. Understanding the strengths and weaknesses of the support system was much more important. In the past caregivers were largely “on their own”. This is changing but change will be slow at first. Actual funding for caregiver services in the home remains sparse and variable. The American Rescue Plan originally provided $400 Billion in home care services. This would have resulted in much more in-home support. But the final approved version of the bill did not include this funding. Much more work needs to be done. Even so the tide is turning. Healthcare for seniors is undergoing a dramatic shift into the home and community.
2. Year one of Artificial Intelligence implementation
Home and community services are highly dependent on increasing the workforce. With the aging of the population this is unlikely unless we have more young workers in the United States.
Technology will not solve workforce issues but is absolutely necessary to increase efficiency. Best Buy, Amazon and Walmart are not typically thought of as healthcare providers. But they are all merging technology with home-based care. Best Buy is known as a consumer electronics retailer. But Geek Squad Agents will be trained to provide health related tech support at home.
2023 is “Year-One” of Artificial Intelligence implementation into home-based care. Little has been implemented yet. But rapid evolution is likely. AI has the potential to provide immediate responses when caregiving issues arise. This is a next step transformation beyond current monitoring systems. Before long, AI will be able to “intelligently” respond to many caregiving situations. Support will be around the clock. AI powered robotic workers are a bit further into the future, but they are not science fiction.
3. Alzheimer’s Disease-a bending of the curve but no home run
There are two classic abnormalities in the Alzheimer's brain. Abnormal plaques containing “amyloid” proteins are located between the neurons of the brain. Abnormal tangles containing “tau” proteins are located within the neurons. A second "anti-amyloid" Alzheimer’s drug was FDA approved in 2023. Both Aducanumab and Lecanemab decrease the number of amyloid plaques.
These drugs have been described as a milestone in the treatment of Alzheimer’s Disease. But there are concerns. The drugs are antibodies synthesized in culture medium. They are given by IV infusion. There are significant side effects. The drugs result in abnormalities on brain MRI’s in as many as 35% of patients. The most common finding is edema/swelling. Bleeding also occurs. Also, these drugs slow down the disease but do not stop progression. One study showed a 25% slowing in the rate of decline. There is a simple way of understanding what this means. People who received the drug did not improve. The disease was not stopped nor reversed. However, they did not decline as fast. In a major study, it took on average 18 months to decline as much as others declined in 13 or 14 months. Experts describe this as bending the curve.
The overall impact of decreasing amyloid is uncertain. That is because the root cause of Alzheimer’s Disease is still unknown. The “amyloid hypothesis” is the leading theory. In this theory, amyloid triggers brain injury. However, some seniors have amyloid in their brains but don't have Alzheimer's Disease. If amyloid is not the root cause, getting rid of amyloid will not resolve the problem.
The SMARRT Study Summarized
The amyloid hypothesis is not yet proven. However, there is no uncertainty about the role of health and lifestyle choices. It is important to maintain a healthy environment in the brain. Physical inactivity, depression, stress, or uncontrolled diabetes or hypertension all injure the brain. Decline in brain health due to poor-quality sleep is of increasing interest. These problems can damage blood vessels, cause abnormal inflammation, and damage neurons. Chronic inflammation results in overactive cellular, chemical, and hormonal reactions. The risk of dementia increases.
Attached are some articles about Artificial Intelligence and Caregiving
AI and the Future of Care Work 2023 (PDF)
Warmest Aloha,
PS: I say it over and over again: There's no one more important than the caregiver in the daily life of a frail person.