Caring for an older workforce: A physician’s perspective

Can you provide an example of how getting older can affect workers who have been injured?

We are all getting older, and unfortunately age can be an unforgiving force of nature on our bodies. For example, we can begin losing muscle mass as early as our mid‑30s. And what’s important to understand is that this loss tends to progress gradually and usually accelerates as we get older. In most adults, our muscle mass declines at a rate of about 3%–8% per decade after age 30, with a more modest increase after age 60. So, to put that into perspective, I could potentially be looking at losing somewhere between 10% to 25% of my muscle mass by my 65th birthday.

Now, suppose I get hurt at work. Whether it’s a knee sprain, a pulled muscle in my lower back or a broken foot, that decreased muscle mass will make my injury recovery more complicated, difficult and prolonged.  Walking will be more painful, physical therapy will be more demanding and my risk of falling will be higher. All of these factors together can lead to me being away from work longer, needing more healthcare services and taking more medications to treat my injury.

And believe it or not, this is just one example of how getting older can affect workers who have been injured. Imagine how much more complicated injury management gets when we start factoring in the other challenges of getting older. These include a slower metabolism for medications and a higher risk of drug-drug interactions as well as chronic health conditions — like heart and kidney disease — that limit our options for safe medications. Getting older can bring challenges, especially when we get hurt.

How should we intervene when we observe deconditioning and functional decline in older adults?

The key is to keep people moving. As we get older, we become more sedentary, develop less lean muscle mass and accumulate more central and visceral fat tissue. Our metabolism slows down, and just about everything else in our bodies starts to slow down.

It's like Newton's first law of motion: A body at rest will stay at rest unless something moves it. We have to keep people moving.

I actually heard someone yesterday mention that they were going to invest in a recliner chair for their loved one because they were no longer able to sleep in their bed due to discomfort and pain. That's the scariest thing — when you put somebody in a recliner at home, and now they're just sitting there with their TV remote, tablet or phone. They sit there all day long without getting up to get any type of joint mobility or strength back.

They tend to decline more rapidly, and all of those behaviors lead to a faster progression of heart disease, diabetes, weight gain, obesity and other illnesses. It's not good for the back or joints to sit in a chair all day. People get into a state of rapid decline as they seek comfort instead of maintaining their conditioning and level of function.

They also tend to become more relaxed in their nutrition and eating habits, turning to more comfort foods. It's all about early education and jumping in to say, "Let's build a body that you want to last you for the next 30, 40 or 50 years, not something that's going to continue to decline and hurt as a result of behavior." That's the key with preventing a cascade of deconditioning and functional decline.

So then the question becomes, “How do you encourage and educate people on the importance of staying active and keeping moving?” Whether it’s going outside each day to get the mail, taking a walk around the block or walking back and forth in the house during winter — whatever it is, we have to keep people moving.

What would you say are the three key barriers to getting older adults back to work after an injury?

The first barrier is access to care, particularly given the healthcare shortage. This applies to any injured worker, but it specifically affects older adults.

A second barrier can be challenging expectations from employers. I've had employers say they won't bring someone back to work until they're full duty — able to lift that 100-pound piece of equipment or device. But we're missing out on very valuable time and recovery by not having that injured worker at modified duty, light duty or fewer work hours.

Having the ability to reason and bargain with employers is being missed in a large number of cases where they want somebody who's full strength with full range of motion all the way back to normal. Let's find a compromise and get them out of the house and back to work. That will help them get to a better place in their recovery.

The third barrier is providing a more in-depth level of education for the older adult. We need to help them understand what we're trying to accomplish from a medication standpoint and from the standpoints of better managing their injury and their comorbid conditions.

So it really is all about resource availability, employers willing to bring their employees back at least at a limited level of duty and then having that older adult know what their risks are from an educational standpoint.  

Can you say more about the challenges in clinical practice of treating older patients with chronic medical conditions or comorbidities, particularly when there has been a workers’ comp injury?

One of the biggest challenges of managing workers’ comp injuries in people with underlying comorbid conditions is that some medications will worsen the pre-existing condition itself, and others will interact with the medications that were prescribed to treat the comorbid condition. Talk about increasing patient risk; this is a prime example where significant risk is hidden in workers’ comp claims.

Would you believe that according to the CDC, around 90% of adults over age 65 have at least one chronic health condition or comorbidity? And many of those people have two or more comorbidities. When it comes to seemingly routine comorbid conditions — like high blood pressure, diabetes, kidney disease, heart disease, and gastrointestinal problems — managing these conditions is anything but routine once an injury occurs.

Here’s an example of the complexity. NSAIDs are highly effective for most workers’ comp injuries and are one of the most prescribed types of medications in workers’ comp claims. This explains why they’re consistently ranked within our top three medication classes every year. But certain comorbid conditions can be worsened by NSAID medications. They are contraindicated and can be fatal in patients with heart disease … period.  NSAIDs can also worsen pre-existing kidney disease, gastrointestinal disorders, and high blood pressure. 

What challenges does the increasing number of available medications create for patient care?

In the history of medicine, we’ve never experienced the current pace of new medication discovery and manufacturing. That brings both benefits and challenges. From a benefit standpoint, we’re seeing more medications that are incredibly effective in treating illnesses with more precision and effectiveness than ever before. For example, the Calcitonin Gene-Related Peptide, or CGRP, medications being used for the treatment of migraines.

They have to be the most effective class of medications ever to be developed for the treatment of migraine headaches, which consistently ranks as one of the greatest causes of lost work time. And then we have the GLP1 medications that are exploding across the healthcare system in a way we’ve never seen before, both in terms of success and popularity for the treatment of obesity.

However, both of these highly effective drug classes also come with high costs. And with migraine headaches and obesity both being extremely common in the general population, the overall cost to the healthcare system for these medications must be factored into estimates in healthcare spending, again not just for group health payers, but also for workers’ compensation stakeholders.

How do you initiate dialogues with providers to address polypharmacy and untangle medication overlaps?

One of the challenges with discussing medications with providers is that, from the prescriber's viewpoint, their patient is considered to be medically stable. So why rock the boat? If they make a change, they could potentially destabilize that patient.

For example, their pain could get worse, their depression could worsen, or something else could deteriorate. To address that concern, I start with the most objective information I have: their age.

I'll say, "Look, this person has reached their older years. We know what happens clinically as we age." Our metabolism slows down, and we don't process medications in our bodies as quickly as we used to. We start experiencing more side effects, more drug-drug interactions, and more comorbid conditions.

The reason I start out as objectively as I can with their age is because there's no argument with what happens as we get older. Next, I bring in other objective points related to the patient's condition, such as comorbid conditions like high blood pressure, diabetes, or use of blood thinners — all conditions that might put them at higher risk with certain medicines.

Then we move on to the higher-risk, specific drug-drug interactions. I can tell them, "If your patient is on a blood thinner and you're prescribing an anti-inflammatory, it's only a matter of time before they have a bleeding event in their stomach, intestines, or brain." The key is keeping it objective.

The good thing about this approach is that when you keep it objective and help remove some of those medications from the picture, it saves on cost. Our clients are happy because they're no longer paying for potentially dangerous medications, and they're also getting the benefit of having a safer employee or claimant.  

Given all of this complexity, how does a PBM function as a quarterback in managing the care of older adults who have been injured at work?

One of the keys to managing the care of an older adult who has been injured at work, and anyone else for that matter, is visibility into the medications they are taking. For example, older injured workers are often prescribed anti-inflammatories like ibuprofen or naproxen for work-related injuries.

Normally, this wouldn’t raise too many red flags or concerns. But what if we know they are also being prescribed other drugs that further increase the risk of complications, for example, medication-related kidney failure? It’s estimated that up to 2% of U.S. adults aged 65-74 years old experience drug-induced kidney injury every year. And that number doubles after the age of 75.

Imagine how impactful it would be if the PBMs overseeing the medications of these older workers were able to notify their prescribers of the increasing risks. It could save them from lifelong complications of kidney injury — even dialysis. And this is just one example where PBMs have an amazing opportunity to help manage care and decrease complications in the care of older workers who have been injured at work.

How are workforce shortages in healthcare affecting access to quality care?

There are some fairly dire estimates — and I hate to use the word dire, but it's what it is — regarding the workforce shortage for healthcare providers over the next 10 years. Some estimates project a shortage of up to 80,000 healthcare providers, specifically physicians, and especially primary care doctors.

This is a challenge — not just because of access to care for everyone, as we would typically think, but because with many of our older adults, we're managing more and more comorbid and complex conditions. Where a patient used to see their doctor for maybe one or two reasons, now they have a whole list of medical conditions and medications that need to be reviewed carefully during each visit.

That naturally makes visits longer and can make it harder to focus on what matters most at that moment. At the same time, workforce shortages mean longer waits across the board. For older adults who are working to get back on the job, these challenges add up quickly. The more trouble they have finding providers or getting timely appointments, and the longer it takes to see specialists or other care providers, the more it increases the risk they might never return to work because they just can't recover from the injury.

We don't heal as fast as we used to as we get older, and there can be frustration, depression and basically just giving up on recovery. Any delay stemming from workforce shortages — whether it's access to their own doctor or finding new doctors for other conditions and injuries — makes it more difficult to get people the care they need. It's going to be a challenge as we progress further into the shortage.

What happens when the difficulty of scheduling appointments causes patients to give up on seeking care?

There are many cases where I see people who say, "This is just the way it is now, and I'm just going to accept it and move on."

It breaks my heart. I saw a patient two weeks ago who told me that he was no longer interested in getting better from his condition — that he just sits on his front porch with a six-pack every night and watches the deer. That's his life now. He's lost. He just can't get back in. My fear is that this is much more widespread than we think.  

How impactful are social determinants of health, such as nutrition, social isolation and economic status?

When it comes to the impact of social determinants of health, we’ve only scratched the surface on the magnitude of their importance, especially in injury recovery. Would you believe it’s been estimated that 30%-55% of health outcomes are strongly associated with these? Let’s take one of the many social determinants of health as an example — financial hardship. People who face daily financial hardship also tend to have more food insecurity and less access to care.

A recent study found that financial hardship was more closely related to worsening blood sugar control in people with diabetes than other factors like psychosocial and neighborhood factors. And although we know that injury-related medications are paid for with a workers’ comp claim, and diabetes medications from group health, healthy foods are not covered. To make matters even more complicated, work-related injuries — especially after surgery — don’t heal as well or as quickly with high blood sugar.

As blood sugar goes up, so do the risks of infections, delayed fracture healing and longer hospital stays. Financial hardship is just one of the many social determinants of health. Imagine for a moment what happens when we factor in other ones like tobacco use, lower education status and less access to quality healthcare. The more of these that affect an injured worker, the more complicated and costly their claim will be.

What role does light duty or modified duty play in helping injured workers return to work?

The key is getting them back into the workplace on modified duty. This gives them a sense of value, helps them feel needed and gets them out of the house.

Bringing them in on modified duty allows you to monitor them while they work. The goal is to get them back to work as soon as they can safely do so.

Should workers' compensation care extend beyond the immediate injury to include preventive health measures?

For any workers’ compensation injury that occurs, one of our first questions — after we know the injured worker is medically stable — is, “What problems or barriers are most likely to keep this injured person from returning to work?” The next question is, “Can we do anything about it?” Let’s take comorbid conditions as an example. If we have an injured worker with a significant spine (neck or low back) injury and they’re a tobacco smoker, their recovery will be slower when compared to nonsmokers. Period.

So the question becomes, how much would successful smoking cessation shorten this claim? Even if it involves counseling, nicotine replacement therapy, medications or a combination of all these treatments — the overall return on investment would be enormous. There would be less chances for failed spine fusions, less need for bone growth stimulators, less likelihood for spinal cord stimulators. All of this sounds like a bargain to me. Not to mention the fact that we have also helped lower an injured worker’s chances of developing lung cancer and heart disease in the process.  

How do you stay current with the constantly expanding volume of medical information and emerging developments in the field?

There are estimates that roughly 1.5 million medical articles are written each year. There has been increasing pressure on researchers over the years to publish more articles and papers, especially in academic centers where research grants and funding could be at risk. In the race to publish, data can get skewed — either accidentally or intentionally — leading to embarrassing retractions and apologies. So, the most important rule in staying current with medical information is to use trusted sources of information, and to view any research through a critical and objective lens.

When it comes to the practice of medicine, we know a lot right now, but we still have much more to learn. With the advent of generative AI, we’re already seeing how the learning of new medical information and emerging developments can be accelerated. AI can be used to identify and summarize the best quality and most evidence-based research studies and filter out those studies with the lowest quality and most limitations. I chose a career in medicine because it demands constant learning and I want to keep learning until the day I die. And I believe that AI is going to help me with that goal.

Speaking of that, how can AI technology like ChatGPT complicate the authenticity and reliability of medical information?

Generative AI technology like ChatGPT has already changed healthcare forever. The days of healthcare providers, insurers, auditors and legal investigators combing through hundreds of pages of patient hospital records, office notes, laboratory studies, medication lists and radiographic studies will soon be over. With generative AI’s ability to rapidly read and summarize massive amounts of medical information, we will never go back to reading volumes of medical records ourselves.

So then, what’s the catch? My kids love to play the game “telephone” at the dinner table, where you start with a sentence, phrase or story and you whisper it into someone else’s ear and they continue to pass what they heard, quietly, onto the next person. The humorous part of the game is when, eventually, your original phrase gets back to you, giving everyone a chuckle when they hear how much has changed since you first whispered the initial phrase.

You know, there was a study about 5 years ago, where over 136,000 patients were allowed to review their medical records for accuracy. It turns out that about 1 out 5 patients found errors or mistakes in their records, with 40% of those patients saying the mistakes they found were “serious” mistakes. Now, what happens when generative AI finds these mistakes and includes them in its medical records summary? These mistakes are passed along and are interpreted as factual, when a human reviewer may have identified and addressed the discrepancy. Just like the first computers, any AI tool will only be as valuable as the data it receives. There is an old expression in computer programming, “garbage in – garbage out.”

Generative AI can only be valuable if it’s using accurate data, so clinicians must be alert and diligent about evaluating AI-generated content with caution and supervision. On the other hand, the explosion of development in AI-enhanced care delivery, as opposed to generative AI, is already assisting providers in delivering healthcare more rapidly and accurately, and this transformative trend will continue.  

Is there anything you'd like to add when it comes to managing the care of older adults?

Imagine sitting in your doctor’s office and hearing the words “this is just the way it is and the way it’s going to be.” I hear statements from treating providers about older injured workers like, “Well, they've been taking opioids for 20 years. Nothing's going to change. This is how they're going to live out their days.”

We just can't be complacent with treatment for older adults — they deserve our best. When our days are rushed and there are a million things to do, it’s important to pause and remember that these are our family members, our mentors and our friends.

One of the best pieces of advice I ever received (when I was a medical student) was from my senior resident physician. He said, “If you treat every patient like they’re your mom, you’ll always do your best for them.” That was pretty good advice nearly 30 years ago. And I often think about those words when it seems like one of our older adults is getting left behind. It reminds me that we can do better … we should do better … and we owe it to them to try to do better.