No Wrong Floor on the Elevator: A Vision for the VA as an Age-Friendly Health System

I thought of the veteran with the sense of humor getting off the elevator and wondered whether the clinician seeing him would have training in some of the many VA resources available for delivering Age-Friendly care (Table).

Would they notice the slow gait speed, a poor prognostic marker that may indicate frailty, but often modifiable when addressed?⁷ Perhaps they would see the difficulty he had getting up from a chair in the waiting room, or climbing on to the examination room table. To address Mobility, the clinician might reach out to the primary care practitioner, or refer the patient to one of the many excellent VA mobility or rehabilitation medicine programs such as Live Long Walk Strong or Gerofit.^8,9 In the Mentation domain, the veteran joked about forgetfulness, but given the high prevalence of cognitive impairment among older veterans, perhaps the clinician would notice missed refills or repetitive questions and perform a cognitive assessment, or consult with the geriatrics or neurology memory clinic if abnormal.¹⁰ For Medications, a clinician trained in Age-Friendly principles would recognize and avoid or deprescribe high-risk medications, such as those on the American Geriatrics Society Beers Criteria, or use a VA tool for optimizing medications such as VIONE.^11-13 And for What Matters, the clinician could ask veterans what their goals are, using programs such as Whole Health, Patient Priorities Care, the VA Life Sustaining Treatment Initiative, or My Life My Story to learn about the patient as a person and align care with goals.^14–17 Working with an interprofessional team, the clinician could connect veterans with the tools needed to support them as they age.

Too often our health care system and health professions education have left clinicians unprepared to care for older adults using an Age-Friendly framework; rather, we have been trained in problem-based or disease-based care that can miss the forest for the trees in an older adult living with multiple chronic conditions and/or frailty. We may focus on providing evidence-based care for individual medical conditions while neglecting the often practical interventions that can help an older person age in place by focusing on what matters, supporting safe mobility, addressing cognition and mood, and optimizing medications.¹⁸

The vision of the VA as the largest AFHS in America is urgently needed; nearly half of the veteran population is aged 65 ≥ years, compared with 16% of the general population.¹⁹ Building on the VA’s legacy of creativity and innovation in geriatrics, and the VA’s goal of being a high reliability organization, becoming an AFHS will ensure that for that older veteran stepping off that elevator there is no wrong floor, and no wrong door to receive the Age-Friendly care he deserves and that we all hope for as we age.^1,5,19,20

Acknowledgments

This material is the result of work supported with resources and the use of facilities at the Veterans Affairs Boston Healthcare System and the New England Geriatric Research Education and Clinical Center.