Addressing “Triggers Of Decline” In Older Adults' Physical, Cognitive, Or Mental Health

By 2030, 70 million Americans-that's one in five-will be over the age of sixty-five.

As more and more people hit that magical number every day, we likely have a picture in our minds of what a “healthy” older adult looks like-maybe going for walks, socializing with friends, doing errands-generally living an active and independent life.

But then something like a fall or an illness happens, and all of a sudden, a once healthy person becomes frail. Such an occurrence limits their daily activities and can ultimately lead to a loss of independence.

At the Health Foundation for Western and Central New York, we call these events “triggers of decline.” Triggers of decline precipitate a decline in physical, cognitive, or mental health for other­wise healthy older adults living in the community. They are not just the risks that older adults face individually, like poor mobility, malnutrition, or chronic illnesses. They can also result from challenges older adults face in the context of their families and communities, such as caregiver stress and weak social networks, and within the health care system and at the societal level, including lack of transportation and medication mismanagement. These triggers can occur suddenly, or they can build over time, and they often overlap and compound one another.

As a funder in the aging sector, the Health Foundation is focused on improving the health of vulnerable older adults and ensuring that they can lead a dignified, independent, high-quality life in their communities. To do that, we want to understand the needs of this population and support organizations that can provide the services that meet those needs. We define vulnerable older adults as “people age 60 or older that meet one or more of the following criteria: [they] are at greater risk for one or more triggers of decline, are in poverty, are dually eligible for Medicare and Medicaid.”

So, to identify the factors that had the potential to trigger frailty or functional decline in vulnerable older adults living in the community, the Health Foundation partnered with the Syracuse University Aging Studies Institute to develop a “Triggers of Decline” conceptual model.

Each trigger in the model has a potential intervention point that can be used to identify at-risk populations of older adults and to develop evidence-based practices to address that risk and prevent the onset of frailty.

What makes this model unique is that while most models focus on what healthy aging looks like, this model focuses on examples of the risk factors that impact older adults.

The triggers included in this model were identified through several phases of research. Foundation staff began developing the model by interviewing experts and practitioners in the aging field. The Health Foundation then worked with the Aging Studies Institute to review evidence-based practices for addressing triggers and to identify relevant measures of triggers in Western and Central New York.

Though we were able to identify triggers for which there was evidence on the effectiveness of interventions, like fall prevention, the impact of hospitalizations, and medication mismanagement, what we found overall was that the available evidence base only scratched the surface in terms of intervening on the multitude of triggers of decline that we identified in our research.

This lack of evidence may be because not as many new ideas are being tested, because there is not enough investment in program evaluation, or merely because results are not being published in peer-reviewed publications.

Another challenge we ran into was a lack of data on local populations at risk of specific triggers. Many data sources only provided information at the state or national levels, which can make it difficult to identify local at-risk populations of older adults.

In addition, any data that were available for different triggers often covered inconsistent periods of time and sources, making it challenging to accurately describe the risks currently faced by local older adults. For example, data for some triggers may be available from the 2010 Census or as three- or five-year estimates from the American Community Survey, while for others, data may be available from the Centers for Disease Control and Prevention for 2009 or the Behavioral Risk Factor Surveillance Survey for 2012.

Also, these varying data sources often define “older adults” differently (for example, age fifty and older versus age sixty-five and older).

But whatever may be the source of these challenges, there is a lot of work that needs to be done to effectively address triggers of decline and to share those successes with the field.

There need to be more standardized interventions and improved measurement and replication of interventions that have proven to have a strong potential impact. Overcoming these problems would allow practitioners to better evaluate the effectiveness of well-known interventions with different subpopulations of vulnerable older adults.

In a white paper, “Identifying Interventions to Address Triggers of Decline in Vulnerable Older Adults,” authors Maria T. Brown, assistant research professor at Syracuse University Aging Studies Institute, and Kara Williams, a senior program officer at the Health Foundation for Western and Central New York, recommend that policy makers and practitioners use the model to improve data collection about at-risk populations, as well as to guide development and measurement of strategies to address triggers of decline and prevent the onset of frailty.

This conceptual model has helped the Health Foundation be more methodical in understanding the different risk factors affecting older adults and identify which triggers may warrant further research and potential funding, and it will help us to ultimately develop new programs to address the selected triggers.

By focusing on interventions around the triggers of decline, our goal is to improve the quality of care for older adults, prevent the onset of frailty, and keep older adults healthy and living in their neighborhoods and communities as they age.