Does your facility provide proper care for the elderly?
Experts claim lack of training hinders care
A man comes to your facility’s primary care clinic suffering from unexplained incontinence. No work-up is performed because the physician assumes the problem is caused by an enlarged prostate gland and prescribes a medication for prostate problems.
The medication significantly lowers the patient’s blood pressure, and he experiences an adverse reaction due to the interaction between the prostate medication and other medications prescribed by a neurologist the patient is seeing for a separate problem.
On seeing the patient’s decline in blood pressure, the neurologist prescribes another drug to increase the patient’s blood pressure. The patient begins having unexplained fainting spells and episodes of losing balance and falling down.
Does this represent an appropriate standard of care for your health system? Would your answer change if you knew the patient was 80 years old?
Older Americans often are asked to accept a level of care that would be considered unthinkable for younger patients, says Kenneth Brummel-Smith, MD, a board-certified geriatrician and president-elect of the New York City-based American Geriatrics Society (AGS). Brummel-Smith also is Bain Chair at the Providence Center on Aging in Portland, OR.
"For example," he explains, "it is very common in normal practices for incontinence to be seen as a normal part of aging, especially in women. Confusion is another good example. If a 25-year-old is confused, people assume the person is taking drugs or has some sort of mental disorder. If the person is 85, they say, Oh, it is probably Alzheimer’s — get a nursing home placement. No work-up is done to find out if, No. 1, it really is dementia, or, No. 2, if it is treatable."
The problem is threefold, says Brummel-Smith: First, clinicians, like the rest of our society, harbor biases against the elderly. Second, there is insufficient available medical training in the specific needs and unique presentations of elderly patients. Third, elderly patients frequently require longer visits and hospital stays, which is discouraged by the current managed care reimbursement environment.
"The AGS has begun to expand geriatric training to other specialties: cardiology, pulmonology, general surgery, orthopedics, urology, and rehabilitation," he says. "We have been doing lots of training with physicians."
It is essential for health care systems to emphasize the importance of knowing how to provide good care to older patients instead of allowing those patients to be swept under the rug, he says.
"We have found, with the physicians, that the big thing is to test them," he says. "We have been working with other specialty societies and their boards to incorporate more geriatric questions into the certification examinations. If you have geriatric questions, people believe geriatrics is important."
Situation is becoming critical
According to the AGS, there are 9,116 geriatric-certified allopathic physicians, approximately half of the estimated 20,000 to 25,000 needed to properly care for today’s population of older Americans. The society frequently gets calls from families seeking a certified geriatrician, says Brummel-Smith. By the year 2030, according to AGS estimates, more than 36,000 physicians with geriatrics training will be needed to care for a projected 76 million older adults.
According to a survey by the Association of American Medical Colleges, 122 out of 125 surveyed medical colleges require geriatrics as part of regular course work, but recent medical school graduates perceived their instruction in care of seniors to be inadequate.
"Another big initiative of the AGS and the Foundation for Health in Aging is to say that medical schools should be held accountable for their geriatric training," he adds. "Sixty percent of our hospital patients are elderly people, and we mostly train doctors in hospitals, so we ought to make sure the training is there. Every medical school in the U.S. requires a pediatric rotation, but not everyone requires a geriatric rotation. We have to do something to change that. Pediatric patients make up only 11% of the patient population, as opposed to 60%."
The first thing that needs to change is the negative attitude many clinicians have toward older patients, Brummel-Smith says. "Surveys have shown that medical students enter school with about the same level of negative attitudes about elderly people as the rest of society, but their attitudes get worse in medicine. One of the reasons, we believe, is that all of their exposure to geriatric patients is negative, they see the worst of the worst."
As a result, clinicians inexperienced in dealing with geriatric patients tend to discount physical complaints as age-related, he says. Many heart surgeons, for example, tend to consider postoperative delirium and disorientation as a normal part of an elder person’s response to surgery, whereas delirium and disorientation would be treated in a younger person, Brummel-Smith illustrates.
"The classic geriatric story is a doctor who examines an older man complaining of pain in his hip, and the doctor says, Well, you’re 90. What do you expect?’ And, the man replies, My other hip is 90 also, and it doesn’t hurt.’"
Elderly present with unusual symptoms
Aside from negative attitudes, many clinicians are simply unfamiliar with unusual signs and symptoms that occur in the elderly population, he says.
"Many physicians lack knowledge of geriatric-specific issues, which we are trying to remedy now," he says. "Certain drugs have side effects in the elderly patient. An elderly patient who has suffered a heart attack may only present with confusion and mild discomfort, as opposed to the crushing chest pain’ a younger patient would have had."
At the other end of the spectrum, many physicians tend to ignore the fact that the patient is significantly older and that very invasive or risky procedures may do more harm than good.
"The flip side of undertreatment is that when the medical ball gets rolling, often nobody stops to think whether it is appropriate care or not," he says. "The fact is, all older people die, and they all eventually die of some medical condition. It is very easy sometimes to frame that normal dying process as a pathologic kind of issue. Instead of paying attention to the real needs of that person, ever-widening and intensive medical interventions are offered."
Coordinating with other caregivers
Not all elderly persons require the services of a geriatrician, notes Brummel-Smith. About 80% of seniors are healthy and independent, he says. Patients with more than one chronic medical problem and those who are very ill cause the greatest worry.
General practice physicians often are reluctant to coordinate with other caregivers to develop a plan of care for a severely ill patient, says Mary Moorhead, MS, MFCC, a Berkeley, CA-based geriatric care manager, certified social worker, and licensed family counselor who specializes in coordinating medical care for elderly patients.
"Let’s say you have a son and daughter who are concerned about their father and take him to see a general internist," Moorhead explains. "The physician establishes a diagnosis of Alzheimer’s or Parkinson’s. Really, that physician’s expertise ends there. At that point, the patient and family are going to be faced with a number of challenges: Does the father need a nursing home placement? Can they afford home health care if he requires it? A trained geriatric case manager is experienced in handling these issues and should be consulted."
Geriatric case managers, who most often are licensed social workers specializing in this area, can sit down with the family, make a home visit and assessment, and help the patient’s caregivers come up with a plan for continuing care of the person, she says. "The physician, if he is seeing 20 to 26 people a day, is not going to have the time to do that."
The National Association of Professional Geriatric Case Managers in Tucson, AZ, is a good source of information about geriatric care management and resources. Its Web site (www.caremanager. org) has a searchable member directory for physicians who need to locate one, she says.
Although not all seniors will require this level of care, many will. AGS data show that seniors (those 65 years and older) are hospitalized more than three times as often as younger people, and their hospital stays are 50% longer. They use twice as many prescription drugs as the general population, and almost three-fourths report at least one disability. "Doctors are not trained in coordinating this type of care and do not know what is available in the community," she says. "It is a whole other world of expertise."
Geriatric care managers often know of valuable community resources available to the patient to meet some of their medical needs and cost issues. For example, most areas have a designated, federally funded agency on aging that coordinates programs like Meals on Wheels, adult day care, and transportation services for the elderly.
"If you put the patient or patient’s family in touch with this agency, it can go a long way to filling in what otherwise would need to be handled through home health or a visiting nurse," she says.
Create a commitment
First and foremost, however, institutions need a firm organizational commitment to 1) providing health care to the elderly that meets the same standards as that of other patients and 2) to providing education for clinicians about geriatric-specific needs, say both Moorhead and Brummel- Smith.
"Again, we have to deal with the public and with misconceptions," says Brummel-Smith. "In our society, we have TV telling older women they ought to be wearing the wonderful [incontinence] pads that make life beautiful, rather than go get a work-up and find out whether the problem could be treated."
Pain, incontinence, and medical problems should not be overlooked or discounted based upon the person’s age.
• Kenneth Brummel-Smith, American Geriatrics Society, The Empire State Building, 350 Fifth Ave., Suite 801, New York, NY 10118. Telephone: (212) 308-1414. Fax: (212) 832-8646. E-mail: [email protected].
• Mary Moorhead, 1664 Solano Ave., Berkeley, CA 94707.
• National Association of Professional Geriatric Care Managers, 1604 N. Country Club Road, Tucson, AZ 85716-3102. Telephone: (520) 881-8008. Fax: (520) 325-7925.
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