Caring for an aging population: a Q & A with our geriatric specialist
It’s not news that America is getting older. In 2009, the percentage of the country’s population that was 65 and older was 12.9 percent, which worked out to roughly 40 million people or one in every eight Americans. By 2030 that figure is projected to grow to more than 72 million elderly Americans or 19 percent of the population, one in five.
An aging America presents many challenges, not least of which is how to adequately care for them. Getting older means, alas, a greater likelihood of aches, pains, ailments, conditions and disease, but attracting and training doctors specialized in the particular health needs of the elderly has become an increasingly daunting task.
We asked Kwi Bulow, MD, a professor and geriatric specialist at the University of California, San Diego School of Medicine to talk about treating older patients and finding the doctors to do so.
Q: Why is it difficult to attract medical school students and new doctors to the practice of geriatric medicine?
A: Students go into clinical medicine because they want to cure diseases and positively impact people’s lives. As a medical student I saw a patient come in with severe pain from gallstones, undergo surgery and experience prompt relief from pain, much to the mutual satisfaction of both the patient and the surgeon. In geriatrics, the results are sometimes subtle and a long time in coming, even though they are definitely there. Experienced physicians who have long-term relationships with patients know that they can do things that can make positive and meaningful differences in their patients’ lives. When students see patients one afternoon in a clinic, it’s hard for them to see that impact. Older patients do not bounce back quickly from illness, so that when students see a very ill older patient in a hospital, they do not see how the patient improved over time in a rehabilitation center and then at home over the ensuing weeks and even months.
Our hospitals, clinics, and care protocols are not very friendly to older patients who may have sensory deficits or have trouble moving quickly or are prone to complications. That also adds to the frustrations of trainees who are trying to get through a busy day taking care of many patients quickly and efficiently. Ideally, there should be an environment that is optimal for treating these vulnerable patients and sufficient number of geriatricians who can model excellent care.
Students are also discouraged by older patients who often have diseases for which there are no effective interventions, though we are now beginning to see some very exciting developments in diagnosis and treatment of diseases like Alzheimer’s. That may help stimulate greater interest in the care of older patients.
Another barrier is that some students feel it is depressing to work with older patient when, in fact, they often have fascinating personal histories and wonderful personalities. To challenge stereotypes about aging and help students learn more about older people, we offer an elective course in which six medical students and six pharmacy students are paired up with 12 seniors in the community to engage in interactive learning. These seniors recognize the need to train health care professionals and they are willing to volunteer to make the difference. Some of them previously had negative experiences with doctors who were not prepared to care for older patients. For example, one woman related that her doctor would address her daughter instead of her, assuming that she must be demented just because she is old.
Q: Other than the obvious fact that the patients are older, how is the geriatric medicine different from a general practice? Does it require a different mindset or approach?
A: In the same way that pediatricians are not caring for pint-sized adults, geriatricians are not simply caring for adults with more remote birth dates. Aging causes significant changes in the body, including loss of functional reserve, metabolism of drugs by the kidney and the way that it responds to disease. The interpersonal variability, the degree to which one person may be different from another, increases with age, such that it becomes increasingly important for a physician to develop a treatment plan that is personalized to that individual, taking into consideration his or her personal goals and preferences. Even something fairly routine and simple in younger patients, such as treating high cholesterol level, becomes a much more detailed conversation with the older patients about risk and benefit, their tolerance for side effects and their overall health care and life goals.
Q: Most clinical trials focus upon patients in the middle decades of life. As a result, drug and therapy research related to their real or potential effects on children is often scant. Is the same true for older patients? If so, how do clinicians address the issue?
A: Older patients are more complicated research subjects in that they may have many diseases and may be taking many medications such that it’s more difficult to isolate the effect of the particular treatment that is being evaluated. In a sense, each older person is almost a unique experiment onto himself or herself, since there may not be another individual with that same disease profile taking the exact same group of medications. Since older patients are more vulnerable to complications, investigators also need to be careful about not subjecting them to harm. When subjects have memory impairment, investigators have to be sensitive and vigilant in making sure that patients and their families fully understand their role in the research and their rights as research subjects.
Q: What tend to be the top concerns of geriatric patients?
A: Many geriatric patients are concerned about preserving a high functional level and maintaining their independence. They want to preserve their quality of life and they are also concerned about not becoming a burden to their loved ones. I recently saw a coffee mug inscribed with a quote “add life to years rather than years to life” That is a good summary of how many geriatric patients feel.
Q: What tend to be the top concerns of the doctors who treat them?
A: Geriatricians strive to honor patients’ wish to preserve their quality of life and to balance that with the goal of extending life. One of the principles of medical ethics which dates back to the Hippocratic Oath is “primum non nocere – first do no harm.” That warning is doubly important as it applies to older patients who are vulnerable to iatrogenic complications – complications that are caused by medical treatment.
At the system level, many of us are concerned about changes in the health care system in which we seem to have less and less time with our patients and in which care is becoming more fragmented across specialties, place and time, resulting in loss of continuity of care. We also have concerns about appropriate use of technology. Electronic records can enhance medical care, but computers can also get in the way of the doctor-patient interaction if the doctor is too busy typing and reading to make eye contact with a patient or hold his or her hand. IBM’s Watson can provide encyclopedic and unbiased information to physicians, but I would want a geriatrician, not Watson, to make an assessment about the impact of a particular plan of care on that patient’s quality of life and to engage the patient in developing and implementing a treatment plan.