A new look at the elderly and how to care for them
From the January-February ACP Observer, copyright © 2007 by the American College of Physicians.
By Stacey Butterfield
An elderly patient admitted to the hospital for surgery complains to a nurse of chest pain. The nurse calls a resident in to see the patient but when the doctor arrives, the patient denies the pain. The doctor walks away a little annoyed at the nurse, never realizing that the patient has dementia.
Rosanne M. Leipzig, FACP, has signed on to a national effort to improve internists' skills in treating geriatric patients. Above, Dr. Leipzig talks with patient Audrey Tobias Davis at Mount Sinai School of Medicine's Coffey Geriatrics Practice.
"The patient really had the pain and that's the same pain that's going to cause a heart attack. But they've forgotten and the housestaff doesn't recognize what's going on with this patient," said Rosanne M. Leipzig, FACP, professor of geriatrics at Mount Sinai School of Medicine in New York City.
Scenes like this occur all too often, revealing significant gaps in internists' training in the area of geriatrics, she said. "Just because you take care of a lot of older people doesn't mean that you know geriatrics."
The number of people age 65 or older in the U.S. is expected to exceed 70 million by 2030, double what it was in 2000. That, combined with a shortage of practicing geriatricians, (see sidebar) will put even greater pressure on internists to care for seniors in the years to come.
Dr. Leipzig is part of an effort, among medical schools, private foundations and medical organizations, including the College, to improve the skills and knowledge of internists in order to better treat geriatric patients. Mt. Sinai's geriatric fellowship program is one initiative under way to give training internists a core of geriatric knowledge.
Even if medical students do not plan to specialize in geriatrics, it's important that they are comfortable with simple methods to determine a patient's cognitive impairment and likelihood of falling, for example, or how to discuss advance directives and break bad news.
The Donald W. Reynolds Foundation has funded programs at 30 different medical schools to strengthen overall geriatrics education. Grant recipients have instituted a wide variety of programs from curriculums that integrate aging in both clinical and scientific training to required portfolios that tracks students' geriatric skills throughout medical school.
"The purpose of our program is to teach someone going into surgery, for example, to better care for frail older patients that they're going to come across in their practice anyway."
"The purpose of our program is to teach someone going into surgery, for example, to better care for frail older patients that they're going to come across in their practice anyway," said Rani Snyder, senior program officer at the Reynolds Foundation.
The foundation also helps to spread the word about strong geriatrics programs, like Mount Sinai's, which became the country's first freestanding academic department of geriatrics in 1982. Funded by the foundation, geriatricians from Mount Sinai, the University of California Los Angeles (UCLA), Duke and Johns Hopkins offer three-day mini-fellowships to teach physicians in other specialties how to instruct their students in needed geriatric skills.
"If you look at these other specialties—neurologists, ophthalmologists, etc—60% of their patients are elderly. Yet when they went through school, did they receive any training about how medicines might be different for the elderly, or surgery might affect the elderly differently?" asks Elizabeth Bragg, PhD, a researcher of geriatric workforce trends.
Timothy L. Gieseke, ACP Member, a nursing home specialist, lacked formal training in teaching geriatrics before he took a part-time geriatric faculty position with the University of California San Francisco last year. To brush up his teaching and geriatric knowledge, he enrolled earlier this year in a Reynolds Geriatric Faculty Development Mini-Fellowship at UCLA, as well as a subsequent four-day UCLA Geriatric Intensive review course.
"I think the course made me a lot more effective and comfortable as a teacher," said. Dr. Gieseke. He has already incorporated parts of a UCLA lecture on geriatric patients with diabetes into one of his own monthly in-services for family practice residents.
Despite having spent many years working with older patients, Dr. Gieseke found plenty of new information in the courses. "You almost have to take a course like this every three years to make sure you're not missing important developments," he said.
The need for updated and improved knowledge in geriatrics applies as much to practicing physicians as educators, said Ms. Snyder. One foundation grantee, a team at the University of Cincinnati, goes into the community to offer hour-long geriatrics instruction sessions at area practices, but while the sessions have been well-received, participants are hard to find.
"Even though practicing physicians say they need it and want it, it's really hard for them to take time away from a busy practice," she said.
Working with internists
As a general internist, geriatrician and educator, Elizabeth Eckstrom, FACP, is well aware of the need for more geriatric skills among both medical students and practicing physicians.
Now an associate professor of geriatrics at Oregon Health & Science University, she was an associate program director of an internal medicine program when she decided to complete a geriatric fellowship. As well as increasing her own knowledge, Dr. Eckstrom said she wanted to address the "huge gap in our training of internal medicine residents in geriatrics."
Dr. Eckstrom has specific data on that gap. Her survey of internists and geriatricians revealed that one of physicians' top concerns was process of care.
"Some of their biggest frustrations would lie in figuring out when somebody couldn't stay home and needed to be placed in a facility and how to do it," she said. "They felt like they didn't have training and resources to figure out transitions of care and counseling for families."
The solution to these frustrations is often cooperation with other professionals—from social workers to pharmacists, Dr. Eckstrom said. "Geriatrics is a field that has really embraced the team concept. A lot of general internists feel unprepared to use team-based strategies."
Geriatricians also emphasize different things when evaluating the success of treatment, she added. While other internists look for medical results, geriatricians focus more on the patient's ability to maintain daily activities, like driving or cooking, or specific life goals, like living long enough to see a granddaughter graduate from high school.
"If the general internist can't have a medical success, they often feel frustrated by providing care," she observed. "We as geriatricians need to help our colleagues with how to think of quality of life as a positive outcome in somebody who has declining health status."
Recently, Dr. Eckstrom helped lead a workshop on dementia at an ACP Oregon Chapter meeting. The workshop covered a wide range, from proper diagnosis of the underlying causes to pharmaceutical options to effective behavior management techniques and communication with caregivers. The response to the workshop was enthusiastic, said Dr. Eckstrom, leading her to believe that general internists are interested and willing to take time to spend on geriatric training.
Earlier this year, the ACP launched a pilot program to test different interventions in managing urinary incontinence and falls.
"It's aimed at reorganizing practice to make it smarter and more efficient, so geriatric conditions can be comprehensively addressed without adding to the length of the office visit," said David B. Reuben, FACP, director of geriatrics at UCLA and co-leader of the project team for the RAND Corp, which is partnering with the College on the pilot.
The pilot grew out of an earlier project, which identified quality indicators in the treatment of a variety of conditions affecting older patients. The quality indicators measured how often recommended treatment guidelines were followed for the conditions, for example, whether patients were put on beta blockers after a heart attack.
"The first study found that doctors weren't doing a very good job of caring for older people," said Dr. Reuben. The monitored physicians met about half of quality indicators overall and only a third for specifically geriatric conditions.
Aiming to improve those statistics, the pilot project staff will assist participating practices, of which there are currently four, in identifying and managing patients with the two target conditions. Then they will develop interventions, such as structured visit notes, patient education materials and access to community resources.
When a patient comes in with incontinence, for example, the structured visit note will remind the physician and his staff to ask all the necessary questions, and patient education materials, such as instructions for Kegel exercises, will be already on hand. "Rather than fumbling around and going back to their administrative offices for handouts, they're right there," said Dr. Reuben.
The pilot also includes patient follow-up sheets to help patients monitor their progress and prompt them to let a physician know if treatment isn't successful. "The idea is that these problems don't fall off the table," said Dr. Reuben.
The end goal of the project is to create a product to help all physicians improve their geriatric care. With the pilot just getting started, Dr. Reuben isn't sure exactly what the product will look like, but he expects it to be different from traditional CME—ectures accompanied by printed materials—which all too often end up sitting on a shelf.
"I think there's no substitute for actually getting into doctors' offices and working with their staff in their own settings," he said. "I think that's going to be a vital component of it."
Whether redesigning practices, attending workshops, or educating medical students, it is clear that interest is growing about geriatric conditions and treatments, said Jane Potter, MD, president of the American Geriatrics Society.
"It's a national trend and you're going to see more and more of that," she said. "Everybody needs to get further up to speed."
The U.S. currently has only about 7,000 certified geriatricians and far too few physicians are entering the field to keep pace with projections of the 36,000 that will be required by 2030 to care for an aging population. Of the more than 400 geriatric fellowship slots open in the U.S. last year, less than 70% were filled.
A few medical schools have instituted pilot programs to entice students to become geriatricians-required clerkships in geriatrics or mentoring relationships with practicing geriatricians-but because recruiting geriatricians is such a struggle, many programs have decided to focus their efforts on improving the geriatric skills and knowledge of all medical students (see main story).
Still, said Jane Potter, MD, a geriatrician and president of the American Geriatrics Society, there's a real need for more certified geriatricians—those physicians who complete a one- or two-year fellowship in geriatrics after their internal or family medicine residencies.
But demand not withstanding, geriatric programs are having a difficult time recruiting young physicians. Some of the chief barriers include:
Financial. According to Dr. Potter, "It's an extreme effect of the same malady that's affecting general internal medicine—that the reimbursement for cognitive services is smaller and smaller every year."
Image. Although a 2002 study published in Archives of Internal Medicine found that geriatricians reported the highest job satisfaction of any physician specialty—"geriatrics isn't considered exciting, because you don't use special equipment and you don't do a lot of procedures," said Elizabeth Bragg, PhD, a researcher of geriatric workforce trends.
Focus. Geriatricians often have to focus more on quality of life than curing disease and "it's hard for medical students to change their mindset," said Elizabeth Eckstrom, FACP, an associate professor of internal medicine and geriatrics at Oregon Health & Science University.
Negative stereotypes. A geriatric patient admitted after a heart attack, for example, might be delirious or have underlying dementia. "They aren't articulate enough to describe their whole situation quickly, and the medical student doesn't have time to sit there and really delve into it," said Dr. Eckstrom. The hurry and confusion of hospitals also tends to confirm negative stereotypes. Noted Dr. Potter, "Where older people are at their worst is at acute care hospitals."
Under the current reimbursement and medical school systems, only a select breed of physicians enters the specialty, conceded Dr. Potter. But those who choose the specialty tend to be happy in practice and, with the projected growth in the older population, they can expect to be in demand for years to come.
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