After decades of striving to forestall aging, the first baby boomers have reached their Medicare years, and internists will be on the front lines of helping them maximize their health and quality of life.
By 2030, nearly 20% of Americans will be age 65 or older, compared with 12% in 2005, according to a 2008 Institute of Medicine report on aging and the health workforce. Today's older adults already consume a disproportionate share of health services, including 26% of all physician visits and 35% of all hospital admissions, according to the report.
“People are going to have normal decline,” said Stephen G. Jones, MD, a geriatrician and director of the Center for Healthy Aging at Greenwich Hospital in Greenwich, Conn. “I use the word ‘normal’ in parentheses, because aging is not a disease, it's a process. Just because you're aging doesn't mean that you're getting sicker. It just means that your body is changing.”
For time-pressed internists, staying on top of chronic diagnoses like diabetes or high blood pressure will be challenging enough. More than three-fourths of older adults are living with one chronic condition, and 20% have five or more. But even seemingly robust patients will also have to be monitored closely for age-related changes such as shifts in thinking or mood, a newfound clumsiness, or dimming hearing or vision, among other possibilities.
And primary care doctors can't anticipate much backup, since geriatricians remain a scarce resource, with just one for every 2,500 older Americans.
Not all older patients will handle physical and mental changes similarly. Some may retreat into denial, while others might lobby for body scans, full heart workups and other aggressive screening regimens. But as a generational group, Dr. Jones predicts that baby boomers will set the expectations bar particularly high compared with prior generations.
“They expect a higher level of health care,” he said. “They expect a higher quality of life. They probably expect to be in the workplace a little bit longer. They expect to be healthier, to be a little more active.”
Perceptions of post-retirement health, though, may not necessarily align with reality, according to a survey conducted in 2011 by the Harvard School of Public Health in conjunction with National Public Radio and the Robert Wood Johnson Foundation.
The findings, based on responses from 1,254 adults age 50 and older, found that 58% of pre-retirees predicted that they'd be healthier during retirement than their parents' generation. Among retirees, 53% were similarly optimistic. Another split: 51% of pre-retirement adults rated their health as better than others in their age group; just 35% of retirees did so.
Under the Affordable Care Act, some new preventive services are covered by Medicare, including an Annual Wellness Visit, a benefit that began in January 2011. The visit, which is considered an age-related risk assessment rather than a physical, is reimbursed by Medicare at a higher rate, nearly three times that of a typical office visit, according to the John A. Hartford Foundation.
The higher reimbursement helps compensate physicians for the “time to talk and listen to the patient,” said Joanne G. Schwartzberg, MD, director of aging and community health at the American Medical Association (AMA). However, awareness of the visit could be better. Just 17% of 1,028 adults age 65 and older surveyed by the John A. Hartford Foundation early this year, reported getting the exam during the prior 12 months, and Dr. Schwartzberg said many doctors still don't know about it.
The Harvard School of Public Health's survey also illuminated signs of financial strain among patients of retirement age. By retirement, 21% reported difficulty paying medical bills for themselves or their spouse. And the long-term price tag can be steep: A 65-year-old couple retiring this year should have socked away $240,000 to cover medical expenses through retirement, according to a Fidelity Investments estimate released this spring.
Keeping financial constraints in mind, doctors also need to alert patients that free screenings covered by Medicare could later end up costing them out of pocket, Dr. Schwartzberg said.
“For instance, you do a colonoscopy and you find a polyp,” she said. “Then you're removing the polyp and that's no longer preventive; that's now a diagnostic service and treatment, so Medicare will require a co-payment from the patient, and possibly also the deductible, if it has not yet been paid. It's a shock to patients to get a bill for their ‘free preventive service, colorectal screening.’”
It is wise to advise patients in advance that while most of the preventive services they need will be covered, there will probably be some co-pays, Dr. Schwartzberg said.
As conditions are identified, doctors might realize that they are intertwined with other problems that might not appear related at first glance.
For example, a flurry of recent studies indicates that hearing loss might inhibit more than just communication. It also might be linked to cognitive difficulties and even to an increased likelihood of falling. A study, published in the Feb. 27 Archives of Internal Medicine and based on self-reported falls from 2,017 adults ages 40 to 69, found that those with at least mild hearing loss were nearly three times more likely to have fallen in the prior year.
Frank R. Lin, MD, PhD, an assistant professor of otolaryngology and epidemiology at Johns Hopkins University in Baltimore, who coauthored that study, cites several possible influences, including hearing damage occurring along with a loss in inner ear balance function or a reduced ability to notice environmental cues that can help prevent falls.
Meanwhile, a sudden uptick in falls could be triggered by anything from fading vision to problematic medications to heart rhythm abnormalities, according to fall prevention guidelines published last year in the Journal of the American Geriatrics Society.
Determining what caused a patient to fall once or twice in a routine setting, such as on a curb near the house, can hopefully prevent a more serious fall later, said Peter Boling, MD, FACP, a geriatrician and chair of the division of geriatric medicine at Virginia Commonwealth University in Richmond.
“You're going to find out that a small percentage [of those individuals] have vision that's not been recently checked, or have arthritis or neuropathy, such that they are not lifting their foot high enough,” he said. “Or, their judgment is impaired because their cognition is off a little bit.”
Physical symptoms, such as hearing, also can be masked by a slow erosion, sometimes not even discernible to the individuals themselves, said Dr. Lin.
Nearly 45% of adults in their 60s have at least mild hearing loss in one ear and more than 25% have loss in both ears, according to an analysis Dr. Lin co-authored in the Nov. 14, 2011, Archives of Internal Medicine. The findings were based on World Health Organization criteria for hearing loss, defined as greater than 25 decibels in the better ear.
“That's a level of hearing loss in which you begin noticing difficulty in communicating in daily situations, such as in a restaurant or any time there's background noise,” Dr. Lin said.
Yet only 7.3% of people in that same age group, age 60 to 69, wear a hearing aid, according to another prevalence analysis that Dr. Lin coauthored, published in the Feb. 13 Archives of Internal Medicine. Dr. Lin blames a number of factors, including the high cost of and limited insurance coverage for the devices, as well as the societal stigma of wearing an aid.
Still, he added, some fault rests with both patients and even physicians for taking age-related hearing loss for granted. “There is this impression that because it's so common, it can't be important,” he said.
Over time, hearing loss also might undercut an older individual's mental acuity, by overloading the brain itself as it struggles to decode the garbled incoming sounds, Dr. Lin said. Also, people might begin to avoid social gatherings, isolating themselves in ways that can impact their mood and brain functioning, he said.
By the time adults reach their 60s, their children have likely left home and they may be retired, losing most of their social network, said Radhika Vayani, DO, assistant professor of internal medicine at the University of North Texas Health Science Center in Fort Worth. A common complaint is generalized fatigue, which can have numerous causes.
Dr. Vayani will check everything from bloodwork for anemia to the patient's life circumstances. “I'll ask, ‘What has changed recently? Do you have family nearby? What do you do during the day?’ I never use the word ‘depression.’ I tend to go around it and ask all of these other things.”
If depression appears likely, Dr. Vayani takes steps to reassure the patient, explaining that it's a common diagnosis much like diabetes or high blood pressure, with symptoms that can be relieved by treatment.
Cognitive changes, meanwhile, might stem from too many medications or chronic usage of medications in the anticholinergic class, said Malaz Boustani, MD, MPH, a geriatrician and an associate professor with Indiana University Center for Aging Research in Indianapolis. The center provides an online resource listing drugs with anticholinergic effects, including amitriptyline (Elavil), clemastine (Tavist), diphenhydramine (Benadryl) and paroxetine (Paxil).
Once medications have been checked out, primary care doctors might refer the patient to a memory specialist if they're still “highly suspicious” of mild cognitive impairment based on feedback from the patient or a family member, Dr. Boustani said. Alternatively, they can perform a quick memory test in advance and make a referral if they remain concerned.
But Dr. Boustani doesn't recommend any routine cognitive screening in the absence of symptoms, saying there are insufficient data to support any benefits. Meanwhile, there's a risk of harming the patient, including stigmatization and related anxiety, he said.
Deniers and worriers
Sorting out these types of complex issues can be time-consuming, and patient personalities also play a role.
For example, some patients who have always been in good health may deny that they have developed a problem. Dr. Vayani described a recent patient, an active 62-year-old woman who initially balked at taking medicine for worrisomely high blood pressure. She preferred to rely on exercise, including yoga, to stay healthy rather than swallow a pill. “She did not like the idea that she had to take a medication every day and depend upon it,” Dr. Vayani said.
But the patient did agree to monitor her blood pressure at home. When her readings failed to dip below 150/100, she started to wonder if hypertension could be causing her recent fatigue and headaches. Within several weeks, the patient returned to Dr. Vayani, asking for a prescription in the hope of improving both her short and long-term health.
Other times, patients will arrive with a daunting list of concerns and related requests, Dr. Boling said. For those “test-everything” patients, he adopts the following stance: “I say, ‘Let's concentrate on the stuff that number one is bothering you, and number two, where we know that treatments we have are going to make a difference.’”
But even routine appointments are opportunities to stress the basics, including exercising and losing weight, said Dr. Boling, echoing a point made by others. “There is no question in the geriatric literature that routine, modest exercise three or four times a week is advantageous in a multiple of ways,” he said.
Kicking tobacco is another example. The cancer risks associated with smoking can take years to reverse, but quality-of-life improvements are noticeable much sooner, he said. Within the first three months of quitting, the body's blood circulation improves, walking becomes easier, and lung function increases by as much as 30%, according to the American Cancer Society.
Both patients and physicians may believe that older patients are sedentary and set in their ways, but that isn't always true, and encouraging behavioral changes that can improve health is an important part of caring for this age group, according to Dr. Boling.
“I think that physicians actually have a really important role in that,” he said. “If we abdicate, then we really are doing a disservice.”