Friday , March 10, 2017 - 12:45 PM
(c) 2017, Kaiser Health News.
For months, Teresa Christensen’s 87-year-old mother, Genevieve, complained of pain from a nasty sore on her right foot. She stopped going to church. She couldn’t sleep at night. Eventually, she stopped walking except when absolutely necessary.
Her primary-care doctor prescribed three antibiotics, one after another. None worked.
“Doctor, can’t we do some further tests?” Christensen remembered asking. “I felt that he was looking through my mother instead of looking at her.”
Referred to a wound clinic, Genevieve Christensen was diagnosed with a venous ulcer resulting from poor circulation in her legs. A few weeks earlier, she had had a procedure to correct the problem and returned to her home in Cottage Grove, Minnesota, a suburb of St. Paul.
Teresa Christenson wondered: Would her mother benefit from seeing a geriatrician? And, if so, she added in an email to me, how would she go about finding one?
I reached out to several medical experts, and they agreed that a specialist in geriatrics might help a patient like this, someone with a history of breast cancer and heart failure, someone who had had open heart surgery at age 84 and whose mobility was now compromised.
Geriatricians are “experts in complexity,” said Eric Widera, director of the geriatrics medicine fellowship at the University of California at San Francisco.
No one better understands how multiple medical problems interact in older people and affect their quality of life than these specialists on aging. But their role in the health-care system remains poorly understood and their expertise underused.
Interviews with geriatricians offer insights useful to older adults and their families.
Basic knowledge. Geriatricians are typically internists or family physicians who have spent an extra year becoming trained in the unique needs of older adults.
They can serve as primary-care doctors, mostly to people in their 70s, 80s and older who have multiple medical conditions. They also provide consultations and work in interdisciplinary medical teams caring for older patients.
Recognizing that training programs can’t meet expected demand as the population ages, the specialty has launched programs to educate other physicians in the principles of geriatric medicine.
“We’ve been trying to get all clinicians trained in what we call the ‘101 level’ of geriatrics,” said Rosanne Leipzig, a professor of geriatrics at the Icahn School of Medicine at Mount Sinai in New York.
Essential competences. Researchers have spent considerable time in recent years examining what exactly geriatricians do.
A 2014 article by Leipzig and others defined 12 essential competences, including optimizing older adults’ functioning and well-being; helping seniors and their families clarify their goals for care and shaping care plans accordingly; comprehensive medication management; extensive care coordination; and providing palliative and end-of-life care.
Underlying these skills is an expert understanding of how older adults’ bodies, minds and lives differ from middle-aged adults.
“We take a much broader history that looks at what our patients can and can’t do, how they’re getting along in their environment, how they see their future, their support systems and their integration in the community,” said Kathryn Eubank, medical director of the Acute Care for Elders unit at the San Francisco Veterans Affairs Medical Center. “And when a problem arises with a patient, we tend to ask, ‘How do we put this in the context of other concerns that might be contributing?‘ “
Geriatric syndromes. Another essential competence is a focus on issues that other primary-care doctors often neglect - notably falls, incontinence, muscle weakness, frailty, fatigue, cognitive impairment and delirium. In medicine, these are known as “geriatric syndromes.”
“If you’re losing weight, you’re falling, you can’t climb a flight of stairs, you’re tired all the time, you’re unhappy and you’re on 10 or more medications, go see a geriatrician,” said John Morley, a professor of geriatrics at Saint Louis University. “Much of what we do is get rid of treatments prescribed by other physicians that aren’t working.”
Recently, Morley wrote of an 88-year-old patient with metastasized prostate cancer who was on 26 medications. The man was troubled by profound fatigue, which dissipated after Morley took him off all but one medication. (Most of the drugs had minimal expected benefit for someone at the end of life.) The patient died peacefully eight months later.
Eubank tells of an 80-year-old combative and confused patient whom her team saw in the hospital after one of his legs had been amputated. Although physicians recognized the patient was delirious, they had prescribed medications that worsened that condition, gave him insufficient pain relief and overlooked his constipation.
“Medications contributing to the patient’s delirium were stopped. We made his room quieter so he was disturbed less and stopped staff from interrupting his sleep between 10 p.m. and 6 a.m.,” Eubank said. “We worked to get him up out of bed, normalized his life as much as possible and made sure he got a [hearing device] so he could hear what was going on.”
Over the next four days, the patient improved every day and was discharged to rehabilitation.
Finding help. A geriatric consultation typically involves two appointments: one to conduct a comprehensive assessment of physical, psychological, cognitive and social functioning, and another to go over a proposed plan of care.
For help in finding a geriatrician, you can consult the American Geriatrics Society’s website. Also, you can check whether a nearby medical school or academic medical center has a department of geriatrics.
Many doctors claim competence in caring for older adults. Be concerned if they fail to go over your medications carefully, if they don’t ask about geriatric syndromes or if they don’t inquire about the goals you have for your care, advised Mindy Fain, chief of geriatrics and co-director of the Arizona Center on Aging at the University of Arizona.
Also, don’t hesitate to ask pointed questions: Has this doctor had any additional training in geriatric care? Does she approach the care of older adults differently? If so, how? Are there certain medications she doesn’t use?
“You’ll be able to see in the physician’s mannerisms and response if she takes you seriously,” Leipzig said.
If not, keep looking for one who does.
This column is produced by Kaiser Health News, an editorially independent news service that is a program of the Kaiser Family Foundation.
Sign up for e-mail news updates.