TRULY SPECIALIZED
KNOWLEDGE
Even if clinicians are mandated to acquire specialty knowledge in geriatrics, there is still the question of how much primary care providers—taxed with knowing something about everything—can be expected to learn. Geriatrics is a complex topic, which many clinicians don’t fully appreciate.
Baker is reminded of the mid-’80s, when primary care clinicians were told they should all be trained to care for HIV patients. “When there was only one test and only one medication, AZT, that was terrific,” he says. “But when that became really complicated, with lots of drugs and lots of tests, and viral loads and CD4 counts, and mixtures of drugs depending on resistance, it got a little harder for primary care providers to give the best possible care.”
The difficulty with geriatrics is that it requires a change in thought process; it challenges clinicians to examine the whole person and his or her familial and social issues, rather than focus on a single organ system or disease state. It also requires familiarity with how conditions present in older patients—some of the differences from younger adults surprise the uninitiated.
“You have to have a much higher index of suspicion,” says Segal-Gidan. “For example, heart attacks as you get older don’t present with chest pain; they present with confusion. So someone who is confused and goes to the emergency department is not necessarily someone who needs an antipsychotic. You have to think differently.”
Physiological changes as a body ages can have significant consequences—for example, how the body absorbs and metabolizes food. “This is key in the area of pharmacology, because medications get absorbed at a slower rate or a faster rate or not at all,” says Bakerjian. “We have greater risk for drug interactions when we get older.”
Kemle recently saw a hospice patient whose case highlights some of the unintentional blunders made when clinicians aren’t trained to think geriatrically. The 100-year-old woman had lost more than 100 pounds in six months and underwent “gazillions of dollars’ worth of tests,” none of which showed a malignancy. Her family was told to take her home and obtain hospice services. When Kemle and her colleagues saw the patient, they discovered the problem was her medications. Once the offending ones were withdrawn, the patient “started eating like a champ,” Kemle says.
“I’m sure the people who started this little lady on all the drugs that were killing her had very good intentions—and most likely, when they were started, they were appropriate,” she adds. “But in 2012, when she’s not eating because she’s digitalitoxic and she’s on a drug that gives her gastritis and another that makes her mouth dry—people don’t seem to understand that this is a different person sitting in front of them.”
Furthermore, the patient underwent a battery of (it turned out) unnecessary tests, at great expense and with the potential to cause more harm than good. “And all we had to do was sit down and listen to her for five minutes,” Kemle says.
Listening is the skill most often cited by clinicians who care for older adults. Other concepts they all mention include the holistic approach and “looking beyond your particular organ system.” And sometimes, it is essential to recognize that what the patient needs most may have very little to do with heavy-duty medical care.
“We try to figure out what’s the most important thing to maximize this person’s function and joy in life,” Kemle says. “Say this patient just wants to go across the street to visit her neighbor—getting her a rolling walker may do her more good and make her happier than all the cholesterol-lowering agents in the world.”
Meeting the needs of America’s aging population is going to require teamwork, whether that means pairing a family practice physician with a GNP or a geriatrician with a primary care PA. Clinicians may also need to acquire knowledge in areas they would typically leave to other professionals.
“If you’re doing an advanced directives family conference, or if you have to decide whether to place a PEG tube, these are complex discussions,” says Baker. “You have to have a little legal background, you have to know about psychosocial and family dynamics, and how to run a meeting where there might be different opinions and how to diffuse tension and move things along.”
All of this is daunting—but there will come a time when it is no longer optional.
PROACTIVE VS REACTIVE
What will it take for the US as a nation—and clinicians in particular—to act on this impending crisis? Given our penchant for being reactive rather than proactive, the silver tsunami may have to hit with all its force before the necessary steps are taken. Otherwise, patients and their families may have a lot to say about the care received (or not).