Your Graying Patients

The oldest patient in Mary E. Frank's practice is 102 years old, and the Rohnert Park, Calif.-based family physician considers rendering medical care "the easy part of the deal" when it comes to treating a growing population of aging patients.

These patients "need two levels of care," she says. "They need medical care and a lot of supportive care. They don't so much want a cure or a fix for their problem but they want someone to talk to about the problem -- whether it is osteoarthritis or social isolation."

Frank, president of the American Academy of Family Physicians, knows the impact of older patients on physicians and the healthcare system is only going to grow with time. The U.S. Census bureau estimates that by 2030, 70 million Americans --  one in five -- will be age 65 and older. That's double the number in 2000.

Theron Pettit, assistant chief of the internal medicine clinic at Madigan Army Medical Center in Fort Lewis, Wash., knows it, too. If you are starting to feel overwhelmed by the needs of your older patients, Pettit has two pieces of advice: get used to it and get prepared.

"The top 10 things you may have seen as a resident are not going to be the ones you will see 10 to 15 years into your practice," says Pettit.

More training needed  

Traditionally, medical schools have done little to train physicians to care for the needs of the elderly. Courses in geratrics were not even offered until the 1980s; today, less than 5 percent of medical students take these classes, which are usually electives, according to Robert N. Butler, MD, president and chief executive officer of the International Longevity Center and professor of geriatrics at Mount Sinai Medical Center in New York City. In 1975, Butler was the first director of the National Institute of Aging, and in 1982 he founded the nation's first geriatrics department at Mount Sinai.

"A lot of physicians think they are prepared," says Butler. "They think it is just a different age group, so what's the difference?"

But there clearly are differences. Physicians need to understand what is a normal part of aging and what is not, and to grasp the special risk factors that may put the elderly in danger or complicate their medical conditions.

For example, while memory loss is common in the elderly, it is not a normal part of aging, according to Sharon Levine, MD, associate professor of medicine and director of education for the geriatrics section at Boston University School of Medicine. Similarly, 85 percent of incontinence problems are treatable, says Levine. She also cites this troubling statistic: Older men have the highest rate of suicide completion of any age group.

"It shouldn't be that the patient comes in and says, 'I am having incontinence,' and the doctor says, 'You're 80; what do you expect?'" says Levine. "It is not normal to fall; it is not normal to be incontinent." To best care for the elderly, physicians "should be taking any CME course they can take and read the books" that are published on the topic, says Butler.

"They should make a special effort, particularly, to learn about those conditions that don't present the same way" in a younger person, Butler says. For instance, an older person experiencing a heart attack might not have the classic symptom of chest pains, he says.

Drugs, rest often overdone

According to Butler, medication management is among the most critical aspects of caring for the elderly. He recommends an "extremely careful discussion" with all elderly patients about prescription and nonprescription drugs they are taking, "including the next door neighbor's [pills] and any herbal supplements they make have picked up at the drugstore.

"Most geriatricians advise patients to bring all their drugs to the appointment in a bag, and you can go through them and toss out those that are not needed," says Butler.

He also says physicians should assess patients' mental health using a mini mental status exam (MMSE), after explaining the purpose of the exam, because "some of the questions seem demeaning" to patients. (A sample MMSE is available on the Web at www.fpnotebook.com/NEU72.htm). It asks patients, among other things, to state the current day, month, and year, and to identify two simple items such as a wristwatch and a pencil.

"It is important to get a physical fitness history, which [physicians] don't think of with an older person," Butler adds. He says older patients should be encouraged to engage in aerobic activity for 30 minutes per day, three days a week.

Butler also warns against what he calls "abuse of rest."

"The typical thing doctors often say is, 'Take it easy.' That is about the worst advice you can give an older person, regardless of their medical condition," he says. "To the degree that it is realistic, have the person be active. Even stroke patients can be active in swimming pools." Such activity prevents bedsores, blood clots, and a host of other problems.

Pettit says his approach to care is also shaped by his view that a patient's psychological age can differ from chronological age.
"If I have a patient sitting in front of me who I think could live to be 105 and is not taking a lot of medications, you bet I am going to think about preventive care," he says.

Better communication helps

Poor communication is one of the biggest complaints that the elderly and their families have about physicians.

"Don't talk to the family in the absence of the [patient]," says Butler. "That is unethical and inappropriate." But physicians routinely do this, he says, because "they have built-in views that older patients have dementia; there is a kind of ageism and infantalization."

"Doctors are not answering their questions, or they will use a fancy medical term, and patients are intimidated by that," says Liz Sedaghatfar, a clinical social worker in Reston, Va., who adds that physicians often don't ask the right questions of elderly patients. "They don't do enough probing about patients' living arrangements or safety factors," she says.

Speaking frankly and clearly with older patients is especially important when it comes to end-of-life care and advance directives. These topics should be broached as soon as practicable and "when the person is well, because it is not as frightening," says Butler. He believes physicians need more training in this area, as well as in palliative care.

Improving your communication skills extends to coordinating care with other providers, Butler and Frank agree.

"Because many seniors have multiple health problems, they need attention paid to integrating their care" among the many specialists they may also be seeing, says Frank. "They want the physician to coordinate their care and tell them what their options are." She notes that this is especially important if the patient is facing surgery.

Experts emphasize taking a personal approach to your elderly patients. When you talk to them, picture your own parents or older relatives as the patient, they suggest.

Resources, office changes helpful

Medical societies are stepping in to train physicians on care of the elderly. Pettit recently attended one such training session at a meeting of the American College of Physicians - American Society of Internal Medicine (ACP) to learn how to use a "toolkit" to assess and treat congestive heart failure in the elderly. That toolkit is one of six available through the Merck Institute of Aging and Health (www.miahonline.org).

The other toolkits available focus on memory loss, urinary incontinence, depression, falls, and persistent pain. While physicians can access them directly from the Web site, Levine says they work best if the physician can attend a seminar, offered in various communities and through medical societies. Levine is the principal investigator for the Practicing Physician Education Project, which developed the toolkits.  

ACP hopes to disseminate information on care of the elderly through a variety of means. For example, those like Pettit who have been trained on the toolkits are being encouraged to arrange to teach others about them through their local ACP chapters, Levine says.

"Doctors really need this information," she says. "It's not that they are not knowledgeable, but these patients are challenging and complex, and they require collaborative care from multiple disciplines."

For Pettit, the toolkits don't necessarily impart new skills, but provide assistance in better organizing the knowledge he already had. They also offer him new methods of assessments and handouts for patients and caregivers. "It helped me make order out of chaos," he says.

Frank adds that physicians need to have senior-friendly offices. "Seniors need chairs with back support, chairs with arms. They need ways to get on and off exam tables. They frequently need patient education materials in large print," she says.

Physicians also must be knowledgeable about community resources for patients. "The doctor has to know who to identify in the community -- a case manager, physical therapist, or social worker who will help the family off-load some of this," Levine says.

When a geriatrician is needed

There may come a point when it would be best if an older patient is in the care of a geriatrician, versus a primary-care physician. 

Levine says a referral could be made when the patient has "multiple functional issues that are having an impact on the older person's ability to be independent," and to engage in activities of daily living, such as bathing, grooming, dressing, eating, and walking.

It may also be a good idea to refer patients who are taking multiple medications that are affecting their abilities, or those whose caregivers are experiencing a lot of stress, Levine says.

Referring the patient doesn't necessarily mean transferring him permanently to another provider for all care, but could simply be a way to better address the patient's needs. A geriatrics clinic or team would assess the patient, including addressing their financial situation, and send recommendations back to the referring physician.

Butler believes geriatricians function best in a consultative role, on issues such as polypharmacy and dementia, but should not take over the care of a patient. And he says geriatricians are most needed to provide more training in medical schools, and to care for those in assisted living and other residential facilities for the elderly.
Butler, incidentally, has been practicing medicine for 50 years and still sees a few patients "who won't give me up." His oldest patient is 92.

Sedaghatfar, who has worked in a nursing home and as a geriatric case manager, adds that once physicians are better prepared for older patients, they could pursue them as a new way to add to their practices. "I find working with them very gratifying," she says. "They are complicated, and they can grate on your nerves. But they adore you when you do right by them."

Theresa Defino is an editor for Physicians
Practice. She has written for WebMD and edited such publications as Managed Care Week, Medicare and Managed Care Strategies, and Practical Guidance on HIPAA and E-Health for the Physician Practice. She can be reached at
editor@physicianspractice.com.

This article originally appeared in the March 2005 issue of Physicians Practice.