Geriatricians Manage the Health of Older Adults

B. B. Hordern

       Several years ago, social worker Erica Karp was asked to help an 87-year-old widow who was wreaking havoc in her Chicago apartment building. “She was knocking on doors, obviously disoriented, and urinating in the hallways,” Karp recalls. “Her doctor had written her off. He said she was just old and needed to be in a nursing home.
      "But when a doctor who specialized in geriatrics examined her," Karp continues, "she discovered she had water on the brain, a very treatable condition." After surgery to resolve the problem, Karp says, the woman not only recovered with ease, she met a nice fellow, fell in love and lived happily into her 90s.
      Odds are the widow's primary-care physician had little training in geriatrics, the care and management of the health problems of older adults. "The vast majority of doctors out there have never been trained to do things like evaluate gait, balance, hearing, urinary incontinence and mental status," says Dr. David Reuben, head of geriatrics at the University of California at Los Angeles School of Medicine. "They just don't know how"
       Any doctor can claim to be a geriatrician. But to be certified in geriatrics, physicians must first become internists or family practitioners, which means completing a three-year residency after medical school and passing a certifying exam. To be awarded a certificate of added qualifications in geriatrics medicine, internists and family practitioners must get additional training: a one- to two-year fellowship in geriatrics. They must also pass a rigorous exam jointly administered by the American Board of Internal Medicine and the American Board of Family Practice, and they must take the exam again every 10 years.
       The discipline is young, and not always well accepted. Fellowships have been required for geriatric certification only since 1996. In 1988, when the geriatrics certification exam was first offered, any internist or family practitioner could take it. Only 54 percent passed.
       Fewer than 9,000 internists and family practitioners are currently certified in geriatrics. In contrast, there are more than 34 million Americans over the age of 65.
       To meet the health-care needs of older adults, medical schools and private organizations are working to improve the level of geriatrics training for all medical professionals, not only those who specialize. Eventually, the hope is, internists or family doctors will be able to treat any adult, with occasional help from geriatrics specialists.
       "Consumers should be raising hell to get adequate funding to create faculty that can do this kind of training," says Dr. Robert N. Butler, president of the International Longevity Center. The first director of the National Institute on Aging, Butler says only about 20 of the nation’s 126 medical schools have good geriatrics programs. “It’s a disaster in America today,” he says.
       Erica Karp, now president of Northshore Eldercare Management in Evanston, Ill., sees the results of this lack of training frequently. "So often the reason our clients and their families are struggling is that there is a medical problem that hasn't been wholly addressed. Sometimes the doctor has not really delved into the situation. Other times the patient may be on several medications that are interacting badly that the primary-care physician may not even know about."
       Nevertheless, many in the field do not want to see geriatrics become a specialty comparable to pediatrics. "We really don't need another expensive specialty," Dr. Butler insists. "What you need to know is if you are 40 years old or 80 years old, the physician you see has the training to treat you. You want a first-rate internist who understands the continuity of human existence."
       Until the general level of geriatric training improves, however, consumers may have to seek out geriatricians on their own.
       "If my dad had been going forever to an internist and I saw him falling or becoming forgetful — or any changes that did not seem to be getting better — I would ask for a consultation with a geriatrician," says Ellen McDonald, associate director for the University of Texas at Houston Center on Aging. "If he is not happy with the way he is feeling, he might not have to feel that way. If he didn't want to change doctors, I'd just ask for a consultation with a geriatrician. If the internist objects, he's not the kind of doctor that (the older person) needs."
       Geriatricians use teams of health-care providers to evaluate the patient's history, present condition and quality of life. The team may include a geriatric nurse, social worker, nutritionist, physical therapist, pharmacist and psychiatrist specializing in geriatrics. They look for common conditions in elderly patients, such as incontinence, frequent falls, confusion, sexual dysfunction and side effects caused by multiple medications. They evaluate the social support available to the patient, and the patient's ability to perform simple activities of daily living.
       Most of this kind of assessment is covered by Medicare. The social evaluation, however, typically runs an additional $800.
       "Many patients face social issues such as 'Where am I going to live, how much help will I need, and should I continue to drive,'" explains Dr. Robert Luchi, director of the Center for Excellence in Geriatrics at Baylor College of Medicine in Houston. "For some patients, we also evaluate financial resources to see how they can afford the help they need. Many require hundreds of dollars of prescription medicine each month."
       Delia Fortson is typical of the patients Dr. Luchi sees. Until two years ago, she walked two miles a day and was mentally sharp. Now 81, she can't get up from a chair. She's confused, and suffers from incontinence and a continuous cough. In addition to her family doctor in Mexia, Texas, she has seen specialists in Waco, Temple and Houston: two internists; three neurologists; two cardiologists; a specialist in ear, nose and throat; and a psychiatrist. She's been on Prozac and as many as a dozen other drugs. She's been told she has Alzheimer's disease and Parkinson's disease; and that she has neither.
       Finally, a friend told Fortson's daughter-in-law, Mary Speck, about Dr. Luchi. "I didn't know what a geriatrician was," Speck says, "but I got her over there. In two hours we got more insight into what is happening with her than we have had in the past two years. The social worker made it easy for her to talk about things that are bothering her. And Dr. Luchi spoke to her; he listened to her. For the first time, someone is not only helping her, but they are also helping us deal with her.”
       Mary Speck's frustration is common, as is that of Alyson O'Mahoney of Westchester, NY. Her grandmother's doctor dismissed her failing memory as "just old age" until O'Mahoney pointed out that memory loss is a common side effect of the cholesterol medicine he'd prescribed.
       "No patient should go to the doctor with symptoms of dementia and hear the words, 'What do you expect at your age,'" says Dr. Thomas Perls, a geriatrician and director of the New England Centenarian Study at Harvard Medical School. "If you're not happy with the answers you're getting from your doctor, or if you're not seeing any improvement, a geriatrician can give you a second opinion."
 

Aging Return