Accommodating Aging: Helping Your Older Patients Live the Life They Want 

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May 4, 2009

The elderly bring a range of challenges to the exam room. Experts offer tips on how to meet their treatment needs.

The coming tsunami of baby boomers means physicians are destined to see an increase in the number of elderly patients in their offices. Preparing to do well by them could require a change in attitude as well as office furniture.

It won't be business as usual, according to the Institute of Medicine's 2008 report "Retooling for an Aging America: Building the Health Care Workforce."

Only about 7,000 physicians in the nation are certified geriatricians, but 36,000 will be needed to provide care for the aging population by 2030, according to the report. The consensus is -- that's not going to happen.

Instead, what will occur is that more and more elderly people will turn to internists and family physicians for care, and the best course of action for these physicians is to prepare for and embrace the inevitable, say a number of geriatricians who offer a variety of pointers.

For starters, "you need to get a sense from them as to what their goals are," said Rosanne Leipzig, MD, PhD, professor of geriatrics and adult development at Mount Sinai School of Medicine in New York City. She also is an adviser to the American Medical Association on aging issues.

Dr. Leipzig works to help her patients live the life they want . She said this mind-set can lead to approaches that vary widely, because older people are a heterogeneous group. "When you've seen one, you've seen one."

Taking the time upfront to consider level of care will save time in the long run. "Is this someone you are going to think about as a robust elder, or someone who is frail, or someone who is in the last stages of life?" Dr. Leipzig asked.

"Some 85-year-olds you would treat as aggressively as you would a 65-year-old," said Jerome Epplin, MD, a family physician who cares for predominantly older patients in Litchfield, Ill.

David Mehr, MD, a professor of family and community medicine at the University of Missouri School of Medicine, in Columbia, noted that "with an 80-year-old you can have a competing athlete or someone with significant disabilities."

Regardless of the patient's level of ability, the treatment goal remains the same: "Keep them functioning independently and having a good quality of life," said Judah Ronch, PhD, professor at the University of Maryland's Erickson School in Baltimore. The school focuses on improving services for older people.

Rewards and attitudes

Caring for this population is a rewarding way to spend the day, said several physicians who do just that. "Geriatrics is going to be the fastest-growing segment of primary care practice, and this is good, because taking care of older people is one of the most thrilling experiences in medicine," said Bill Thomas, MD, also a professor at the Erickson School.

M. Mayes DuBose, MD, a geriatrician who established the first geriatrics-only medical practice in Sumter, S.C., also revels in his work. "I think I got into it for the right reasons. Otherwise I think I'd be burned out." And the right reasons? "The desire to provide high-quality care to America's older adults. And the desire comes from the recognition that they are such a vulnerable population," Dr. DuBose said.

Only about 7,000 U.S. physicians are certified geriatricians. 

Caring for older people is "one area of medicine where you can practice the true art of medicine," Dr. Epplin said. The goal is maintaining a proper balance between treating enough to make a difference without overtreating, he said.

Plus, "you have to have an interest in it," Dr. Epplin said. Developing that interest may require an attitude adjustment. Some physicians may see patients older than 70 and assume they are on a downhill course, he said. A conversation may include: "Your knee hurts? You're old, what do you expect?" The biggest complaint Dr. Epplin hears from his patients is that other physicians dismiss their concerns. "Remember that these are very viable people who have a future as well as a past. Then you look at it in a more positive way."

At the same time, legitimate concerns surround the time commitment necessary to care for these complex patients. The primary care physician who is going to care for a significant number of America's elderly has to be willing to change his or her standard of practice, Dr. DuBose said. "There has to be more time taken, and it has to be a slower process than the typical office visit."

Sharpening communication skills is one way to use limited time effectively, several doctors said. Poor communication can cause the entire medical encounter to fall apart, noted John C. Houchins, MD, assistant professor in the Dept. of Family and Preventive Medicine at the University of Utah School of Medicine, and others in a 2006 article in Family Practice Management.

Their communication tips include avoiding distractions, sitting face-to-face with a patient, maintaining eye contact, listening and sticking to one topic at a time.

Patients also may be unable to hear well, whether because of a hearing loss or the loss of the ability to hear higher frequencies. Women doctors may have to enlist the help of male colleagues with lower-frequency voices to improve a patient's ability to hear them, Dr. Leipzig said.

But Dr. Thomas cautions that not all older patients are hearing-impaired, and physicians shouldn't assume they are. "I like to first speak in a normal voice to all older people."

Doctors also should be aware that their oldest patients may not be forthcoming with information because they don't want to cause the doctor any problems, Ronch said. "They might not be comfortable communicating issues that are important for the physician to know about."

Caution also should be taken to ensure that patients can read the materials they are provided. Use large font sizes and high contrast, so the letters are black and the paper is white and nonglare, Dr. Leipzig said.

The top priorities

Some concerns loom as exceptionally important when caring for older patients, and among them is the elimination of medication errors.

Geriatricians agree that all patients should bring a bag of their medications to each visit. Included should be prescription and over-the-counter items, vitamins and herbal products.

Eliminating medical errors is a top priority when caring for older patients. 

Dr. DuBose likes to have patients bring the bottles, rather than a list of medications, so he can write on the bottles if a change is required. "Medication errors are very common," he said. "So a doctor or a nurse needs to make a dedicated effort to review all their medications."

Having a good, online resource to check for dosing information and drug interactions is also invaluable, a number of physicians said.

Another top priority is the ability to diagnose dementia and differentiate between dementia and delirium.

Dementia isn't always obvious at earlier stages, Dr. DuBose said. But once it is diagnosed, doctors can prescribe medications to slow its progress. Financial and health safeguards can be put in place for patients' protection.

A primary care physician doesn't need to be able to deal with every complicated patient with dementia, but they should have a good basic approach to follow if a family member expresses concern about an individual or if a patient comes in and says they are concerned about their memory, Dr. Mehr said.

Preventing falls is another area of importance. "One of the most devastating things you can help prevent is falls and resulting hip fractures," Dr. Leipzig said. An evaluation of gait, balance, vision and use of psychotropic medications is necessary.

A "get up and go test" is a fairly simple way to determine an individual's capability, Dr. Mehr said. "Ask a person to get up from their chair, walk across the room and walk back. You want to see if they use their hands to get up."

Doctors also should be sensitive to incontinence, he said, which is common in older women.

Caring for this population is a team effort. Physicians often enlist office staff to carry out many evaluations, and they should also be aware of community resources so they can help connect their patients with services such as visiting nurses, senior centers and entitlement programs. "You don't need to be a social worker, but you need to refer," Dr. Leipzig said.

Changes to the office layout also can make a difference to older patients. Ease of entry is a help to patients of all ages, Dr. Thomas noted. "People living with disabilities will thank you, as will younger people who have torn their Achilles tendons and are on crutches.

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