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Doctor's Word: Why Bridging Practitioners to Elder Research Makes Sense

Posted: Dec 15, 2012

SAN DIEGO--Academic experts in aging stand on their college and university hilltops watching the health care battles going on down below. These gerontologists see the big picture better than practicing geriatricians, the doctors toiling in the trenches with older patients, who often feel they know what’s really happening.

As the huge baby boom generation reaches its later years, it will be increasingly important for the academics, medical practitioners and family caregivers, too, to listen to each other.

Sometimes we doctors need distance to understand today’s major health delivery issues. Any geriatrician attending the recent Gerontological Society of America (GSA) conference in San Diego might have been fascinated to discover the academic-research world worries as much as physicians do about our aging society’s problems.

Few Emergency Departments Geared for Seniors

As a geriatric physician (well, one retired from practice, since I’m now 80), I was struck by one research poster displayed at the GSA conference in November showing that only a dozen states have hospital emergency departments (EDs) for older patients.

This chart shows that although the 12 states with EDs geared especially for seniors have substantial elder populations, only two of the nation’s 10 biggest 65-plus populations have geriatric emergency departments (Florida, were 17.2 percent of the population is older, and Iowa with 14.8 percent).

Produced by researchers at the University of Maryland Baltimore School of Medicine and Baltimore County Center for Aging Studies, the chart reveals that among the top 10 senior states without geriatric-focused and trained EDs are such states as West Virginia with an over-65 population of 15.8 percent, and Pennsylvania with 15.4 percent.

I also attended a related symposium titled “Geriatric ED Care: An Uncharted Frontier.” Speaking were four academics from the UCLA School of Nursing. They offered such substantial and useful common-sense approaches drawn from practical nursing experience that for a geriatric doctor, it was like listening to ideas from a parallel universe.

Leading the panel was Mary P. Cadogan, who noted a study by the UCLA School of Nursing Center for Advancement of Gerontological Nursing Science. It identified 18 particular geriatric syndromes that have brought elders to emergency departments.

For instance, ED doctors without geriatric training commonly misdiagnose elderly patients with dementia when they actually have pneumonia. That’s because while pneumonia usually presents in younger people with coughing, fever and sputum, a frequent symptom in older adults is confusion, even delirium.

So a proper exam should include a chest X-ray for any older patient whose relatives bring them in saying, “We think he has suddenly developed Alzheimer’s, doctor!” 

Cadogan and her colleagues are putting their energy into where it may do some good. Surely, for example, we need to redefine emergency departments -- not just to improve what’s there, but rather to redesign them for today’s needs -- perhaps by loading them with more social workers.

UCLA found that of 18,316 geriatric encounters they examined, one-third of them (6,427) were repeat emergency room users. This suggests the “revolving door” of hospital admissions can be initiated in EDs even earlier.

None of the 18 geriatric syndromes UCLA found are quick fixes. Elderly patients can linger in EDs forever with nurses seeking relatives and searching for information, while patients get parked in corridors, often blocking cubicles, and their tests dominate lab work. Helping senior patients will take better staff training and hands-on attention to improving geriatric care.

Reducing Hospital Readmissions

Kaiser Health News published a story in collaboration with The Washington Post on July 19, 2012, that declared the nation’s hospitals were making little headway in reducing the frequency of patient readmissions. One patient in five was returning to the hospital within one month of discharge.

The news story quoted Harvard physician Ashish Jha, associate professor of Health Policy and Management, as saying, “Either we have no idea how to really improve readmissions, or most of the readmissions are not preventable and the efforts being put on it are not useful.”

One development that might help nationally is that the Affordable Care Act includes penalties and incentives to reduce the number of readmissions that happen within 30 days of a patient’s hospital discharge. Experts determined in a 2005 study that this is a $17 billion a year problem, much of it avoidable.

Again, research will be critical not only to decode how best to cut down on hospital readmissions, but generally to improve care. For instance, at the gerontology conference academics from the University of Michigan Geriatrics Center and Institute of Gerontology showed that its rehabilitation program was able to cut the average stay for older patients in the U-M Health System by more the two-and-a-half days, to eight-day stays on average.

This was apparently achieved due to seamless communications between the hospital and the rehabilitation facilities. All patient records were integrated into the same heath computer system, and the rehab facility had immediate access to hospital records including physicians’ examinations, laboratory records and imaging studies. That approach should be the rule, not the exception.

Gaps in Long-Term Care

Another study at the conference by Kristie Kimbell, of the University of Texas School of Social Work, showed that seven in 10 people will require some form of long-term care (LTC) during their later years. The cost of LTC is rising — the total national spending for LTC in 2010 was $208 billion.

“The current LTC system is not sustainable with the silver tsunami,” Kimbell said, referring to the huge wave of aging boomers.

Two-thirds of nursing-home patients in the United States end up covered by Medicaid, most of them after they have spent down their retirement savings until they are poor enough to qualify for what is basically a poverty program.

Private LTC insurance, according to some speakers at the conference, is not a feasible solution. Policies are often unreliable, and insurance companies have found LTC insurance too risky and have been dropping out of the market.

As a physician, I have long thought the documentation for LTC claims was potentially dishonest. Families would bring insurance forms to me and say, “You have to sign here at the bottom, doctor!” But the document swore there was no other way the patient could be handled except in a permanent nursing facility.

That was almost true, except many other families without access to LTC care had been forced to work out successful caregiver alternatives. I felt their adaptation to their situation would give the lie to any physician’s signature that declared LTC in a nursing home the only way.

But at a panel during the conference, Susan Reinhard of AARP said that a study she recently led [bit.ly/QTrIbn] showed “almost half of the 42 million family caregivers in the U.S. perform complicated, exhausting, and sometimes high-tech medical and nursing tasks for loved ones with inadequate training and support.”

“Caregivers are doing work that would make a nursing student tremble,” said Reinhard, senior vice president for public policy at AARP. She sees the problem of LTC compounded by the reality that many elders live in rural areas long vacated by young family members. There’s no one around to be a caregiver.

Until this country develops an integrated support plan for caregivers, Reinhard suggested that those getting caught up in the demands of family care should recognize they’ve become a caregiver.

Just as parents on airplanes are told what to do in an emergency, she said, “You need to put your oxygen mask on first!” (Maintaining your own health is the priority.)

Reinhard added that caregivers deserve support and should not hesitate to ask for help and build up support for your network.

Eric Anderson, MD, who lives in San Diego, is the one-time president of the New Hampshire Academy of Family Practice. This article is adapted from a commentary he wrote under the MetLife Foundation Journalists in Aging Fellows program organized by the Gerontological Society of America and New America Media. He has written five books, most recently The Man Who Cried Orange: Stories from a Doctor's Life.

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