Experts in aging pondering a grayer America
It was January 2006 when John McClure realized he had to do something or he was going to lose his mother.
Marian McClure's health had started to go downhill a couple of years earlier when, in her early 70s and living by herself in Florida, she suffered a series of small strokes. Other problems soon followed, including hallucinations and short-term memory loss. Eventually, she was diagnosed with Lewy body dementia. By the summer of 2005, Mrs. McClure had been put in an assisted-living center in the Miami area. She wasn't getting any better.
"If she wasn't feeling well, they would send her to the emergency room where she would be prescribed a pill for whatever symptoms she was having," her son recalls. With her husband long deceased and no family living nearby, she had no one to drive her to see her regular physician. As a result, her care was dispersed among multiple physicians.
John McClure was attending law school at UC Davis, so moving to Miami wasn't an option. Instead, he brought his mother to live with him. After an unsatisfactory experience with one Sacramento-area physician, she eventually saw Michael McCloud, a UC Davis geriatric specialist.
McCloud immediately took her off several medications — she was on 17 at the time — that were either unnecessary or causing her symptoms. He also recognized that her underlying problem wasn't dementia but a treatable condition other doctors had missed — hyper-parathyroidism, which produces excessive levels of calcium in the bloodstream and is most common in women older than 65.
Within a month of her having surgery to correct this condition, John McClure had his "old mom back."
Unfortunately, the "prescription cascade," as McCloud terms it, did lasting damage — Marian McClure, who is 76 now, has what appears to be drug-induced parkinsonism.
"Gerontological knowledge should be a core competency for all health-care providers, given the age of most consumers of health care. We have lots of work to do to change the picture."
— Heather M. Young, dean of school of nursing
Of geriatricians and gerontologists
The nightmare that the McClures endured may become more common in coming years for a simple reason — demographics. The first of the nation's 78 million baby boomers will begin reaching age 65 in 2011. But just as the ranks of people growing older, retiring and developing more persistent medical problems begin to swell, the health-care work force will shrink.
"The biggest cadre of caregivers — the baby boomers — is becoming the biggest cadre of care-getters. Who'll take care of this group?" McCloud asks.
He says that only 300 new geriatricians are being trained each year, which is insufficient to meet the coming demand.
"There's no way we're going to come up with the number we need. There are currently a little more than 7,000 geriatricians in the U.S. Projections are for a need of about 36,000 by 2030."
Increasing the number of geriatric physicians will help to a point, says Heather M. Young, associate vice chancellor for nursing at UC Davis and a nationally recognized expert in gerontological nursing.
She points to federal statistics that show geriatric patients use 50 percent of all hospital and nursing care and more than 80 percent of home-care services, and occupy 90 percent of all nursing-home beds in the United States.
"Health professionals across the continuum of care for older Americans, from direct-care providers to nurses, social workers, pharmacists and others, are in short supply, leaving us with a widening gap as the population ages," says Young.
McCloud says a team approach that utilizes the expertise of various gerontological practitioners, including geriatricians, nurses, physical therapists, pharmacists and psychiatrists is another way to better meet the growing need.
"That's the only way we're going to keep up," says McCloud, who runs UC Davis' popular Mini Medical School, a series of classes on healthy aging for Sacramento area residents. The classes are intended to help seniors manage and contend with their own aging process.
In addition to a more inclusive use of teams, Young envisions the role of nurses evolving as the population ages.
Along with their traditional role of delivering both primary care, as geriatric nurse practitioners, and nursing care in hospitals, community-based, long-term care facilities, and clinics, nurses are well prepared to work with older adults and their families to manage chronic health conditions and changes in functional ability, she says. They also can assist families in adopting healthy lifestyles for people of all ages.
"Because nurses work in many settings, they are ideally positioned to serve as facilitators of communication and integrators of health care among the interprofessional team, the consumer and the family," she says.
This integrated approach will become vital as the ranks of individuals with arthritis, sensory impairment, dementia and other chronic diseases grow — and as more health-care professionals and policy makers realize that a health-care system primarily designed to treat acute problems through short hospital stays no longer works.
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"Philosophically and in an organizational way, our health-care system is ill-prepared to care for individuals whose primary needs are long term," Young says.
For example, the number of people with arthritis will double during the next 20 years, from 21 million now to 41 million by 2030. The demand for knee replacements will soar by 673 percent over the same period.
Young says consumers as well as practitioners need better understanding of how to manage chronic conditions. She believes that greater health promotion stressing the benefits of a healthy lifestyle would keep elderly citizens healthy longer, putting fewer burdens on the health-care system.
In addition, chronic conditions will increase demand on certain kinds of specialists.
"If you have a knee replaced at 55, you may need two or three more later. The ripple effects of aging are dramatic everywhere you look," Young says.
"Not only will increased longevity require many more orthopaedic surgeons, but more nurses, physical therapists, social workers and others will be needed to help seniors adjust to limits in their mobility."
Young also calls for more emphasis on gerontology in nursing programs, citing statistics that show only 3 percent of nurse practitioners and clinical specialists are certified in geriatrics and just 23 percent of nursing programs have required geriatrics courses.
"Gerontological knowledge should be a core competency for all health-care providers, given the age of most consumers of health care. We have lots of work to do to change the picture," says Young.
The Betty Irene School of Nursing, of which Young is the dean, will include a strong focus on gerontological nursing. The New York-based John A. Hartford Foundation, a national leader in the funding of educational programs and policy development in geriatric nursing, has already committed to funding two training fellowships for school faculty.
One pitfall in treating elderly patients — as the McClure case shows — is the danger of causing harm by prescribing too many medications.
Timothy Albertson, chief of pulmonary and critical care medicine and a pharmacologist and toxicologist, warns that the elderly are particularly susceptible to the central-nervous-depressant effects of agents like benzodiazepines or some antidepressants. Older patients who tend to be on multiple drugs also have elevated risk of serious or dangerous drug interactions.
"As you grow older you lose kidney function, so drugs eliminated by the kidney need to be carefully monitored," Albertson says. He says that heart disease, liver disease and other organ problems "all may impact the rate of metabolism of a drug."
McCloud says older adults, pharmacists and even physicians need to be attentive to medication safety.
"As of 2005, more adults over 65 were going to the hospital for medication mishaps than for motor vehicle accidents."
Balance problems are also prevalent among older adults. Huey Lin, who runs a fall assessment clinic, says that elderly people who struggle to maintain balance are at risk of fractures and head trauma, and, in severe cases, permanent disability and loss of independence. He says individuals who live alone are particularly vulnerable.
If someone falls, incurs injuries and is unable to get up, he or she may remain prone and helpless for extended periods of time, Lin explains. That can lead to "muscle injury [resulting from] prolonged compression of the large muscle groups on the floor, dehydration, malnutrition and inability to access one's medications."
Lin stresses the importance of having neighbors and relatives check in regularly to avoid such problems for older adults. He recommends keeping pay-as-you-go cell phones in the pocket or wearing them on a hip belt or around the neck as a safety precaution. Another option is wearing emergency-alert bracelets or necklaces.
Older adults can help prevent falls themselves, according to Lin. Regular exercise maintains and improves strength, flexibility and balance. Seniors should discuss their medications regularly with a physician, particularly after a dose adjustment or when given a new prescription. Noting that half to two-thirds of falls happen in or around the home, Lin urges the improvement of home environment safety through improved lighting, reduced clutter, and use of double-sided tape to prevent loose rugs from sliding.
A clear view
Vision screening also is essential, says Lawrence Morse, an ophthalmologist and an expert in age-related macular degeneration.
About 40 percent of his patients suffer from macular degeneration, which is a leading cause of blindness among the elderly; and that another 30 percent have diabetes, which also causes vision problems among the aged.
Both have to do with blood vessel abnormalities that cause scarring and loss of visual function. And both have a genetic component that activates inflammation that in turn is worsened by what Morse referred to as "poor lifestyle choices."
Older adults who smoke and have a diet high in fat but low in fish, fruits and vegetables are more at risk for ocular problems, he says.
Dementia is a condition that most elderly people perhaps fear most, says geriatric psychiatrist Andreea Seritan. While dementia can be an affliction of old age, many psychological conditions of elderly people are similar to those of other age groups — anxiety, depression or bipolar disorder, bereavement and psychotic disorders.
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Seritan says that typically "the ideal treatment is a combination of medication management and nonpharmacologic approaches, such as behavioral modification in the case of patients with dementia, or psychotherapeutic modalities for patients without cognitive deficits or with only minor cognitive deficits."
Noting the greater risk of medication side effects among the elderly, Seritan says that "geriatric practice requires more sophistication and patience compared to general adult psychiatric practice."
A relieved son
When John McClure thinks back on the harrowing experience his mother went through, he sometimes shivers at the thought of what might have happened to her without McCloud's intervention.
"The core issue was the [parathyroid] gland, and I'm not sure anybody else would have seen that," McClure says. "And Dr. McCloud was just fantastic in recognizing that drug interactions explained a lot of my mom's symptoms."