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Thursday, 03 May 2007

Our Elder Bodies, Our Elder Selves

category_bug_journal2.gif Chad Boult, who is a professor of geriatrics at Johns Hopkins University, was asked recently what can be done to ensure that there are enough geriatricians as the elder population grows in coming years.

"'Nothing,' he said. ‘It’s too late.’ Creating geriatricians takes years,” continues writer Atul Gawande, “and we already have far too few. This year, just three hundred doctors will complete geriatrics training, not nearly enough to replace the geriatricians gong into retirement, let alone meet the needs of the next decade.” [emphasis added]
The New Yorker, 30 April 2007

Gawande, an assistant professor of surgery at Harvard Medical School, spent time sitting in on examinations of elder patients with his hospital’s chief geriatrician, Juergen Bludau, and visiting with 87-year-old, retired geriatrician Felix Silverstone whose lifetime passion has been to understand human aging.

The result of Gawande’s time and effort is an extraordinary piece in last week’s New Yorker titled “The Way We Age Now” which is stuffed with facts about aging in America today. The section on falls in the elder population alone is particularly enlightening:

  • Each year 350,000 Americans fall and break a hip
  • Of those, 20 percent (70,000) never walk again
  • 40 percent (140,000) will end up in a nursing home
  • The three primary risk factors for falling are poor balance, taking more than four prescription medications and muscle weakness
  • Elderly people without these risk factors have a 12 percent chance of falling in a year
  • Those with all three risk factors have almost 100 percent change of falling in a year/li

Gawande also explains that the complexity of treating old people takes time, patience and lacks the glamour of other specialties. Sometimes seeing that an elder’s toenails and calluses are regularly trimmed contributes more to health – and preventing falls - than medication:

“The job of any doctor, Bludau later told me, is to support quality of life, by which he meant two things: as much freedom from the ravages of disease as possible, and the retention of enough function for active engagement in the world. Most doctors treat disease, and figure that the rest will take care of itself. And if it doesn’t – if a patient is becoming infirm and heading toward a nursing home – well that isn’t really a medical problem, is it?

“To a geriatrician, though, it is a medical problem…”

Unlike too many anti-aging gurus and “elder coaches” on the web, Dr. Gawande is a realist:

“Decline remains our fate; death will come. But, until that last backup system inside each of us fails, decline can occur in two ways. One is early and precipitately, with an old age of enfeeblement and dependence, sustained primarily by nursing homes and hospitals. The other way is more gradual, preserving, for as long as possible, your ability to control your own life.

“Good medical care can influence which direction a person’s old age will take. Most of us in medicine, however, don’t know how to think about decline…Give us a disease, and we can do something about it. But give us an elderly woman with colon cancer, high blood pressure, arthritic knees, and various other ailments besides – an elderly woman at risk of losing the life she enjoys – and we are not sure what to do.”

What is worse, is that there will be fewer geriatricians who have any idea how to treat us as the number of elders increases in coming years. Dr. Gawande also tells us:

  • The number of certified geriatricians fell by a third between 1998 and 2004.
  • Applications for geriatric training programs are plummeting while applications in the fields of plastic surgery and radiology have reached record numbers

It is not just scorn of those who believe they can turn back the clock with plastic surgery that leads to so much effort expended at Time Goes By writing about the futility of it. It is the risk of having no physicians with the knowledge to treat elders’ real medical problems.

It is a supply and demand issue. If aging people by the millions were not demanding to be made into facsimiles of youth, doctors would not choose plastic surgery as a specialty. If we brought to bear the same pressure against plastic surgery as has been given to anti-smoking campaigns and nowadays, the burgeoning environment movement, elders would have a chance of finding educated, experienced geriatricians to help them live independently as long as possible.

Until that happens, we elders are on our own. We must keep ourselves educated and up to date on the finer points of elder health - such things as why keeping toenails and calluses clipped helps prevent falls and why it is important to discuss fewer prescription medications with our (non-geriatrician) physicians if possible.

To that end in this little corner of the blogosphere, I have undertaken a search for a practicing geriatrician who will write a bi-weekly column for Time Goes By with that kind of advice. I hope that will be done soon.

Remember what Chad Boult, the professor at Johns Hopkins, said about what can be done to ensure that there are enough geriatricians to serve the elder population:

“Nothing. It’s too late.”

[Speaking of health issues, Chuck Nyren has contributed a story at The Elder Storytelling Place today that he has bravely titled The Slobberer.]


Posted by Ronni Bennett at 02:30 AM | Permalink | Email this post

Comments

An aging population has an impact on other medical specialisms too. I recently spent some time on an orthopaedic ward and at 60 was usually the youngest there. In the UK at least, the staffing levels don't recognise the increased demands for personal care this change in age profile generates. Consequently the standard of care slips - my worst experience was waiting 30 minutes for the nurse call button to be answered, but it could have been a lot worse.

Several years ago, I attended a nursing education seminar on aging. The well-known nursing educator got a chuckle from all of us when she noted that "South Dakota has the longest life expectancy in the US. It also has the fewest physicians per capita!" Pardon some of my skeptism which only increases when I read the latest alarmist news. However, the key words in your remarks....."(elders")must keep ourselves educated & updated...." tell the tale. So bring on the weekly blog by the geriatrician. Dee

I think one of the best thiings elders can do is learn Tai Chi. Tai Chi is slow paced, gentle, and works on balance and strength. I take classes with people who must be eighty or more. It helps your breathing, your spine, your sense of balance, and your blood pressure.
I think our society overlooks ways to well being like Tai Chi because it seems too simple to work. There are classes everywhere.

Ronni--My first thought upon reading the article from The New Yorker that you site was, "I must point this article out to Ronni." Never fear, of course...you found it.

Zuleme--A couple of weeks ago, my physician demonstraited some Tai Chi for me, she of the long, lean limbs and the age of my children. It was my first contact with the discipline. She was amazing! Otherwise, I would probably have poof, poofed your assertion.

The article (especially the opening paragraphs) made one thing very clear to me; it's not age that people fear, it's decrepitude. Given that no one is going to be around to take care of us when we are decrepit, why discourage our attempts to improve our own health through diet and exercise? I think Zuleme's suggestion on Tai Chi is excellent...Tai Chi focuses on helping balance.

My 77 year old father, a track star in his youth, began running marathons in his 50s. He still runs or bikes every day. Compared to his younger self, there is, inevitably, some decline. But compared to my mother who has never exercised in her life, he is vigorous and healthy.

It is never too late. Recently, a little park with a track was completed behind my parents' house. Now my Mom accompanies my Dad for his morning run. She walks slowly once around the track while he runs around it thrice. She's getting faster and less breathless every day. She's lost some weight and has more energy than she has in years. She looks more vibrant than she has in years.

Can we avoid the decline of our bodies? No. Can we mitigate some of the symptoms. Sometimes.

We might be doomed to lose our teeth someday but it doesn't mean we stop brushing now.

Good luck with finding a geriatrician with time to spend. I hope you succeed as a physician's insight would be an invaluable addition.

My own internal medicine doc is so overloaded with Medicare patients, he doesn't have time to blink on any given work day. I have to make well-patient check-ups a year in advance.

Which brings me to the other dilemma -the number of doctors who will accept Medicare patients is dwindling at sonic pace.

I think one solution is, as others have mentioned above, is to stay active. I heard even a 90-year-old can still build muscle.

My parents pretty much "didn't do doctors." This was voluntary -- they expected decline, but didn't expect doctors could "fix" them. One lived to 87, the other to 90. They did get their toenails clipped and went to the dentist (and both died with most of their teeth.) They stayed as active as they could as long as they could, walking and riding bicycles -- and keeping up a house themselves through physical work.

They lived this way because this was how they thought the world worked. We're going to live this way discontentedly, thinking it ought to work some other way that includes our having access more interventionist medicine. Gawande lays out a very small part of why we won't. (The rest of why most of us won't is "for-profit disease care" occupying the space where medicine ought to be.) As I near 60, my parents' way doesn't look so bad.

Just as an aside, Dr. Gawande is an incredibly 'good read' - and I can recommend his latest book BETTER. It is well worth a look.

Ronni, I've been reading your blog for a long time without commenting. I am a 65-year-old friend of all the young techies, and I am acutely aware of the gap in our ages. I am looking to buy a four-plex so I can live with three or four single friends and we can look after each other. I don't believe the doctors really care about us after a certain age, and it's not only because of Medicare. It's because they can't, as the NYer article points out, CURE us.

Very important and great post! Well done!

Amazing post. Sobering thoughts, doses of reality, and a great idea (a guest blogger-geriatrician bi-weekly). I have forward this post to Dr. Vicky, my doctor in Israel (where I am blessed to have national healthcare coverage afforded to all its citizens). Dr. Vicky is that rare healer whom we hope to meet and sometimes do! (I blogged about her in the post, "Israeli medical doctor.") She has been casting about for a new specialty, despite the attendant hurdles of retraining, certifications, and so on. Putting the word out to our practitioners and friends in the profession (including pre-professionals) is, despite sounding naïve, another proactive stance to add to the short list of actions each of us can do to protect ourselves, our communities, and the next generation. Around the world.

This is such an excellent post as are the ideas expressed here. I, too, hope you are able to attract a geriatrician to contribute to this blog.

As usual, you provide some possible approaches to solving an identified problem,

"If we brought to bear the same pressure against plastic surgery as has been given to anti-smoking campaigns and nowadays, the burgeoning environment movement, elders would have a chance of finding educated, experienced geriatricians to help them live independently as long as possible."

I think it's an idea deserving of more wide spread exposure and serious consideration by all.

Whatever else, I echo what you said and others noted here:

"Until that happens, we elders are on our own. We must keep ourselves educated and up to date on the finer points of elder health..."

In the absence of a geriatrician it is wise to have a talk with your primary care physician. I did when I was forced to change doctors (my other doctor quit his practice). The result was, we both agreed that he would not try to extend my life but would help me maintain the quality of life. He only requires those tests that affect the quality of my remaining years and we dispense with routine tests.

Excellent post!

Francine's comment about the fine idea of buying a four-plex to share with friends so that they can look out for each other brings up an importantant consideration: so many elders are, and will be, isolated. That old TV show, "Golden Girls," may have been a sit-com, but at its heart was the serious advantage, financially and emotionally, of having a good support system set up if you find yourself on your own as you're growing older.

Also, if and when you're seriously incapacitated, you absolutely must have an advocate overseeing your medical care, preferably a family member or friend who knows you well and cares enough to fight vigorously for your welfare. The finest, most well-intentioned doctors and hospital staff can overlook a patient's needs simply because they are so busy. Your advocate can make certain that doesn't happen to you.

This brings up the importance of preparing durable powers of attorney and an advance health care directive. Two different documents are required (check your state's laws). They are used should you become incapacitated, one allowing someone of your choice to handle your legal and financial affairs, and one allowing someone of your choice to make medical decisions on your behalf based on your previously stated wishes.

People are too often reluctant even to draw up a will or trust, which can create a very messy situation for their heirs, but it is equally important to prepare these important powers of attorney, especially if you have no heirs.

Ronni, I'll have to search your posts to see if you've covered the topic of attorneys who specialize in elder law -- you are so thorough that you probably have. These specialized attorneys can be particularly helpful, as can numerous not-for-profit legal groups that help those who are unable to afford a private attorney.

Most excellent post Ronni

And I hope you can achieve this soon

"I have undertaken a search for a practicing geriatrician who will write a bi-weekly column for Time Goes By"

If you cannot get a commitment for a bi-weekly column, how about once a month>

Excellent and most helpful post! Well done as usual, Ronni! I got so much from this and the comments. Thanks!

I don't even know if the specialty exists here in Italy.

My demur is that a geriatrician I consulted about my 85 yr old father tried to apply his opinions to me, at 50. Fifty doesn't have to be old nowadays, nor 60 and maybe even 70. We now know that everything isn't inevitable, that a lot of what was accepted aging is actually neglect of our diets, our bodies, our minds.

Of course time goes on and eventually we wear out, but I think it is useless and possibly dangerous to categorize most failings as natural aging effects. Correct to ask, "Is it possibly an effect of age?" but incorrect to accept it all as decline because it could be disease or misuse.

One of the possible solutions could be a really thorough connection to the NIH and NIMH from primary physician and patient, so that conclusions could be made by non-specialists that aren't just catch-all decisions.

I constantly preach staying flexible which helps every part of one's life to remain more graceful and therefore less prone to accident. Maintenance is crucial, but folks that didn't maintain themselves for vanity's sake probably aren't aware enough to start for safety's sake.

I'm not surprised that long life expectancy and fewer physicians are correlated. Most physicians are too quick to reach for the prescription pad. When they do, they miss clues:

  • ”I'm depressed” - that could indicate several things – natural sadness due to grief (I'm of the belief that grief is best treated with minimal medication), SAD, being stuck inside in a “changing” neighborhood, loss of social supports, and being too inactive, physically. None of these indicates the need for anti-depressants.
  • Early cancer – I've seen studies that show one of the markers for it can be a feeling of heaviness or depression.
  • Pain – it's a symptom, not something you send a person to la-la land for. If the patient hurts, treat the problem, don't anesthetize them.
  • Hormones – yeah, this hits women harder, since we experience drastic hormonal changes at every age. Short-term treatment with hormonal supplements might be a better choice.
  • Related to above – the accelerating heartbeat that sometimes occurs in menopause. Many women, not knowing how common the symptom is, interpret it as a panic attack. Which, doctors often treat by sedating them.
These are just some of the things I've observed in elderly people I've known. The trouble is, too many people don't ask the vital question, “when can I stop taking this medication?” So, one medication gets added to another, until we have the walking zombies that fall.

If I sound like a preacher, both my mother and my husband's mother were over-prescribed - both had to be de-toxed.

HiRonnie,
I bought a pair of weights at 70.Ifound that it gives you the ability to lift your arms overhead to comb your hair.I was amazed at how many people can't lift a cup of tea or raise their arms.Everyone should exercise,healthy diet,keep weight down and lift weights.It works for me.Love,Vera

Thank you for your interesting comments!

I thought perhaps you may also find this related post and a subsequent discussion interesting to you:
Longevity Science: The Way We Age

Hi Ronnie, I came to visit through Naomi. I'm 49, so I guess that's middle age. I noticed all the commentors talked about excersise, which is primary, but only two people mentioned the inclusion of others. Isolation, is a major problem too. Even the elderly woman in the New Yorker story, had a dog.

The most important lesson I learned from taking care of elderly relatives, including both parents was, besides "use it, or lose it," was don't be too alone.

There HAS to be a push for inter-generational contact and caring; and not just from your middle-aged kids, who can be a pain in the butt, when they DO show up.

I live in an apartment building in the Bronx, with a number of elderly folk, who I see, more than their kids do. We look out for and take care of each other. We enjoy each other's company, and learn from each other––dances, excercises, and recipes (I hook them up with the healthy versions).

We couldn't get this message across to the MIDDLE-AGED KIDS, of one friend, who they were moving "out of the neighborhood" to their home in the suburbs ("she'll have her own room"). What!? only a room? To do what?

From what I heard, she's not doing well, in a house full of people, no less. I guess her kids don' understand, that its having friends of all ages, who keep you current and going. They can get you to do what's good for you sometimes, better than your people can.

I'm hopeful that there can be a revolution in elder care. I saw a transformation in end of life care, when Hospice started a conversation about aleveating pain and increasing comfort. We need a convesation about increasing the quality of life in the last 20 years of life; sure it's more difficult than curing and requires more fuzzy logic but we can do it!

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