At a recent lecture titled “Making a Difference to Seriously Ill Older Adults,” Louise C. Walter, Chief of the Division of Geriatrics at the University of California-San Francisco, first answered the question she’s asked most often: How old do you have to be to get treated by a geriatrician?
To the surprise of many, geriatrics — loosely defined as treating and preventing diseases and conditions related to aging — doesn’t apply only to patients who have achieved a particular age. What qualifies a person for geriatric care is having a complex condition, medical disability, or cognitive impairment. And what distinguishes geriatric care from “regular” medical care is its emphasis on weighing the benefits of a particular regimen or procedure against its risks while focusing on the individual patient’s goals and wishes.
Walter traces her passion for geriatrics to her early days as a med student, when she was disappointed to see that many patients — especially older ones — left the hospital essentially cured of their underlying medical problems, but weaker or more impaired than when they were first admitted. Quite often, whether hospitalized or not, they were overtreated by procedures or drugs with lasting debilitating results.
As a case in point, Walter points to her own grandmother — a lively, engaged woman who lived independently in a huge farmhouse until medical problems started to surface when she turned 92. That kicked off a series of medical near-missteps.
- At age 93, Dorothy was diagnosed with Alzheimer’s dementia; her doctor ordered her to undergo a colorectal screening, or colonoscopy.
Walter points out that any benefit a patient might gain from a colonoscopy would not be evident for about 10 years; the risks to an older patient — bleeding, tearing, or adverse reactions to anesthesia — would far outweigh the benefit.
- At 95, Dorothy evidenced a slightly elevated blood pressure; doctors prescribed a medication that would dangerously slow her pacemaker.
Walter instead encouraged a complete review of all medications Dorothy took, which resulted in eliminating some and adding a low dosage of another that brought the blood pressure measurement down.
- When she turned 97, despite showing no signs of blood sugar irregularities, doctors advised her to forego her cherished nightly dish of ice cream.
This, Walter said, just seemed mean-spirited as well as unwarranted: “You don’t tell a 97-year-old not to eat ice cream.”
Walter recently shared the top lessons she says she’s learned so far in her years as a practicing geriatrician. They’re valuable in defining good medical practices — whether or not a person is under the care of a geriatrician, who are still a rather rare breed. Fewer than 8,000 doctors in the U.S. are certified as geriatricians; it’s estimated we will need 30,000 by the year 2035 to keep up the pace with the burgeoning population of older patients.
Lesson 1: When it will help is as important as how much it will help.
A good medical treatment should involve weighing the potential benefits and potential harms. The harm will happen immediately. But in treating older patients, it’s essential to look at life expectancies to see whether they are likely to live long enough to benefit; medical practitioners often underestimate how long an older person may live — and there’s a great variation in lifespans depending on genetics, lifestyle, and sheer luck and pluck.
Lesson 2: Ask patients about their goals of care early and often.
Patients’ goals of care are personal and wide-ranging, and may include controlling pain or dizziness, avoiding hospitalizations, prolonging life, promoting comfort, or remaining able to travel or walk.
Walter acknowledges that teasing out such goals takes time, which is an elusive luxury for many doctors who are chained to a skimpy timetable for patient appointment; also, Medicare does not currently cover such consultations. She points out that as a practicing geriatrician, she has the luxury of spending 30 minutes with each patient. Also, patients are given a form in the waiting room asking them to indicate any concerns about health and well-being they’d like to discuss at the appointment, which helps focus the talks.
Lesson 3: Less can be more.
Sometimes avoiding medical care such as invasive procedures unlikely to produce any real benefit is the best of care. Walter emphasizes this should not be considered as abandonment, but as a true focus on reality and the patient’s wishes.
Taking less medication can also be more beneficial than loading up daily doses — and this is especially true for older people. “Meds can be started with a keystroke, but it may take as long as one or two years to taper off from some of the drugs currently prescribed,” Walter says.
The first step a doctor should take during a visit is to do a complete medication review; it’s usually best if patients bring in the labeled bottles of all prescription and over the counter drugs they take. Then the aim should be on “de-prescribing” drugs or additives that are no longer needed or may actually be harmful when taken in tandem with others.
Lesson 4: Sometimes, what needs treatment isn’t the patient.
To illustrate this adage, Walter tells of one of her patients, a widower who suffered a stroke at age 78, which basically left him immobilized. Insistent that he wanted to remain home rather than live in a nursing facility, he was left in the care of his grandchildren, who were well-meaning, but not trained about how to move him or care for the worsening bedsores he developed.
Walter was able to intervene and get some training for the grandchildren in how to provide care as well as how to keep him more socially engaged and active. “The best care is 50% medical, 50% everything else,” she says.
Lesson 5: There are many ways to “save a life.”
Walter also emphasizes that the best medical care focuses on the patient’s quality of life. For example, she was able to adjust one of her patient’s medications so that he no longer became dizzy — and once again, was able to bend over and pet his cat, who had become a dear companion.
Lesson 6: Often the most useful data is not on a screen.
This is a corollary to paying attention to a patient’s individual wishes and goals, but all too often overlooked by doctors who remain most intent on staring at the number in a lab report.
Lesson 7: Improve the quality of life by improving multiple problems incrementally.
In truth, many of the conditions and diseases older patients get have no real cure. Alzheimer’s is a good example of that. But by finding drug-free ways to alleviate pain a person with Alzheimer’s is experiencing, providing appropriate social stimulation, and security, much of the quality of life can be maintained.
Lesson 8: Medical care does not equal healthcare.
Walter says it’s important to “keep the medical footprint in life small” rather than fixating on intensive and expensive care. Though a doctor with lots of hours logged in hospitals, she says most older people should try to stay out of them, as hospital stays can reduce their independence and impair functions. She cites the alarming statistic that on average, most people in the hospital spend 23.5 hours in bed. Then she cites the equally alarming research that recently showed that after only four days of such bedrest, marathon runners were rendered unable to walk.
Lesson 9: If a policy or approach isn’t working, change it.
“We still have a long way to go to achieve an age-friendly health system,” Walter says. But she’s also adamant that some changes are essential, especially to meet the specialized and evolving needs of older patients. Recent programs she cites as hopeful include medical house calls, better transitional care, acute hospital care focusing on avoiding rehab, geriatric emergency departments, and partnerships between hospitals and skilled nursing facilities.