New Challenges for an Aging America
By Charles Buchanan

The future, it seems, looks a lot like Florida. About 18 percent of the Sunshine State’s population is 65 and older, according to the Census Bureau, and by 2030 the entire United States will surpass those figures, with a predicted geriatric population of 20 percent, or 73 million. It will be the age of aging—the heyday of gray—when baby boomers have become senior citizens and medical advances lead to longer lives. But as America grows older, it faces a growing problem: finding enough geriatricians to care for everyone.

It’s sometimes said that geriatrics is not rocket science—and that’s both a problem and advantage. Across the country, medical students and residents bypass it for “superspecialties” promising high-tech treatments, high-profile careers, and high pay, resulting in a shortage of geriatricians. But physicians who do enter the field soon discover the benefits of its big-picture approach to medicine, which emphasizes compassion and quality of life over cures and treating the whole patient instead of focusing on specific diseases.

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“It’s stepping back and looking at the patient through a different set of glasses,” says UAB geriatrician Kellie Flood, M.D. Specialists in the field focus on each patient’s overall functional status, managing the multiple “geriatric syndromes”—chronic conditions ranging from arthritis and balance problems to diabetes and memory loss—that impact daily life and complicate acute illnesses.

“It’s utilizing the best standards of care for each organ system while paying attention to the patient’s geriatric issues and their goals and expectations,” says Flood. “We ask, ‘Is this patient’s goal to have an ejection fraction of 40 percent, or is it to be able to go to their grandson’s graduation? And how do we make that happen?’ Because if we get their ejection fraction up to 40 percent, but to do that, their blood pressure is 80, and they fall over every time they stand up, then they can’t go to their grandson’s graduation.”

The clinical challenges don’t end there. Elderly patients are often frail. They’re already taking several medicines and are more vulnerable to side effects. Their memories may not be what they used to be. They may not have a support network of family and friends. And often they won’t tell a doctor about their symptoms, believing they’re a natural part of aging—or, in the case of incontinence or depression, simply something you don’t discuss in public.

That’s a lot to consider, and it’s why interdisciplinary care is “essential,” says Kathryn Burgio, Ph.D., director of UAB’s Continence Program. She, along with Flood and 40 other physicians and scientists, is part of a comprehensive team in the UAB Division of Gerontology, Geriatrics, and Palliative Care working to enhance lives as they lengthen. “The care is coordinated,” explains Burgio. “We have managed to bring together a number of disciplines to communicate on a daily basis about what treatments we’re offering and what’s best for the patient.”

Stop, Look, and Listen

Most UAB geriatricians begin those treatments by doing nothing—and simply listening to their patients. “You have to keep your eyes open and apply simple medicine you learned in your first and second years of medical school,” says associate professor Ali Ahmed, M.D., who specializes in treating heart failure in older adults. He recalls an octogenarian patient who frequently visited the emergency room for dizziness and breathing problems, followed by hospitalizations and invasive tests. When she finally visited Ahmed’s geriatric heart failure clinic, she told him she had recently lost her husband of 50 years, sold her home, and moved to a new city to be close to her children. Ahmed realized that the source of the symptoms wasn’t physical, but emotional. The major life-changing events had led to depression, but the patient was not aware of it. After he treated her depression, “all her symptoms got completely better,” Ahmed says.

Burgio says that listening is the key to success in diagnosing and treating incontinence, which has many potential triggers and many potential solutions. You have to “really understand the exact condition the person has so that you can rule out some of the easily reversible causes,” including bladder infections and caffeine sensitivity, she says. “Are they leaking urine because the bladder is spasming when it shouldn’t? Are they losing control over bladder function? Or is it that they have a weak pelvic floor, where the opening to the bladder doesn’t stay closed tightly enough? If we understand the mechanism, we can figure out the best interventions.”

Daniel Marson, J.D., Ph.D., director of UAB’s neuropsychology division, which includes a geriatric clinic, adds that patience keeps his team from jumping to conclusions. “There are many reasons why an older adult might experience memory loss” aside from Alzheimer’s disease, he says. “They often present with a number of different issues that have to be sorted out.”

Flood agrees that a little extra time listening to geriatric patients can make a major difference. “It may take longer to get information,” she says. “But if you allow them to tell their story, you will get the information you need. And if they have memory impairment, you have to get the history from the family.” What she learns often leads her to prescribe nonpharmacological remedies, helping patients avoid the extra costs and side effects of additional medications.

Medical Care without the Medicine

These are the types of solutions geriatricians often prefer, because they are safe and effective without being invasive. “Many older patients are in a delicate balance, so we want to intervene as little as we can,” says Burgio. Consequently, UAB’s geriatrics specialists offer an arsenal of nonpharmacological options. For incontinence, which impacts about a third of older adults, particularly women, Burgio says behavioral interventions have high rates of success. “We spend a lot of time teaching patients where their pelvic floor muscles are, how to contract them, how to exercise and strengthen them, and how to use them when they have an urge to go to the bathroom,” she explains. “We’ll have them keep a bladder diary so that we can become aware of what situations cause them difficulty, and we teach them what to do in those situations—how to contract those muscles to close the door of the bladder.” Instead of prescribing new medications, Burgio and her colleagues sometimes adjust the drugs patients take for other conditions, which may be prompting bladder-control problems.

Marson helps aging patients try to reduce their risk “or perhaps the timeline” for developing Alzheimer’s disease by promoting a healthy heart and brain. “We know that cerebrovascular and cardiovascular disease seem to accelerate the onset of Alzheimer’s disease,” he says. “Another thing that’s important is to engage in cognitively stimulating activities during your life—a hobby, playing a musical instrument, or playing card games with friends can all cumulatively reduce risk later on.”

Ahmed says patients who have heart failure caused by hypertension, heart attacks, or valvular disease can help prevent further damage with proper therapy for those underlying causes and simple education. “I have a heart-failure patient who told me he did not know he needed to restrict his salt or fluid intake,” he says. “Another patient who was chronically nonadherent to his blood-thinner medicine started religiously taking it once he learned its importance.”

Two-Part Treatments

When older patients do require more extensive treatment, the approach often comes down to a two-pronged strategy: make patients feel good and help them live longer. “When you have constant fatigue and shortness of breath when you try to do usual things at home, such as walking to the restroom, that really affects quality of life and the psyche,” Ahmed says. He first helps patients reduce the extra fluid building up in their bodies with medicine and education; then he prescribes other medications that help extend their lives. It’s important to stabilize patients first because “if they are not feeling well, they may not use this medicine.”

Innovative medications are beginning to help Marson and his colleagues as well. “For people who have developed significant memory loss, we now have a first generation of medications called cholinesterase inhibitors, including one by the name of Memantine,” Marson says. “But these have modest efficacy in Alzheimer’s and a condition called mild cognitive impairment, which is a transitional state to Alzheimer’s. We’re a lot further along than we were 15 years ago, but we have a long way to go in terms of therapeutic interventions.” And the need for them is growing fast: Marson says that by the middle of the century, America will see a threefold increase in the number of patients with Alzheimer’s.

As for surgical solutions, elderly patients “should not be excluded just because they are old,” says Burgio. “But it does introduce a higher level of risk.” Women who don’t respond to behavioral interventions for incontinence often find relief with a sling that supports the urethra, lifting it into proper position and preventing leakage during coughing or sneezing. For men, who most often experience incontinence after prostate removal, an artificial sphincter is an option.

Rethinking the Hospital

When surgery is prescribed, hospitalization provides a new set of challenges for elderly patients, who don’t leave their geriatric syndromes at home—and run the risk of developing more in the hospital, says Flood. Put an older patient in bed, and “they lose functional status very quickly—some within 24 hours,” she explains. After a few days of that, “a large percent of these patients can’t go back home—they have to go to rehab or a nursing home. We have to keep patients as mobile as they can possibly be in the hospital.” Also, the extra medications they receive can cause problems, including grogginess and falls. And some elderly patients, who may already be malnourished, must deal with the hospital’s restricted diets and forced fasting before tests. “It doesn’t take a lot for these older patients to develop a downhill spiral,” says Flood. “We may fix their pneumonia, but all these other things may have happened to them, and then they’re actually worse off when they leave than when they came in.”

To address those problems, Flood is directing the development of an Acute Care for Elders (ACE) Unit at UAB Hospital. Planned to open in 2008 as a 15-bed inpatient unit, the ACE Unit will “make life easier” for patients as well as the doctors and nurses caring for them. Last year, 1,160 of UAB Hospital’s general medicine patients were 75 years or age or older, and Flood explains that the future unit will provide patients like them with an interdisciplinary team approach; while their physicians treat their pneumonia or heart failure, an “extra layer of care” will focus on their geriatric syndromes from admission through discharge and transition of care.

Led by a geriatrician, these teams typically include a gerontological nurse specialist, physical and occupational therapists, nutritionists, social workers, pharmacists, and others who develop care plans to help physicians manage or prevent geriatric issues. “And when you do that every single day, you can intercept a lot of problems,” Flood says.

ACE units also feature a different look and feel from the rest of the hospital. “A typical unit is a very geriatric-friendly floor,” designed to promote mobility and cognitive stimulation, Flood notes. Areas are set aside for activity therapy and to encourage patients to interact, and meals are served at tables so that patients get to move out of their beds. Flood and her colleagues also plan to develop a walking program to help patients stay active and a nonpharmacologic sleep protocol to reduce medication use.

The approach has been successful worldwide. Surveys have shown that ACE patients have better functional status when they leave the hospital and are less likely to go to nursing homes or take high-risk medication. They’re more satisfied with their care and “bounce back” into the hospital less often than other patients. One study even showed reduced mortality following their stay. Flood hopes UAB’s ACE Unit will set an example. “We want to study every intervention that we do and demonstrate what works so that other people can implement it at their institutions.”

Caring for Illnesses without End

When illnesses advance to the point where they severely limit or threaten life, patients and physicians can turn to UAB’s strong clinical programs in palliative care, which include consultation services, an outpatient clinic, two homelike inpatient care units at UAB Hospital and the Birmingham Veterans Affairs Medical Center, and a home-based program. Christine Ritchie, M.D., director of UAB’s Center for Palliative Care, says many of their patients suffer from cancer or advanced organ failure, as well as other conditions that complicate care. “And we’re seeing more patients with a number of different conditions together causing significant problems, leading to poor nutrition and functional change and loss of muscle mass.”

Not all palliative care patients are elderly; Ritchie and Rodney Tucker, M.D., the medical director of the UAB Hospital unit, estimate that about half the population in the UAB Hospital unit is considered geriatric. But Ritchie sees a “natural intersection” between geriatrics and palliative care, since both fields focus on symptom management and quality of life and employ an interdisciplinary approach. In addition to Ritchie, who is a geriatrician, UAB’s palliative-care team includes nine physicians (including four others trained in geriatrics), nurses, psychologists, counselors, pastoral care staff—and even art, music, and pet therapists.

Tucker says palliative care addresses “the four domains of suffering: physical, emotional, psychological, and spiritual,” and services can shift to meet the changing needs of the patient and his or her family. A cancer patient undergoing treatment, Tucker explains, might need care for a high physical symptom burden at first, but later, as he becomes a survivor, he might develop more psychological symptoms from a feeling of anxiety that the disease will return. Care can last for years, since life-limiting illnesses aren’t necessarily end-stage illnesses. Tucker cites the example of HIV patients: “Just 20 years ago, HIV was a young person’s disease. In the next 10 years, you’re going to have your first patients moving into their 60s with a life-threatening illness that has become a chronic illness like diabetes.” Ritchie sees emerging technologies as key tools for providing coordinated palliative and geriatric care—and helping patients stay as independent as possible. She plans to develop programs using telemonitoring, Web-based interactive support, or perhaps even handheld digital devices to support patients with complicated medical issues.

Though elderly patients present many challenges and complications, UAB’s geriatricians find them inspiring. “We learn a lot about the beauty and pain that life brings by listening to and learning from our older patients,” says Ritchie. “They invite you to walk into their history. There’s always important lessons that come from that.”

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