Who will take care of the elderly? We have a lot of know-how, but few experts

35 years ago, Jerry Gurwitz was one of the first doctors in the United States to be certified as a geriatrician – a doctor who specializes in treating the elderly.

“I understood the demographic imperative and the issues facing older patients,” said Gurwitz, 67 and chief of geriatric medicine at the University of Massachusetts Chan Medical School. “I felt this field presented tremendous opportunities.”

But today, Gurwitz worries that geriatric medicine is in decline. Despite the increase in the elderly population, there are fewer geriatricians now (just over 7,400) than in 2000 (10,270), he noted in a recent article in JAMA.

In these two decades, the population aged 65 and over increased by more than 60%. Research suggests that each geriatrician should care for no more than 700 patients; the current ratio of providers providing services to elderly patients is 1 in 10 thousand.

Furthermore, medical schools are not required to teach geriatrics to students and less than half require any training in specific geriatrics skills or clinical experience. And the number of doctors who complete the one-year fellowship required to specialize in geriatrics is small. Of the 411 geriatric fellowship positions available in 2022-23, 30% were unfilled.

The implications are stark: Geriatricians will not be able to meet the growing demand for their services as the U.S. elderly population grows in the coming decades. There are very few of them. “Unfortunately, our healthcare system and its workforce are woefully unprepared to deal with an imminent increase in multimorbidity, functional disability, dementia and frailty,” warned Gurwitz in his JAMA article.

This is far from a new concern. Fifteen years ago, a report from the National Academies of Sciences, Engineering, and Medicine concluded: “Unless immediate action is taken, the health care workforce will not have the capacity (both size and skill) to meet the needs of elderly patients in the future.”

According to the American Geriatrics Society, 30,000 geriatricians will be needed by 2030 to care for frail and medically complex elderly people. And there is no possibility that this objective will be achieved.

What is impaired progress? Gurwitz and other doctors cite a number of factors: low Medicare reimbursement for services, low income compared with other medical specialties, lack of prestige, and the belief that older patients are unattractive, too difficult, or not worth the effort. .

“There is still tremendous ageism in the health care system and in society,” said geriatrician Gregg Warshaw, a professor at the University of North Carolina School of Medicine.

But this negative outlook is not the full story. In some respects, geriatrics has been remarkably successful in disseminating principles and practices designed to improve the care of the elderly.

“What we’re really trying to do is widen the tent and train a healthcare workforce where everyone has some degree of experience in geriatrics,” said Michael Harper, chairman of the board of the American Geriatrics Society and professor of medicine at the University of California – San Francisco.

Among the principles that geriatricians have advocated: Elderly people’s priorities should guide plans for their care. Doctors must consider how treatments will affect functioning and independence in older adults.

Regardless of age, frailty affects how older patients respond to illnesses and therapies. Interdisciplinary teams are best at meeting the often complex medical, social, and emotional needs of older adults.

Medications need to be re-evaluated regularly and the prescription is often required to be discontinued. Getting up and moving around after an illness is important to preserve mobility. Non-medical interventions, such as paid help at home or training family caregivers, are often as important or more important than medical interventions. A holistic understanding of the physical and social circumstances of older people is essential.

The list of innovations led by geriatricians is long. Some notable examples:

• Hospital at home. Elderly people often suffer setbacks during their hospital stay, as they remain in bed, lose sleep and eat poorly. In this model, elderly people with acute but non-life-threatening illnesses receive care at home, closely managed by nurses and doctors. As of late August, 296 hospitals and 125 health systems – a fraction of the total – in 37 states were authorized to offer hospital-at-home programs.
• Age-friendly healthcare systems. Focusing on four key priorities (known as the “4Ms”) is fundamental to this broad effort: safeguarding brain health (Mentality ), carefully manage the medicines preserve or promote the mobility and attend to what is more important for the elderly. More than 3,400 hospitals, nursing homes and urgent care clinics are part of the age-friendly health systems movement.
• Surgery standards with a focus on geriatrics. In July 2019, the American College of Surgeons created a program with 32 standards designed to improve care for older adults. Hampered by the Covid-19 pandemic, it got off to a slow start and only five hospitals received accreditation. But as many as 20 are expected to sign up next year, said Thomas Robinson, co-chair of the American Geriatrics Society’s Specialist Geriatrics Initiative.
• Geriatric emergency rooms. The bright lights, noise and busy atmosphere in hospital emergency rooms can disorient seniors. Geriatric emergency departments address this with staff trained in elderly care and a calmer environment. More than 400 geriatric emergency departments have received accreditation from the American College of Emergency Physicians.

New models of dementia treatment. This summer, the Centers for Medicare and Medicaid Services announced plans to test a new model of care for people with dementia. It is based on programs developed over the past few decades by geriatricians at UCLA, Indiana University, Johns Hopkins University and UCSF.

A new frontier is artificial intelligence, with geriatricians being consulted by entrepreneurs and engineers developing a range of products to help older people live independently at home. “For me, this is a huge opportunity,” said Lisa Walke, chief of geriatric medicine at Penn Medicine, affiliated with the University of Pennsylvania.

Conclusion : After decades of geriatrics-focused research and innovation, “we now have a very good idea of ​​what works to improve care for older adults,” said Harper of the American Geriatrics Society.

The challenge is to take advantage of this and invest significant resources in expanding the reach of the programs. Given competing priorities in medical education and practice, there is no guarantee that this will happen. But this is where geriatrics and the rest of the healthcare system need to go.

*KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism on health issues and is one of the primary operating programs of KFF – the independent source for health policy research and journalism.