Aging parents, adult children: the awareness gap

Adult children visit their aging parents for the holidays and discover a refrigerator full of spoiled food, stacks of unopened mail and a parent who seems alarmingly frail or confused. A closer look at the finances reveals unpaid bills or, worse yet, a bank account depleted by scammers.

In online forums for caregivers dealing with dementia, examples of this are abundant. One person describes a house overflowing with clutter and aged parents who were going up and down an unlighted basement stairway to do the laundry. Someone else relates her shock at seeing her father’s house fall into disrepair as he became more disabled.

Can adult children be so disconnected or so deep in denial that they don’t see what’s happening to their own parents?

Sometimes that’s the case. But let’s not be too quick to judge, because there can be a considerable gap between how older adults present themselves to the world and how they truly fare on a day-to-day basis.

“As the child who lived close by when my parents were still in their home and having siblings who lived far away, there may be a lot more going on in their home than you may be aware of,” wrote a member of an online Alzheimer’s forum.

This family felt their father’s cognitive skills were fine. But “there was a lot going on behind the scenes with them that they hid well,” she wrote.

In fact, it’s far from unusual for older adults to hide their struggles with health, cognition and daily life from those around them. And it’s far from unusual for adult children or other relatives to have difficulty gauging the severity of the situation or knowing when to take action.

Carolyn Rosenblatt, a contributor to Forbes who writes about healthy aging and caregiving, describes a typical scenario:

The signs are subtle at first. The brain-destroying disease that creeps up unannounced and steals your loved one comes in disguise. “Maybe he’s just getting old”, you tell yourself.

Your aging parent may have noticed being unable to remember things for some time. Dad will compensate by changing the subject, or finding some other words to replace the ones he can’t find. But he might just stop in the middle of a sentence.  He works at covering up the problem.

Mom will insist she’s fine. She knows she isn’t but doesn’t want you to find out. She’ll do anything to keep her memory loss a secret. She fears you’ll put her in a home. To her, that’s a death sentence.

When the adult children live far away and can’t – or don’t – visit their parents often, which is increasingly the case for many families, it becomes even more challenging for them to accurately assess the situation.

The issue can be compounded by reluctance or refusal to talk about what’s really going on, leading to significant gaps in knowledge and, by extension, readiness for caregiving. When The Boomer Project conducted a survey for Home Instead Senior Care a few years ago, only about one in 10 of the adult children who responded were realistic about the likelihood of being thrust unexpectedly into caring for their parents.

Nor were they well informed about their parents’ health. Only about half were knowledgeable about their parents’ medical conditions or could name any of the medications their parents took. Forty percent didn’t know the name of their parents’ primary care doctor or whether their parents even had a primary care doctor.

At this time of year, providers of services to older adults start receiving a barrage of phone calls from worried adult children who come home for the holidays and discover their parents aren’t doing as well as they thought.

Older adults and their grown children may think that as long as everything seems OK, there’s no need to plan for the future. But this mindset can lead to a family crisis, experts say.

Waiting for “the right time” to have a honest, respectful discussion with aging parents about their needs won’t cut it, because it can be too late sooner than you think, Rosenblatt writes. “You don’t want to be the one lulled into a false sense of security because no one has diagnosed your aging parent with a specific form of dementia. It doesn’t matter. Trust your own eyes and ears. If your gut tells you there’s something wrong here with your loved one, there probably is something wrong.”

Further resources:

Tips for starting sensitive conversations

Recognizing the difference between ordinary forgetfulness and signs of dementia

‘Looks older than stated age’

Pity the young, pretty blonde doctor who’s constantly mistaken for being less accomplished than she truly is.

“Sexism is alive and well in medicine,” Dr. Elizabeth Horn lamented in a guest post this week at Kevin, MD, wherein she describes donning glasses and flat heels in an attempt to make people take her more seriously.

As someone who used to be mistaken for a college student well into my mid-20s, I certainly feel her pain. But let’s be fair: Doctors judge patients all the time on the basis of how old they appear to be.

It’s a longstanding practice in medicine to note in the chart whether adult patients appear to be older, younger or consistent with their stated age. Doctors defend it as a necessary piece of information that helps them discern the patient’s health status and the presence of any chronic diseases.

According to theory, patients who look older than their stated age are more likely to have poorer health, while those who look more youthful than their years are in better health. But does it have any basis in reality? Well, only slightly.

An interesting study was published a few years ago that examined this question. The researchers found that patients had to look at least 10 years older than their actual age for this to be a somewhat reliable indication of poor health. Beyond this, it didn’t have much value in helping doctors sort out their healthy patients at a glance. In fact, it turned out to have virtually no value in assessing the health of patients who looked their age.

Other studies – and there are only a few that have explored this issue – have come up with conflicting results but no clear consensus, other than the conclusion that judging someone’s apparent age is a subjective undertaking.

When there’s such limited evidence-based support for the usefulness of noting the patient’s apparent age, then why does the habit persist?

I’ve scoured the literature and can’t find a good answer. My best guess is that doctors are trained to constantly be on the lookout for risk factors – which patient is a heart attack waiting to happen, which one can’t safely be allowed to take a narcotic, which one is habitually non-adherent – and assessing apparent age vs. actual age is one more tool they think will help, a tool they may have learned during their training and continued to use without ever questioning its validity.

Appearances can be deceiving, however. A patient who looks their age or younger can still be sick. Someone who looks older can still be relatively hale and hearty.

And beware the eye-of-the-beholder effect. One of the studies that looked at this issue found that younger health care professionals consistently tended to overestimate the age of older adults. When you’re 30, everyone over the age of 60 looks like they’re 80, I guess.

Whether you’re a young physician fighting for the respect your training commands or a patient fighting against assumptions in the exam room, the message is the same: You can’t judge a book by its cover.

Downsizing all the stuff

If you’ve ever had to downsize your belongings or help a parent or aging relative with downsizing, what you’re about to read will come as no surprise.

Most of us possess an enormous quantity of stuff. Stuff we don’t use and don’t need, yet continue to hang onto for whatever reason.

Although consumer spending looms large in the American economy, there’s been little research on what we actually do when it comes to keeping and disposing of our many possessions, especially as we get past middle age.

A recent study in the Journals of Gerontology: Series B tackles this issue and concludes that although many older adults find comfort and identity in the things they’ve accumulated during their lifetime, the sheer quantity can become burdensome – not just to the owner but also to relatives who might eventually be forced to deal with all the excess belongings.

The study also turned up a finding that could make many of us think twice before procrastinating on cleaning out the attic or the closets: Past the age of 50, we become less and less likely to dispose of our possessions.

The researchers drew their findings from the 2010 Health and Retirement Study, an annual survey of Americans 50 and older that for the first time included four questions about what people did with their belongings. What they found: 30 percent of respondents who were over age 70 had done nothing in the previous year to clean out, donate or dispose of excess belongings, and 80 percent had sold nothing. Even after controlling for various factors such as widowhood or a recent move from a house into a small apartment, activities to reduce what the authors call “the material convoy” consistently grew less with advancing age.

Yet more than half of the survey respondents in all age categories felt they had too much stuff. Among those in their 50s, 56 percent believed they had more possessions than they needed; for those in their 70s, it was 62 percent.

(To be clear, we’re talking here about the ordinary lifetime accumulation of possessions, not hoarding.)

One need only look at the proliferation of articles and advice about downsizing to recognize this as a growing social issue. What happens to all the belongings we no longer need or have room for as we age – does most of it end up in landfills? What about older adults who have a large accumulation of stuff they haven’t disposed of – does it become a hindrance to moving into a living situation that might be safer or more manageable? Who makes decisions about the stuff if the owner is unable to do it himself or herself?

Perhaps this is a problem unique to the current older generation, folks who came of age during the Depression and who tend to save and reuse things instead of throwing them away. Then again, the increasing square footage of the average American house (1,740 square feet for the average new single-family home in 1980; 2,392 square feet for the same home in 2010) suggests that with more space, younger families may fill it with more belongings than their parents ever had, thus perpetuating the problem when it’s eventually their turn to downsize.

Perhaps declining health and reduced stamina simply make it harder to deal with excess stuff as we get older, regardless of which generation we belong to. There’s an emotional aspect as well to parting with items that we’ve lived with for many years.

How we accumulate and dispose of our possessions might seem like a purely personal issue but bigger issues are at stake, the study’s authors wrote. While we may treasure our belongings, the stuff can also become burdensome, especially as we age and our vulnerability increases. “To the extent that possessions – not just single, cherished items but in their totality – create emotional and environmental drag, individuals will be less adaptive should they need to make changes in place or even change place,” the researchers wrote. “The material convoy is not innocuous, mere stuff; its disposition must be undertaken sooner or later by someone. The realization of this is why the material convoy – personal property – becomes an intergenerational or collective matter.”

Additional reading on downsizing an aging household:

20 tips to help you get rid of junk

Family things: Attending the household disbandment of older adults

Tips to help you get a grip on downsizing possessions

Moving in with the adult children

Are middle-aged adults ready to have their aging parents move in with them?

Sort of, but if the results of a recent survey are any indication, many adult children anticipate there will be some difficult moments – if, indeed, they’ve thought about it at all.

The survey was released this week, just in time for Mother’s Day. It was commissioned by Visiting Angels, an in-home senior care company with some 450 private-duty agencies across the United States, and provides a revealing snapshot of how adult children view their responsibilities toward aging parents.

The good news: Most of the survey participants (there were 1,118 respondents age 40 and over, three-fourths of whom were women) said they would do whatever it takes to look out for their parents. Nor were they motivated by hopes of an inheritance; three out of four said they would pay for a parent’s care out of their own pocket if necessary.

The not-so-good news: Most adult children haven’t spent much time thinking about any of this. In fact, almost three-fourths of the survey respondents said they didn’t have a plan for taking care of an aging parent. And about half had never even talked to their parents about the kind of care they want as they age.

This is no small issue. Middle-aged adults increasingly are caught between managing their own lives and caring for an older parent (and often looking out for their own children as well).

Some interesting statistics from a Pew Research Center report released in January:

– Nearly half of American adults in their 40s and 50s have a parent who is 65 or older, and about one in five provided financial support to an aging parent.

– The majority believed adult children have a responsibility to take care of their parents.

– Adult children are a leading source of emotional support as well as financial and practical help for older parents. Also, their responsibilities usually increase as their parents get older.

But as the Visiting Angels survey revealed, decisions about a parent’s living arrangements adds a whole new layer of issues. The survey found, for instance, that lack of room and lack of privacy were the two biggest concerns among adult children contemplating having a parent move in with them. Only 31 percent wanted their parents to move in with them, and four out of 10 said they preferred to have their parents remain in their own home with a caregiver.

The survey uncovered potential for conflict among siblings as well. When asked which of the adult children should have the most responsibility for Mom and Dad, here was the breakdown: Adult children who live closest to their parents topped the list, followed by the child perceived to have fewer other responsibilities, i.e. no spouse and/or children, and lastly by the child who was the most secure financially. (The survey didn’t ask whether adult children felt this was fair.)

In a final and telling statistic, close to half of the survey respondents anticipated some kind of conflict with a parent, a sibling or a spouse or significant other over decisions on how to care for an aging parent.

When recently posed the question, “Do you regret the decision to have an elderly parent move in with you?”, there were more than 200 responses ranging from positive to frustrated to outright at-the-end-of-my-rope.

“Yes, I regret agreeing to move cross country, leaving my good paying job and becoming primary caretaker for my father-in-law. God help me, I am so looking forward to this being over,” one person wrote.

Someone else lamented how her parents took over the family’s life after moving into a specially built addition to her home. “What I forgot when we decided to let them live with us is that they have never had a respect for our privacy and my father and I have never gotten along,” she confessed.

Yet another commenter was enduring sleepless nights, wondering whether to have her mother move in with her. “If she lives here our lives will completely revolve around her,” she wrote.

But then there were responses like this one: “I love having my Dad live with me… When I was a kid, he worked all the time, so I missed out on a lot of time with him. Now I REALLY know my Dad, and he is a wonderful man.”

Many adult children seem realistic about the issues they’re likely to face as their parents grow older, even if they haven’t thought too deeply about it yet.

But if the survey results, and the voices of those who’ve already been there, are any indication, adult children ought to start thinking well ahead of time about the what-ifs. Too often, decisions aren’t made until there’s a crisis and everyone’s emotions are running high, says Larry Meigs, CEO of Visiting Angels.

His advice: “You need to meet now with your parents and siblings to decide on a solution that appeals to everyone involved.”

A new view of successful aging?

Amid the flood of news coverage that followed Pope Benedict XVI’s surprise announcement yesterday that he is retiring this month as the spiritual leader of the world’s 1.1 billion Roman Catholics, there were constant reminders of his age – 85 years – to illustrate that the Pope is in fact elderly.

Commentators wasted no time examining his infirmities: his difficulties with walking, for instance, and his declining vigor.

For someone of advancing years, this is hardly unusual. At 85, the Pope has joined the ranks of what’s often referred to as the “old old” – those 85 and older (ages 65-84 are known as the “young old”).

It raises a question, however: What do we really mean when we say someone is “old”, and what does it mean to age well?

For years, successful aging has been defined as aging in good health. A recent study in the Canadian Medical Association Journal, for instance, defined successful aging past 60 as: good cognitive, physical, respiratory and cardiovascular functioning; absence of disability; absence of mental health problems; and absence of chronic disease such as coronary artery disease diabetes, stroke or cancer.

But an intriguing new paper, published late last year in The Gerontologist, challenges this as too narrow a definition.

The authors interviewed 56 older adults at an eldercare program in California to explore their perceptions about being old and aging successfully. The participants represented a cultural cross-section that included whites, African Americans, Latinos and Cantonese-speaking Chinese.

All of them had at least one late-life disability which, objectively speaking, excluded them from most traditional definitions of successful aging. But as the researchers talked with these older adults, they learned that the majority saw themselves as aging successfully anyway. The elders who felt this way had an attitude of counting their blessings, of being able to adapt and reframe their situation in ways that helped them cope.

Have we taken too limited a view of aging? If you consider successful aging to be the absence of any disease or disability, most of the population would likely flunk this test. Even with optimal health behavior, most people will eventually acquire some health baggage as they age.

The real message of this study, say the researchers, is that the definition of successful aging ought to be broader and more realistic.

“Efforts to minimize disease and disability in late-life are important and cannot be dismissed; however, it is inevitable that everyone will age, and for most, a period of deterioration will precede death,” they wrote. “… From a policy perspective, the major implication is that more funding should be directed toward understanding and supporting those who live with late-life disability, as opposed to the current emphasis on prevention.”

The awkwardness of open notes

Do patients really need to know what the doctor is thinking? The potential awkwardness of sharing the doctor’s notes, especially with older patients, was explored this week at The Health Care Blog, where it generated some interesting discussion about the pros and cons of how much information patients should be allowed to have.

It’s not that she’s against transparency or believes patients shouldn’t be engaged and have open access to their medical record, Dr. Leslie Kernisan writes. “It’s because in my own VA practice caring for WWII vets, I used to frequently document certain concerns that would’ve been a bit, shall we say, awkward for the patient to see. Reading about these concerns would’ve quite possibly infuriated the patient, or the caregivers, or both.”

She lists the sensitive areas: Possible cognitive impairment. Possible substance abuse, especially alcohol. Possible prescription misuse or diversion. Possible elder mistreatment. Concerns about ability to live safely at home or safely drive. Concerns voiced by family or caregivers.

Many of these can be issues regardless of the patient’s age. But they’re of particular importance in caring for geriatric patients, and they have a history of being under-recognized and under-addressed in the clinic setting, Dr. Kernisan writes.

It’s delicate to talk to a patient and family about the possibility of Alzheimer’s disease, or to suggest that an elderly person might no longer be able to manage independently at home or drive a car, she writes. It can get even more complicated when caregivers and family members are involved. Do the doctor’s private observations and speculations about what’s happening with the patient belong in an open medical record?

Dr. Kernisan wonders: “I’m not sure what I’d do if I were told tomorrow that all my patients (and whichever caregivers the patients give access to) would be able to read everything I write about them. For the most part, it would be fine, but I’d certainly have to work out an approach for handling the awkward issues I describe above.”

Complete open access to the medical record – including the doctor’s notes – is still fairly new, and there’s considerable learning yet to be done on how doctors adapt to it, how patients react to it and whether it has an effect, positive or negative, on the doctor-patient relationship.

OpenNotes, the largest project to date that has implemented and studied open access to the doctor’s notes, may have eased some of the early concerns about sharing more of the doctor’s thought processes with patients. According to the results so far, it hasn’t been more time-consuming for doctors or upsetting for patients to incorporate open notes in patient care. Most of the participants in fact have given it glowing reviews, and it seems to be fostering more patient engagement.

As Dr. Kernisan points out, however, the patient population in the OpenNotes study is middle-aged on average; what about elderly patients who may be dealing with dementia, vulnerability, loss of independence and other difficult issues unique to their stage of life?

The responses to Dr. Kernisan’s blog have been rather revealing in terms of who’s saying what.

A physician commenter felt it could be too anxiety-inducing for patients to read the entire contents of their medical record, doctor’s notes and all. “It’s not so much that I put things in patients’ notes that I don’t want them to see, it’s that some of the things they see they don’t have the knowledge to interpret,” she wrote.

There may be benefits to “limited access,” she wrote, “but only if the doctor is available and compensated for making sense of it to their patients.”

A biomedical and computer scientist with a Ph.D. suggested that sensitive notes be kept  in a “vest pocket” section of the record, inaccessible to patients.

Not surprisingly, laypeople saw it differently. One person wrote:

If you’re my doctor, I want you to discuss your concerns with me. If you’re wondering about cognitive impairment, it’s very likely that I already worry about that. Writing it in your notes without telling me seems… Well, you’d have to explain your rationale.

The reaction from someone else: “Sensitivity is not secrecy – it is learning to say the whole truth with tact and with a compassionate understanding of how the knowledge will be applied.”

Although it was left unsaid, the entire debate raises the question: If sharing the doctor’s notes can lead to moments of awkwardness, for whom is it most awkward – the doctor or the patient?

Here’s another question: Should there be different standards of openness depending on the patient’s age?

Many people want to be able to exercise more preference over how much information they receive. Some may only want limited information and would probably make little use of open notes if they were available. But others want more and are willing to accept the anxiety, the uncertainty and whatever other negative emotions might arise as a result of reading their medical record.

As the ongoing open-notes debate shows, however, doctors have reservations about whether this is always best for the patient. Is there any way these two perspectives can be brought closer together?

Update, Jan. 28: Two of the pioneers in the OpenNotes initiative respond on The Health Care Blog with some observations on their own experiences with open notes and on the conversations they’ve had with other providers.

Who’s old? Not I

To someone in their teens or early 20s, anyone over 30 is old. When you’re in your 40s, the 70s seem impossibly ancient. And when you’re 70-something? Well, then it’s the octogenarians who are old.

We think we know what it means to get old, yet our perceptions often are fueled by stereotypes about older adults – and as with most stereotypes, it can end up doing more harm than good.

The down side of pigeonholing older adults was astutely explored in a recent entry at the Covering Health blog. Although it was aimed primarily at reporters, it contains a larger message about what can happen when we categorize older adults as “old” instead of seeing them for what they are: a highly diverse population with diverse needs and in diverse states of health.

For starters, older adults themselves often don’t perceive themselves as old, writes Judith Graham, topic leader on aging for the Association of Health Care Journalists.

She cites a 2009 study by the Pew Research Center that reveals some interesting insights about aging. Here’s one: Of the adults over age 65 who participated in the poll, 60 percent said they felt younger than their actual age, and many said they felt 10 to 20 years younger than they actually were.

Here’s another: There’s a measurable gap between what younger adults expect their lives to be like as they get old – negatives such as memory loss, loneliness, depression – and what older adults report as their own experience.

In other words, despite the stereotypes, aging often isn’t the burden younger adults think it is.

So why do we persist in viewing the elderly as, well, elderly – and, more to the point, what are the consequences of doing so? Some provocative studies have suggested that when older adults internalize the widespread cultural stereotype that to get old means to become frail and diminished, they are more likely to be in poor health and less likely to take care of themselves, Graham writes.

In response, there has been a push to rewrite the script on aging to portray it in more positive terms, she writes. But beware making too many assumptions in this direction, Graham warns:

The danger here is that efforts to create a new narrative focused on the positive aspects of aging – one that centers on activity, wellness, encore careers, volunteering, and having more time to spend with friends, family – risks marginalizing older people who aren’t especially healthy or well off financially.

I’d add that it also risks sending the message that older adults who aren’t as healthy are somehow doing it wrong and are in need of being “corrected.”

To be sure, efforts to create a better, more healthy old age are beneficial, not only to individuals but to the communities they live in as well.The key, points out Graham, is to view older adults as individuals, each with his or her own life story, challenges and desires. When she advises that “there’s no substitute for face-to-face interactions,” she could be talking about the setting of the medical exam room, the hospital room or the skilled nursing facility.

It may take time to encourage older adults to talk about themselves, Graham says. “But I suspect you’ll be surprised by what older people will tell you, if you take the time, suspend judgment and truly listen.”

Is the doctor too old?

Here’s a dilemma: The doctor is 83 years old and still seeing patients. There’ve been no complaints – so far – about the quality of his care, yet hospital leaders sense it’s only a matter of time before a patient is harmed.

How do you transition an aging physician out of patient care in a way that’s both dignified and safe? Dr. Kenneth H. Cohn recently asked this question on the Hospital Impact blog, triggering an interesting online discussion about the difficult balance between protecting patient safety and respecting an aging doctor’s skills and knowledge.

It’s not an idle question. Americans are getting older and this includes doctors. “This challenge of guiding aging physicians will come up with increasing frequency over the next decade,” Cohn notes.

Look no further than here in Minnesota, where nearly one-third of all the state’s practicing physicians in 2008 were 55 or older. Slightly more than 7 percent were over the age of 65.

A report produced by the Minnesota Department of Health on the physician workforce notes these statistics about older doctors: 19 percent of doctors who were actively practicing in Minnesota in 2008 (this was the most recent year in which workforce information was collected) said they planned to retire in the next five years and more than 40 percent expected to retire within the next 10 years. But of even more note, 10 percent of the doctors older than 65 planned to work for at least another decade.

American society is starting to redefine what it means to retire, and I suspect we’ll be seeing an increasing trend of doctors continuing to practice medicine well into their 70s and possibly even 80s. The recession also has caused many doctors to rethink their retirement plans and decide to work longer.

It’s not unreasonable to wonder whether older doctors can continue to keep up and still provide quality care.

Consider a New York Times article published a year ago that explores this challenge. It outlines the case of a 78-year-old vascular surgeon whose skills were called into question after a patient died. He remained in practice for another four years until a competency assessment was finally ordered, revealing serious cognitive deficits. The surgeon was asked to surrender his license.

The article cites a 2005 study that found doctors who’d been out of medical school for 40 years were more likely to face disciplinary action than doctors practicing for only 10 years.

Just because a doctor is getting old doesn’t mean he or she is no longer fit for medicine, the article notes. “But physicians are hardly immune to dementia, Parkinson’s disease, stroke and other ills of aging. And some experts warn that there are too few safeguards to protect patients against those who should no longer be practicing.”

The generation gap isn’t a new issue in medicine. I blogged awhile back about the differences between old and young doctors. Which is better – youth, energy and the latest knowledge or skills acquired and refined through years of experience? How do you help aging doctors recognize their fallibility without selling them short?

Cohn asks this question on his blog and got some thoughtful responses. One physician wrote: “I consider [m]andatory [r]etirement blatant age discrimination that opens up the possibilities of legal suits and rests on the premise that after a certain age, a different standard is arbitrarily applied in the physician credentialing process.”

Perhaps physicians past a certain age could be required to undergo a cognitive assessment to ensure they’re still able to practice skillfully and safely, someone else suggested – but neurocognitive tests aren’t always reliable, plus there’s the issue of who would pay for it, he wrote.

Another commenter offered a different perspective. He wrote that he has a neighbor who’s a doctor and is about to turn 90. “He volunteers at a nearby free clinic 2-3 days a week. They use his considerable experience effectively and they have a dialogue regarding limitations of practice. It is rewarding for my neighbor and provides a real and needed service to our community.”

Rather than putting older doctors out to pasture, we should find ways to make meaningful use of their skills and experience, urged another commenter. Helping them stay productive would benefit society and allow aging doctors “to ride into their sunsets with graceful dignity and a sense of fulfillment.”

Regardless of age, most doctors want “meaningful work that makes a difference in patients’ lives, a sense of community, and regular and reliable feedback that affirms their value,” Cohn concluded. But as they get older, it’s a good time to think about how they want to be remembered, he suggested. “Legacy becomes increasingly important when the marginal value of seeing one more patient diminishes.”

The next big health story

What’s going to be the big health story of 2012 – health care reform? The impact of state and federal health spending cuts?

Nope. The next attention-grabbing story could well be about the future of Medicare, the federal program that covers millions of older Americans. This is the assessment of Trudy Lieberman, a contributing editor at the Columbia Journalism Review, who recently blogged about Medicare’s ascendancy as an issue of critical importance.

I’m inclined to agree.

Medicare is headed for a crossroads. Given the size of the federal budget deficit, cuts to the Medicare program are almost inevitable and will likely hit both providers and enrollees – the former in the form of less pay for caring for these patients and the latter in more out-of-pocket costs. The millions of baby boomers poised to become eligible for Medicare over the next couple of decades will only add to the pressure.

Lieberman writes that the outcome of the policy debate about Medicare “will determine whether nearly 50 million older and disabled people will be able to afford health care at all and what kind it will be.”

Most people’s eyes tend to glaze over when the conversation turns to Medicare. It’s not an exciting topic. I’d argue we should make a better effort to pay attention, however, because as with any policy discussion of this magnitude, decisions ultimately will trickle down to the local level.

Imagine, for instance, the hard decisions some doctors might have to make between turning away Medicare patients vs. losing money by continuing to see them.

To be clear, there’s no evidence this will become a widespread trend. But physicians are talking about it and some of them have already taken the step – for instance, a family practice clinic in Raleigh, N.C., that stopped seeing new Medicare patients three years ago. One of the partners told WRAL TV, “Our job is to take care of patients, which is what we love, but if we can’t run our business, we can’t take care of any patients.”

A potentially even larger issue is what might happen if seniors have to start paying more out of pocket for their care.

Lieberman points out, “When you consider that the median income for older women receiving Social Security is only about $15,000 a year and for men about $26,000, you can see why they get upset when there’s talk of cutting benefits or ending the program. Without it, they would get no health care.”

I’d hate to think of this happening to my parents or, for that matter, to any of us as we get older. While it’s true that health decisions made in our younger years can help make or break our health in later years, there’s no escaping the fact that age is an overall risk factor for health issues, period. The social cost of creating an entire future generation of aging adults unable to afford health care hardly even bears thinking about.

What’s the solution for Medicare? I wish I knew. In the meantime, I plan to stay tuned to the debate.

The case for geriatricians

If ever there was a case to be made for the importance of gerontology as a medical specialty, it can be found at the GeriPal geriatrics and palliative care blog, where several recent entries focused on the special needs and dynamics surrounding health care for older adults.

One entry explored what’s known as “hospital disability syndrome,” or the downward spiral that can occur among older adults for whom a hospital stay might result in higher risk of falls, delirium, poor nutrition and functional decline.

Another entry raised important issues about the growing use of standard, one-size-fits-all indicators to measure quality of care. While rigorous control of blood pressure and blood sugar is beneficial for the majority of adults, it can result in more medication, a higher risk of side effects and a higher risk of harm for older patients, blogger Ken Covinsky wrote. “A key issue is that quality indicators almost always promote more medical intervention and more medical is not always better. This is especially the case for frail older persons, where the risk of treatments often exceeds the benefits.”

Finally, an entry titled “Too Much of a Good Thing” analyzed a recent study in the New England Journal of Medicine about emergency hospitalizations among older adults due to adverse drug events, and drew two conclusions: First, many of the older patients in the study got into trouble because they were receiving too much of a prescription medication – for instance, too much insulin. Second, many of the less obvious adverse drug events among the elderly, such as drug-induced delirium, can be difficult to recognize in the emergency room and indeed might not be identified at all.

Geriatrics is defined as “the branch of medicine concerned with the diagnosis, treatment and prevention of disease in older people and the problems specific to aging.”

It’s not a specialty that carries much allure. Doctors who specialize in geriatrics tend to earn some of the lowest salaries in medicine. Moreover, in America’s youth-obsessed culture, caring for aging patients with multiple health issues often holds little appeal.

It’s not surprising, then, that the U.S. health care system is woefully short of geriatricians, even as the number of older adults has been rising dramatically. According to the Geriatrics Workforce Policy Studies Center of the American
Geriatrics Society, only 86 students who graduated from medical schools in the U.S. in 2009 chose geriatrics as a specialty. That’s fewer than 1 percent of family medicine and internal medicine grads. And it’s not for lack of training slots, because about half of the fellowships available in gerontology were left unfilled.

The Geriatrics Workforce Policy Studies Center estimates there’s currently one geriatrician for every 2,620 Americans over the age of 75. By 2030, this ratio is projected to fall to one geriatrician per 3,798 older adults.

You could argue that we don’t really need specialists in geriatrics. Why can’t the care of aging adults be managed just as well by internists or family medicine physicians? There’s in fact a fair amount of debate on this point, helped along by confusion on the part of many patients and families about what, exactly, a geriatrician does.

To be sure, many internists and family medicine doctors are skilled and knowledgeable in caring for the elderly. And not everyone who’s old necessarily needs to have a geriatrician, particularly if they’re relatively healthy.

But let’s not underestimate what geriatricians bring to the table. In “The Way We Age Now,” a lengthy article that appeared in 2007 in The New Yorker, Dr. Atul Gawande takes readers into the world of aging, what it means in the medical sense to age, and what it takes to help older adults remain healthy and functional.

Gawande makes many important observations about care of the elderly, one of them being this: “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.”

And this: “People can’t stop the aging of their bodies and minds, but there are ways to make it more manageable, and to avert at least some of the worst effects.”

Although primary care doctors can certainly fulfill this role, it’s perhaps unrealistic to think they’ll be able to keep up with the new research being added almost daily to what we know about aging. Moreover, it takes both expertise and experience to understand the nuances surrounding geriatric health – to recognize, for instance, that when we talk about rigorous cut-off points for blood sugar levels, it can be harmful to older adults whose bodies don’t function the same way as younger adults and who have much more to lose from side effects such as dizziness leading to falls.

If we can’t buy into geriatrics from the standpoint of enhancing the quality of life for older adults, maybe we’ll be swayed by the economics of what it’s likely to cost if we don’t become better at meeting the health needs that come with aging.

Photo: Wikimedia Commons