As a growing elderly population faces economic pressures and a societal shift in family dynamics, physicians now are facing different challenges when treating elderly patients as opposed to younger ones.
According to several Mid-South physicians specializing in geriatric medicine, challenges include a lack of available family members to care for elderly relatives, polypharmacy and a shortage of physicians to treat the elderly. Despite the difficulties, physicians say advancements in pharmacology, telemonitoring and a team-based treatment approach can aid in preventing conditions from developing and keep elderly patients out of the hospital.
“We tend to lump older adults together, but a treatment that may work for a 65-year-old isn’t the same for an 85-year-old,” said Robert Burns, MD, a physician with Geriatrics Group of Memphis and professor of preventive medicine with the University of Tennessee Health Science Center. “As adults get older, they acquire diseases and health risks increase. A 65-year-old man is still working, robust and healthy. Typically, this isn’t the case for an 85-year-old. The complexity of care increases as the patient ages.”
In addition to varied treatments, family dynamics have shifted compared to a decade ago, according to Jeff Mullins, MD, a physician with MidSouth Family Medicine.
“People are living longer and children have moved far away from their parents,” Mullins said. “In many cases there aren’t any family members geographically close to look after them and make sure they eat right and take their medication correctly.”
A report titled “Family Caring For an Aging America" was released last month by the National Academies of Sciences, Engineering and Medicine, non-profit institutions that provide independent, objective analysis and advice for solving complex problems and inform public policy decisions related to science, technology and medicine. The report said nearly 18 million Americans care for family members 65 and older, but the pool of potential family caregivers is shrinking.
The report found that family caregivers assist the elderly in things from wound care to daily living tasks, and in some cases the family caregivers care for more than one family member, yet they do not receive proper training.
“Caregivers are highly important to both the patient and the physician because they make sure the patient receives daily exercise, takes medication properly and eats a nutritious meal,” Mullins said. “They also provide social interaction for the patient, which reduces dementia.”
According to Linda O. Nichols, PhD, co-director of the caregiver center at the Memphis Veterans Affairs Medical Center and professor of preventive medicine at UTHSC, the report recommended that the Department of Human and Health Services and the Department of Veterans Affairs work with healthcare systems to train family caregivers on the proper care for elderly patients at home and encourage physicians to include the family caregivers in the care of patients. She was one of 19 experts who collaborated on the report.
In addition to a lack of available caregivers, patient care can become fragmented, which can lead to polypharmacy, according to both Burns and Mullins.
“As people get older, they develop multiple health issues and they tend to see several specialists depending on the ailment,” Mullins said. “If not monitored by a family caregiver, internist or family medicine practitioner, polypharmacy can easily occur.”
Polypharmacy refers to the effects of taking multiple medications concurrently to manage coexisting health problems.
“In some cases, a patient could be taking 10 to 15 medications which could be interacting with one another,” Burns said. “It’s not uncommon for an elderly patient to see three physicians for different issues, which means the patient is on more drugs and has more tests and procedures.”
According to the Center for Disease Control, 76 percent of Americans over 60 use two or more prescription drugs and 37 percent use five or more.
Mullins and Burns say it’s important for the patient’s internist or family medical practitioner to take a team-based approach and be a gatekeeper for specialists.
“It’s important for physicians to work together to make sure the patient is taking the right medications,” Mullins said. “I make sure to coordinate care for the patient and pay attention to any possible drug interactions.”
Burns said other avenues are in place to make sure the patient takes the correct medications. Medicare Part D has pharmacy benefits managers who look at patients’ medications and check for any adverse effects.
Pharmacists do this as well, said Anna Rikard, PharmD, a pharmacist with Walgreens who is board certified in geriatric medicine.
“Pharmacists perform medication therapy management with complex patients who take multiple medications,” she said. “It’s a service we provide, which is paid for by the insurance companies. We set up an appointment to go over the patient’s over-the-counter and prescription medications to look for any drug interactions and adverse effects, as well as counsel the patient on how to take the medication properly. We create a medication action plan with patients so they can have the control and manage their own care properly.”
With a shortage of physicians on the horizon, doctors must think of new ways to treat patients, especially the indigent and elderly population, Mullins said.
“The goal is to provide better care, but there are more sick people than physicians to treat them,” he said. “It’s important to have physician assistants, nurse practitioners involved in their care, as well as telemonitoring. We can treat 50 more patients by monitoring their health at home even though we do not see them face-to-face. If we didn’t have this, there would be a crisis. Collaboration of good minds results in good care of patients.”
Telemonitoring refers to when a patient’s health is monitored electronically and the results are sent to a nurse or physician in real time.
“We can check a patient’s weight, blood pressure and oxygen saturation level with real time monitoring from home without the patient being seen in the physician’s office,” Mullins said. “For instance, if a patient’s blood pressure goes up at home two months before their follow-up appointment, a doctor can treat that quickly. This makes it easier to keep the elderly out of the hospital. We have better outcomes when the patient doesn’t go into the hospital. We need to get to a place where we prevent conditions instead of chase them, and this is the first step.”
Burns said the future of geriatric care will be very different than it's been the last 30 years, and it’s growing. According to the National Academies of Sciences, Engineering and Medicine report, 14 percent of the current population is over 65, and by 2030 that group will be over 20 percent. Burns said they will have different expectations.
“The baby boomers are a different group,” he said. “They will push innovation, they are familiar with technology, know computers and believe that anything is possible. There will be different expectations of hospital systems and providers.”
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