Who will look after older adults? We’ve loads of know-how but too few specialists

Thirty-five years ago, Jerry Gurwitz was among the many first physicians in america to be credentialed as a geriatrician — a physician who focuses on the care of older adults.

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

But today, Gurwitz fears geriatric medicine is on the decline. Despite the surging older population, there are fewer geriatricians now (just over 7,400) than in 2000 (10,270), he noted in a recent piece in JAMA. (In those twenty years, the population 65 and older expanded by greater than 60%.) Research suggests each geriatrician should look after not more than 700 patients; the present ratio of providers to older patients is 1 to 10,000.

What’s more, medical schools aren’t required to show students about geriatrics, and fewer than half mandate any geriatrics-specific skills training or clinical experience. And the pipeline of doctors who complete a one-year fellowship required for specialization in geriatrics is narrow. Of 411 geriatric fellowship positions available in 2022-23, 30% went unfilled.

The implications are stark: Geriatricians might be unable to fulfill soaring demand for his or her services because the aged U.S. population swells for a long time to return. There are only too few of them. “Sadly, our health system and its workforce are wholly unprepared to take care of an imminent surge of multimorbidity, functional impairment, dementia and frailty,” Gurwitz warned in his JAMA piece.

This is way from a brand new concern. Fifteen years ago, a report from the National Academies of Sciences, Engineering, and Medicine concluded: “Unless motion is taken immediately, the health care workforce will lack the capability (in each size and skill) to fulfill the needs of older patients in the long run.” In line with the American Geriatrics Society, 30,000 geriatricians might be needed by 2030 to look after frail, medically complex seniors.

There is not any possibility this goal might be met.

What’s hobbled progress? Gurwitz and fellow physicians cite various aspects: low Medicare reimbursement for services, low earnings compared with other medical specialties, an absence of prestige, and the assumption that older patients are unappealing, too difficult, or not definitely worth the effort.

“There’s still tremendous ageism within the health care system and society,” said geriatrician Gregg Warshaw, a professor on the University of North Carolina School of Medicine.

But this negative perspective is not the complete story. In some respects, geriatrics has been remarkably successful in disseminating principles and practices meant to enhance the care of older adults.

“What we’re really attempting to do is broaden the tent and train a health care workforce where everybody has some extent of geriatrics expertise,” said Michael Harper, board chair of the American Geriatrics Society and a professor of drugs on the University of California-San Francisco.

Among the many principles geriatricians have championed: Older adults’ priorities should guide plans for his or her care. Doctors should consider how treatments will affect seniors’ functioning and independence. No matter age, frailty affects how older patients reply to illness and therapies. Interdisciplinary teams are best at meeting older adults’ often complex medical, social, and emotional needs.

Medications have to be reevaluated often, and de-prescribing is commonly warranted. Getting up and around after illness is essential to preserve mobility. Nonmedical interventions comparable to paid help in the house or training for family caregivers are sometimes as vital as, or more vital than, medical interventions. A holistic understanding of older adults’ physical and social circumstances is crucial.

The list of innovations geriatricians have spearheaded is long. A number of notable examples:

Hospital-at-home. Seniors often suffer setbacks during hospital stays as they continue to be in bed, lose sleep, and eat poorly. Under this model, older adults with acute but non-life-threatening illnesses get care at home, managed closely by nurses and doctors. At the top of August, 296 hospitals and 125 health systems — a fraction of the whole — in 37 states were authorized to supply hospital-at-home programs.

Age-friendly health systems. Give attention to 4 key priorities (referred to as the “4Ms”) is vital to this wide-ranging effort: safeguarding brain health (mentation), fastidiously managing medications, preserving or advancing mobility, and attending to what matters most to older adults. Greater than 3,400 hospitals, nursing homes, and urgent care clinics are a part of the age-friendly health system movement.

Geriatrics-focused surgery standards. In July 2019, the American College of Surgeons created a program with 32 standards designed to enhance the care of older adults. Hobbled by the covid-19 pandemic, it got a slow start, and only five hospitals have received accreditation. But as many as 20 are expected to use next 12 months, said Thomas Robinson, co-chair of the American Geriatrics Society’s Geriatrics for Specialists Initiative.

Geriatric emergency departments. The brilliant lights, noise, and harried atmosphere in hospital emergency rooms can disorient older adults. Geriatric emergency departments address this with staffers trained in caring for seniors and a calmer environment. Greater than 400 geriatric emergency departments have received accreditation from the American College of Emergency Physicians.

Latest dementia care models. This summer, the Centers for Medicare & Medicaid Services announced plans to check a brand new model of look after individuals with dementia. It builds on programs developed over the past several a long time by geriatricians at UCLA, Indiana University, Johns Hopkins University, and UCSF.

A brand new frontier is artificial intelligence, with geriatricians being consulted by entrepreneurs and engineers developing a spread of products to assist older adults live independently at home. “For me, that’s an important opportunity,” said Lisa Walke, chief of geriatric medicine at Penn Medicine, affiliated with the University of Pennsylvania.

The underside line: After a long time of geriatrics-focused research and innovation, “we now have a superb idea of what works to enhance look after older adults,” said Harper, of the American Geriatrics Society. The challenge is to construct on that and invest significant resources in expanding programs’ reach. Given competing priorities in medical education and practice, there is no guarantee it will occur.

Nevertheless it’s where geriatrics and the remaining of the health care system have to go.

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