- The Washington Times - Monday, February 12, 2007

Margaret Pergler goes to the doctor more than most people. At age 93, she has had three hip replacements, a knee replacement, two disks replaced in her cervical spine, four surgeries on her hands because of arthritis, cataract surgery and treatment for uterine cancer.

The Alexandria woman is thankful that she has found one doctor to coordinate her many health needs — a geriatrician. Otherwise, she says, her life would be more complicated than it already is.

“I accepted the fact that I was getting too old for a lot of things,” Ms. Pergler says. “I still get around when I want to. I enjoy my time. I do really. I read a lot. I do some things around the house still. I cook. I can’t say I clean a lot anymore. I have a good life.”

Geriatricians are experts at managing the multiple problems and medications of the elderly. However, because of a shortage of the specialists, the American Geriatric Society says it is estimated that by 2030 there will be only one geriatrician for every 7,665 older adults.

Elderly patients have different needs than other patients, says Dr. Beal Lowen, an internist and geriatrician who has a private practice at Mount Vernon Internal Medicine south of Alexandria and in Lorton. He also is an attending physician at Inova Mount Vernon Hospital.

“The treatments are often less aggressive,” Dr. Lowen says. “The goals are different. The patients’ perceptions of their lives come very much into play. People who have lived a long time have a different perception of mortality.”

Many times, the elderly fear illness more than death, Dr. Lowen says. Further, an older person metabolizes medicine differently than middle-aged people.

“Just as you would handle medications in a pediatric practice, in a geriatric practice, your pharmacology changes,” he says.

Geriatric doctors have expertise in the process of aging, common conditions of older adults, how the health care system serves older adults’ needs, the transition of care across care sites, and working with a multidisciplinary team, says Dr. Samuel Durso, clinical director of geriatric medicine and gerontology at Johns Hopkins University School of Medicine in Baltimore.

Further, about 50 percent of patients older than 65 have three or more conditions, he says. Prioritizing those conditions is an important part of balancing care of the elderly. The person shouldn’t have more medications than is helpful. Preservation of independence and function is also something to consider.

“You try to understand what is foremost in the patient’s mind about what is important to them,” Dr. Durso says. “This should be true to all patients, particularly true as patients enter the last phases of adulthood.”

Treating pain, reducing the burdens of medications, longevity, and being close to family and friends are among the considerations of the elderly, he says.

Once a patient with an irregular heartbeat requested not to take an anticoagulant because it can cause bleeding. Because she didn’t take the anticoagulant, she had a higher risk of stroke, he says. Eventually, she did have a small stroke, but she still didn’t want to take the medication.

“These kinds of decisions are common,” Dr. Durso says. “Sometimes things like guidelines are not foremost in a patient’s value system. Geriatricians are accustomed to it because patients have many competing preferences besides the outcome of a disease.”

Because the number of geriatricians is insufficient for the population and only getting worse, care for older Americans should be a significant point of reformation in the health care system, he says.

Conditions will be missed and over- or undertreated, he says. There will not be nearly enough clinician educators to train the next generation of medical students and house staff or clinician researchers to expand knowledge about the common conditions that affect older adults.

“It’s a disaster waiting to happen,” Dr. Durso says. “It’s a huge problem that the American people just don’t seem to be aware of. In 2006, Congress canceled funding that disseminated advanced training programs in geriatric medicine, geriatric psychiatry and geriatric dentistry. It also cut funding for geriatric education centers. It was an unbelievable bungle.”

Society’s prejudice toward aging is one of the reasons the elderly population is overlooked. However, the elephant in the room is funding for primary care services through Medicare, Dr. Durso says.

Geriatric doctors are the lowest-paid doctors per hour worked, says Dr. Jane Potter, president of the American Geriatrics Society, headquartered in New York. She is the chief of geriatric medicine at the University of Nebraska Medical Center in Omaha.

When medical students are graduating with $150,000 to $200,000 of debt, there is less incentive for them to enter the field of geriatrics, she says.

Possible solutions to the quandary are programs of loan forgiveness, better pay for geriatric doctors and more research funding for the field.

“We don’t have to be on the bottom of the heap,” Dr. Potter says. “More time and energy should be spent explaining the joy of geriatrics.”

Geriatrics originated in the 1970s as a speciality because adults were living longer, says Dr. Eric De Jonge, section director of geriatrics at the Washington Hospital Center in Northwest.

With modern medicine, antibiotics, public health, plumbing and specialized surgeries, the average life expectancy has increased to age 78. In 1905, it was just 47, Dr. De Jonge says.

Because people died at age 47, most of them never suffered from dementia. Geriatricians specialize in recognizing dementia, a 20th-century phenomenon because of people living longer.

One of the most important questions that geriatric doctors face is how to take care of someone who is dying.

“We don’t have cures for them many times,” Dr. De Jonge says. “I have medicines to help them feel more comfortable. Inevitably as a geriatrician, your patients die.”

The concerns are not addressed in the standard internal medicine training or basic family practice residency, he says.

“You need extra training in geriatrics,” Dr. De Jonge says. “Geriatrics is not a profitable enterprise. We struggle to convince the Medicare health system that geriatrics is a good thing.”

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