An ageing population, without the doctors to match

Studies indicate that seniors who get good geriatric care spend less time at the hospital or nursing homes. They also tend to function better physically and socially, enjoying more active and independent lives.
Studies indicate that seniors who get good geriatric care spend less time at the hospital or nursing homes. They also tend to function better physically and socially, enjoying more active and independent lives. PHOTO: STEPHEN CHERNIN

We talk a lot these days about what constitutes a good way to die. There's also much discussion about the art of healthy ageing.

But largely absent from the conversation are all the people who fall between the two. People who aren't dying but who are growing more frail. People who have significant health concerns. People who suddenly find themselves in need of healthcare.

People who are, by and large, miserable.

We have a name for this part of life in our family. We call it "the land of the pink bibs".

In his 70s, my father, a highly respected orthopaedic surgeon, developed Alzheimer's. Later in the course of his disease, he broke his hip. One day, when we visited him at the nursing centre, about six months after his accident, we found him sitting in a row of patients all wearing pink bibs, left on after they had finished eating. Like the others, he had his head bent towards his lap. His eyes were open, but they were not focused on anything. His shoulders were slouched, like a rag doll's, and his mouth hung slightly ajar.

We were not prepared to see him like this.

"Oh, not a stroke," the nurse said. "He is fine. He's just on a new drug - a mood stabiliser. He was becoming violent to the aides. Patients often get like this when they have Alzheimer's."

We were suddenly confronted with issues about his care that we didn't understand. Many families face similar questions: Do we move Mum out of her house to assisted living? Dad is so forgetful and argumentative, does he have dementia? Do our parents have enough money to hire a caregiver - do we? When should we move them to a nursing home? What kind of care will they need there?

These are difficult questions. Yet, when you look around for help, you find there isn't much to be had.

Why not? Most healthcare professionals have had little or no training in the care of older adults. Currently, 97 per cent of medical students in the United States do not take a single course in geriatrics. Recent studies show that good geriatric care can make an enormous difference.

Older adults whose health is monitored by a geriatrician enjoy more years of independent living, greater social and physical functioning, and lower presence of disease. Also, these patients show increased satisfaction, spend less time at the hospital, exhibit markedly decreased rates of depression and spend less time in nursing homes.

Our family witnessed first-hand the value of geriatric care.

After seeing my father slumped in his chair, we reached out to a leading geriatrician and researcher, Dr Kenneth Brummel-Smith of Florida State University. After listening to me recount my father's health history (his broken hip and significant arthritis), Dr Brummel-Smith suggested that the cause of his behaviour might have been pain. The doctor explained that, of all the suffering that goes with dementia, pain is one of the most common and least recognised issues, simply because patients can't express themselves.

Dr Brummel-Smith urged me to have my dad examined by a local geriatrician recommended by him. In a week, the new doctor went to the nursing home. Dr Brummel-Smith's suspicions proved to be right. Despite my father's broken hip and history of arthritis, he was receiving nothing for pain. Immediately, the geriatrician put my father on a regimen of 1,000mg of Tylenol, three times a day, and discontinued the mood-altering drug.

After that, my father's behaviour rapidly turned around. His quality of life improved vastly. He could look around at his surroundings. He could converse. He could smile when we played music for him.

And, within days, he was able to escape the land of the pink bibs.

However, as relieved as I felt, I could not help wondering: What about all the other people in nursing homes who aren't as fortunate as my father?

Currently, there are fewer than 8,000 geriatricians in practice nationwide - and that number is shrinking. "We are an endangered species," said Dr Rosanne Leipzig, a geriatrician at Mt Sinai Medical Centre in New York.

Meanwhile, those 65 or older make up America's fastest-growing age group. Government projections hold that, in 2050, there will be 90 million people aged 65 or above, and 19 million over 85.

The American Geriatrics Society argues that, ideally, the US should have one geriatrician for every 700 ageing people. But with the looming shortage of geriatricians, the society projects that, by 2030, there will be only one geriatrician for every 4,484 people aged 75 or above.

Why is there such a growing gap between the increasing number of patients and the decreasing number of doctors required to treat them? Geriatrics is a low-paying field of medicine, even though it requires years of intensive specialisation. Most geriatricians are reimbursed solely by Medicare and Medicaid, whose rates make it unsustainable to keep an office running. Many medical clinics and geriatric hospital units nationwide are closing down.

For those entering their senior years, according to Dr David Reuben, a leading geriatrician at the UCLA Medical Centre, a true national crisis is brewing.

A vast majority of Americans have no conception of what lies ahead and - without geriatricians available to provide their healthcare - how substantially their lives will be affected.

I know. It means that, soon, we might all be in the land of the pink bibs.

NEW YORK TIMES

A version of this article appeared in the print edition of The Sunday Times on October 11, 2015, with the headline 'An ageing population, without the doctors to match'. Print Edition | Subscribe