Gearing up for a graying America (AGS annual scientific meeting)

Release of a sentinel report on the future of geriatric medicine offers steps to take now to make a difference in the long run.

By Peggy Peck, amednews correspondent — Posted July 4, 2005

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As a specialty, geriatrics is in critical -- but not terminal -- condition, according to "Caring for Older Americans: The Future of Geriatric Medicine," a long-anticipated report from the American Geriatrics Society.

Release of the report, which lays out the current work-force situation and puts forth a plan for future action, was the pivotal event at the AGS scientific meeting, held in Orlando, Fla., May 11-15.

Though there has been significant progress in the evolution of geriatric medicine, health care for older people is now at a crossroads, notes the report, which was published as a separate supplement to the June Journal of the American Geriatrics Society. "The clinical, educational and research approaches of the 20th century are unable to keep pace and require major revision," it states. The document also warns that maintaining the status quo will translate into falling further behind.

There was an initial burst of enthusiasm when geriatric training programs were established in the 1970s and the first examination in geriatric medicine was jointly administered in 1988 by the American Board of Family Practice and the American Board of Internal Medicine. But since then, geriatrics has run into a recruiting wall. According to a study accompanying the report, "fewer than 300 physicians entered geriatric medicine fellowships in 2003."

Thus, just as America is graying and baby boomers are turning into golden oldies, geriatrics has a shortfall of more than 7,000 geriatricians. There is only one trained geriatrician for every 5,000 Americans 65 and older. The AGS projects this number to reach a shortfall of 36,000 geriatricians by 2030.

That is the grim prediction in a report that sets an upbeat, can-do tone. A paradox? Yes, but that paradox is characteristic of geriatricians, who are consistently ranked as the lowest paid medical specialty and yet still usually ranked at the very top in job satisfaction surveys.

"As geriatricians we love our work, but, unfortunately, our work is not 'valued' in the same way as the work of procedure-oriented specialties," said AGS President David B. Reuben, MD, a professor of geriatrics at the David Geffen School of Medicine at the University of California, Los Angeles. For example, despite long struggles in the 1980s to have the so-called "cognitive" services reimbursed at a rate comparable to payment for procedures, Medicare continues to pay more for procedures than for "high-touch medicine, which is what geriatrics is," he said.

And the low pay spills over into meager funding for geriatrics research, Dr. Reuben added. So while geriatricians remain an underpaid minority in medicine, research and innovation aimed at improving care for the elderly has been "neglected by major federal agencies," the report states. The AGS document calls on those key agencies -- the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality -- to join together to finance pilot programs similar to the geriatric care programs provided by the Dept. of Veterans Affairs.

The VA, according to the AGS, "has been a leader in developing and evaluating new models of geriatric care that foster a multidisciplinary approach."

By contrast, Medicare has no mechanism to pay for "social services and other components of geriatric care that don't include a face-to-face encounter with a physician," said Meghan Gerety, MD, associate chief of staff at South Texas Veterans Health System and professor of medicine at the University of Texas Health Science Center, San Antonio. Dr. Gerety is immediate past president of AGS.

Geriatrics has evolved and developed as a team-based approach to care, and this model is the model that will go forward, she explained. "So we need to find a way to pay for these nonphysician services."

Moreover, it is unlikely that geriatric medicine can attract enough new geriatricians to meet the predicted shortfall 25 years from now, Dr. Gerety said. The AGS report also tacitly acknowledges this circumstance by suggesting all physicians receive more basic training in geriatrics.

But even this measure will be difficult to implement because "a paucity of academic geriatricians remains, and most educators in geriatric medicine are dependent upon clinical income, as academic institutions have generally been unable to provide adequate support for teaching geriatrics," the report states. To meet these training needs, "geriatricians will need to partner with other teachers. Most often, geriatricians will lead other faculty, including general internists, family physicians, surgeons and related specialists, to develop, implement and teach the geriatrics curriculum to medical students and residents."

Finally, the report suggests geriatricians mobilize patients into an effective health care lobby by forming coalitions of professional societies and community groups.

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Essential goals for geriatric medicine

  • Expand the geriatrics knowledge base and ensure that every older person receives high-quality, patient-centered care.
  • Recruit physicians into careers in geriatric medicine and increase the number of health care professionals who use the principles of geriatric medicine.
  • Unite professional and lay groups in efforts to influence public policy and improve the health of seniors.

Source: "Caring for Older Americans: The Future of Geriatric Medicine," American Geriatrics Society, May

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A crunch in the making

  • By 2030, the number of adults 65 and older will nearly double, to 70 million. Meanwhile, adults 85 and older are the fastest-growing segment of the entire population, with expected growth from 4 million today to 20 million by 2050.
  • Adults with five or more chronic conditions represent a large share of geriatricians' patient population, with 20% of the Medicare population having at least five chronic conditions.
  • The number of medical students choosing to specialize in geriatrics is decreasing. Nationally, in 2003, only 62 physician-fellows were in their second or subsequent years of training in geriatrics research.

Source: American Geriatrics Society

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Research findings: Reversing frailty; testing for functional decline

Is it possible to reverse frailty in elderly patients? Sometimes it may be, according to a study funded by the National Institute of Aging. Findings were reported in May at the American Geriatrics Society annual scientific meeting in Orlando.

Dennis Villareal, MD, assistant professor of medicine at Washington University School of Medicine in St. Louis, focused on an overlooked subset of elderly patients -- obese, frail elderly. "We theorized it is possible to reverse frailty in [these] patients," he said.

From 27 frail, obese volunteers, Dr. Villareal and colleagues randomized 17 people to a six-month program of diet and exercise and 10 people to the study's control group. At baseline, their mean body mass index was 38 and their mean age was 70.

After six months, those in the diet and exercise arm lost an average of 10% of their initial body weight, he said. Moreover, their scores on the Physical Performance Test improved in comparison with the control group. Body fat also decreased in the diet and exercise group, but there was no change in total fat-free mass or in total bone-mineral content. Subjects in the diet and exercise group also showed improvement in knee strength as well as small but significant boosts in walking speed and obstacle course performance.

"This study demonstrates that frailty can be reversed and function improved in this population," Dr. Villareal said. The findings also contradict a generally held belief that elderly people "are resistant to weight-loss interventions because they have lifelong, established eating patterns."

Dr. Villareal's research is a pilot for a larger NIA study that will compare the effects of the diet and exercise intervention to diet alone, exercise alone and a control group. That study, which is recruiting subjects, will use a 12-month intervention.

Predicting functional decline

In the continuum of aging, diminished function often precedes frailty, so assessing function is an important issue for many geriatricians and primary care physicians. Yet standard tests often fail to ascertain true functional ability in elderly patients, said Anne B. Newman, MD, a professor of epidemiology and medicine at the University of Pittsburgh.

A better measure is a 400-meter-walk test that can easily be set up in a long corridor and can be predictive of mortality in apparently able adults ages 70 to 79, she said.

Dr. Newman is an investigator with the Health, Aging and Body Composition -- Health ABC -- study, a multicenter investigation funded by the NIA.

The Health ABC study recruited 3,075 men and women ages 70 to 79 at centers in Pittsburgh and Memphis, Tenn. Forty-five percent of the subjects were African-American. Three hundred and ninety-five patients were excluded based on self-reported history of chest pain, dizziness or leg pain or because they failed to meet baseline cardiovascular criteria.

A total of 2,324 subjects completed the 400-meter walk, and 356 failed to do so. The subjects were followed for five years after the initial assessment.

Those who could not complete the walk had a 30% to 40% increase in five-year mortality risk compared with those who did complete the walk. Moreover, people who took more than 5.5 minutes to complete it also had an increased risk of dying in five years -- a 35% increase for every minute over the 5.5 minute pace. Failure to complete the walk or exclusion from the test was also associated with a 60% to 100% increase in risk of disability, Dr. Newman said.

While the 400-meter test is simple and cheap to administer, it does take time, and some physicians maintain that other, faster tests are better options. Tests such as the 6-meter gait-speed test or examining the patient's ability to get up from a chair without using one's arms, however, allow subjects to mask lurking disabilities by "maximizing their ability in a short test," she said.

By contrast, the 400-meter walk is a good, initial assessment. "Typically, we assess people with lots and lots of expensive tests when we don't know if there is anything to be found. This tells us whether or not we need to look for something at all," she said. The downside, however, is that "it doesn't tell us what to look for."

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External links

Information about lectures, presentations and other developments at the American Geriatrics Society 2005 Annual Scientific Meeting (link)

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