FOCUS: HEALTH CARE
Health care system is unprepared to care for legions of frail elderly
Western New York is ahead of the curve in geriatrics
The 90-year-old woman came into the hospital dehydrated, confused and bleeding in her gut. As Dr. Bruce Naughton looked into her sunken eyes, it was yet another reminder to him of the way many of us will spend the last years of our lives.
Getting old used to be simpler. As people aged, they became seriously ill for weeks or months, or suddenly died. That’s no longer the case. Instead, the end of life is lasting years.
Naughton’s patient, one of many he came upon recently during rounds at Buffalo General Hospital, offers a glimpse at what an estimated 40 percent of Americans experience and what’s to come for millions of others.
Because of improvements in prevention and care, more and more people are living longer. But they live with a precarious combination of chronic diseases and impairments, including dementia and adverse reactions from mixing too many drugs. They become increasingly fragile, until something as simple as a cold or a fall sets off a cascade of complications, any one of which could be fatal.
“It’s the intersection of aging and disease, when an accumulation of little things leads to catastrophic events,” said Naughton, head of the Division of Geriatrics at Kaleida Health and the University at Buffalo.
Little research has been done on the most effective therapies for the very old. And the nation faces a shortage of geriatric specialists like Naughton who are trained in the nuances of caring for the elderly, whose population is expected to double by 2030.
The nation’s health care system, with its focus on treating acute episodes of illness and paying mainly for procedures, remains unprepared to offer the coordinated care in different settings that the frail elderly need.
Nor is the country prepared for the costs. Nearly 70 percent of spending on Medicare, the federal health program for people 65 and older, already goes to the 20 percent of beneficiaries with five or more chronic conditions.
“The health system is designed around episodic care with incentives to hospitalize. We need medical care to the elderly that focuses on the function and quality of life of a person, not just on treating a disease,” said Dr. Robert Schreiber, physician-in-chief at Hebrew Rehabilitation Center in Boston and a national expert on geriatrics.
Improvements in care have led to a larger proportion of the population living long enough to suffer from a combination of common ailments, from heart disease and diabetes to osteoarthritis and cancer.
Prolonged disease and advancing age also lead to dwindling function. Patients lose judgment and strength.
“You can have a 100-year-old person who seems perfectly fine. But if there is a stress to their system, they don’t have the reserves to fight back. It takes less and less of an insult to push them over the edge,” said Dr. Robert Stall, a private geriatrician who also serves as medical director at Beechwood and Blocher nursing homes.
As a growing number of people spend their last years in a state of progressive frailty, the demand for geriatricians has grown. These specialists try to look beyond particular diseases to focus on preventing or reversing declines in function.
“We can’t resolve everything and have to help people set priorities,” said Naughton.
The work of a geriatrician often comes down to helping people live as long and as comfortably as possible despite their sicknesses.
“In nursing homes, the causes of many problems are loneliness, boredom and helplessness, not necessarily disease. It’s the loss of touch in people’s lives, the underestimated importance of something as simple as a hug,” Stall said.
A balancing act
Naughton’s 90-year-old patient reflects the challenges in geriatrics of balancing high-level medicine with ethics and the wishes of patients.
The woman came from a nursing home to the hospital dehydrated and bleeding in her gastrointestinal tract. She also was confused, weak and, due to heart failure, on a diuretic that stimulates the kidneys to remove more water from the body. An emergency room doctor ordered a colonoscopy and sent her to the hospital’s intermediate- level-of-care unit.
The unit was designed as a way station for patients coming out of surgical or medical intensive- care units who, despite the best efforts, still aren’t well enough to leave the hospital.
Patients here often have seen multiple specialists for a multitude of problems. It’s likely there’s been little communication among them. Naughton’s job is to tie things together.
“Rehydrating someone is not like watering a plant,” he said outside the patient’s room. “If they have dementia, their confusion makes them less willing to eat, and there’s a high likelihood this will happen again. She’s also on medication. It’s an insidious problem.”
As Naughton explained the dilemma of using a feeding tube to rehydrate a failing patient, a nurse approached him with a dicier issue.
The colonoscopy, a procedure to visually examine the colon for abnormalities, seemed like an appropriate recommendation based on the bleeding. But it would be burdensome and of unknown benefit for someone in her condition.
“Cancel it, please,” the nurse quietly pleaded. “You can’t put her through that.”
Naughton agreed. His inclination was to keep her comfortable back at the nursing home rather than to pursue aggressive therapies in the hospital.
But what did the patient and her family want?
She couldn’t speak for herself, so Naughton called her son about sparing his mother the colonoscopy and feeding tube.
The son had the impression Naughton was recommending hospice, which wasn’t the case, and believed incorrectly that hospice was about hastening a person’s death. Naughton helped him see the procedure posed risks and was unlikely to help his mother live longer.
He then guided the son through another tough decision — whether to fill out a do-not-resuscitate order. This is a request not to have cardiopulmonary resuscitation if the heart or breathing stops.
The son agreed to the DNR order but, confused by its meaning, also said he wanted CPR. Naughton explained that CPR would lead to his mother being on a ventilator, an undesirable outcome.
Naughton said her case raises a larger issue: How to reform a health system that encourages trips to the emergency room, hospitalization and invasive procedures when many disabled patients of advanced age would be better off without aggressive care.
Not enough specialists
The medical field doesn’t pay geriatricians as well as other specialists, one of the reasons few medical students pursue geriatrics. That’s a problem.
The nation faces a crisis as the number of older patients with complex health needs significantly outpaces the number of physicians with the skills to care for them, warns a report by the Institute of Medicine.
Even if more students chose geriatric training after medical school, it would take years before they were available.
“There aren’t enough, and there are unlikely to be enough,” said Stall. “But what we do is not rocket science. It involves a shift in the way physicians provide care.”
Western New York has one of the highest proportions of elderly in the country. In geriatrics, the region appears ahead of the curve.
UB in 2004 began a plan to strengthen its program after receiving a major grant as part of an effort to improve geriatrics training in the nation. Rather than producing more geriatricians, the idea is to teach the skills to all new doctors.
“Older people are seen as undesirable to take care of. They are seen as, ‘the other,’ ” said Naughton. “But they are us.”
hdavis@buffnews.com ">email: hdavis@buffnews.com
