An aging population, without the doctors to match

WE talk a lot these days about what constitutes a good way to die. There’s also much discussion about the art of healthy aging.

WE talk a lot these days about what constitutes a good way to die. There’s also much discussion about the art of healthy aging.

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

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 pink bibs.”

In his 70s, my father, a highly respected orthopedic surgeon, developed Alzheimer’s. Later in the course of the disease, he broke his hip. One day when we visited him at the nursing center, 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, his head was bent toward his lap; though his eyes were open, they were not focused on anything. His shoulders 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 stabilizer. He was becoming violent to the aides. Patients often get like this when they have Alzheimer’s.”

We were suddenly confronted with decisions about his care that we didn’t understand. Many families face similar questions: Do we move Mom 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 — and do we? When should we move them to a nursing home? What kind of care will they need when they get there?

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

Why not? Most health care professionals have had little to no training in the care of older adults. Currently, 97 percent of all 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. In addition, these patients show increased satisfaction, spend less time in the hospital, exhibit markedly decreased rates of depression and spend less time in nursing homes.

Our family witnessed the value of geriatric care firsthand.

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 behavior 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 recognized, simply because patients can’t express themselves.

Dr. Brummel-Smith urged me to have my dad examined by a local geriatrician, whom he recommended. In a week, the new doctor came to the nursing home. Dr. Brummel-Smith’s suspicions had been 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 1,000 milligrams of Tylenol, three times a day. He discontinued the mood-altering drug. After that, my father’s behavior rapidly turned around. His quality of life vastly improved. 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.

But, 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 Center in New York.

At the same time, the nation’s fastest-growing age group is over 65. Government projections hold that in 2050 there will be 90 million Americans 65 and older, and 19 million people over age 85. The American Geriatrics Society argues that, ideally, the United States should have one geriatrician for every 300 aging people. But with the looming shortage of geriatricians, the society projects that by 2030 there will be only one geriatrician for every 3,798 older adults.

Why such a growing gap between an increasing number of patients and a decreasing number of doctors required to treat them? Geriatrics is a low-paying field of medicine, even though it requires years of intensive specialization. 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 U.C.L.A. Medical Center, 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 health care — how substantially their lives will be affected.

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

New York Times | By MARCY COTTRELL HOULE

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