02016 aar geriatrics book text - alliance for aging research · providers and the aging of the...

AcknowledgmentsThe Alliance for Aging Research is grateful to all whoassisted in the preparation of this report. In particularwe wish to thank Mr. Gerald A. Reed, an independentconsultant in government relations and health care pol-icy, and Mr. Paul DelPonte and his firm Hyde ParkCommunications for their help.

Several prominent national experts in gerontology andgeriatrics agreed to provide input and review of thisreport. They include: Richard Besdine M.D., FACP,Brown University Center for Gerontology and HealthCare Research; Elizabeth Bragg Ph.D., RN, Institute forHealth Policy and Health Services Research, University ofCincinnati; Robert N. Butler M.D., InternationalLongevity Center; William Hazzard M.D., University ofWashington School of Medicine; Jerome Kowal M.D.,Louis Stokes Veterans Medical Center, David ReubenM.D., UCLA Department of Medicine; Judith A.Salerno M.D., National Institute on Aging; John F. SantosPh.D., former Director of the Center for GeriatologicalEducation, Research, and Services, Professor EmeritusUniversity of Notre Dame; and Gregg Warshaw M.D.,University of Cincinnati School of Medicine.

Daniel PerryExecutive DirectorAlliance for Aging Research

This report was made possible through a grantfrom the Retirement Research Foundation.

A L L I A N C E F O R A G I N G R E S E A R C H1

AcknowledgmentsThe Alliance for Aging Research is grateful to all whoassisted in the preparation of this report. In particularwe wish to thank Mr. Gerald A. Reed, an independentconsultant in government relations and health care pol-icy, and Mr. Paul DelPonte and his firm Hyde ParkCommunications for their help.

Several prominent national experts in gerontology andgeriatrics agreed to provide input and review of thisreport. They include: Richard Besdine M.D., FACP,Brown University Center for Gerontology and HealthCare Research; Elizabeth Bragg Ph.D., RN, Institute forHealth Policy and Health Services Research, University ofCincinnati; Robert N. Butler M.D., InternationalLongevity Center; William Hazzard M.D., University ofWashington School of Medicine; Jerome Kowal M.D.,Louis Stokes Veterans Medical Center, David ReubenM.D., UCLA Department of Medicine; Judith A.Salerno M.D., National Institute on Aging; John F. SantosPh.D., former Director, Center for GeriatologicalEducation, Research, and Services, Professor EmeritusUniversity of Notre Dame; and Gregg Warshaw M.D.,University of Cincinnati School of Medicine.

Daniel PerryExecutive DirectorAlliance for Aging Research

This report was made possible through a grantfrom the Retirement Research Foundation.


Foreword

This is the Alliance’s third report to the nation on theshortage of health professionals trained to care for thenation’s older patients. This study, however, is differentfrom the earlier reports in three fundamental ways.

• This report focuses on the health professions team, noton physicians or geriatricians only. Appropriate care ofthe elderly requires a team of health professionals. Theshortages we document are equally severe in nursing,pharmacy, social work, and indeed all the allied healthprofessions.

• By no means do we say that every elderly individualshould receive care from a geriatric specialist. We do,however, suggest that every health care provider whotreats elderly patients requires some specialized training.

• Time is running out. Baby Boomers, who begin toturn 65 in a decade, will make a serious problem todaypractically impossible to solve in a few years.

Today, February 27, 2002, nearly 6,000 Americans will celebrate a 65th birthday. Tenyears from today, the U.S. will have nearly 10,000 people a day turning age 65. And still,too few doctors, nurses, psychologists, social workers and other health professionalsreceive any formal training in how to provide the best care for older patients. This dis-turbing fact has been highlighted by numerous studies and organizations over the pasttwo decades, yet only modest progress has been made — even that may be lost in thenext round of professional retirements.

We have less than 10 years before the huge first wave of Baby Boomers ignites a SeniorBoom. If the U.S. fails to reform professional health education, equipping moreproviders with good geriatric health care techniques, we can’t be surprised with the con-sequences. It will be a crisis that was a long time in coming and with plenty of warning.There will be no easy excuses.

This report identifies 10 reasons why our nation has notyet addressed this critical issue. Behind these barriers arethree inconvertible facts:

• The numbers of older Americans have never beengreater, and are about to soar.

• The numbers of health professionals with some formaltraining in caring for the elderly are woefully inadequateeven for today’s population.

• The American people expect this problem to be fixedfor themselves and their families. A recent survey con-ducted for the Alliance by Opinion Research Corporationshows that three out of every four Americans feel it is veryimportant that their healthcare providers have some specific training to care for the elderly.

Our newest report is intended to bring greater nationalattention to this subject. Medical Never-Never Landdescribes a problem, offers recommendations, and callsupon the nation’s political and medical leadership tobecome engaged in shaping solutions.

Daniel PerryExecutive DirectorAlliance for Aging ResearchFebruary, 2002

A L L I A N C E F O R A G I N G R E S E A R C H 2

Executive Summary

In the new Disney movie Return to Never Land, Peter Panjourneys back to London after an absence of many yearsto find that Wendy is grown up and has children of herown. For everyone not on the island of Never-NeverLand, aging is a fact of life that even Disney can admit.That much of American life and culture denies the real-ity of aging may be amusing. But when it comes to healthcare, the consequences of age denial can be downrightdangerous.

More than 20 years ago the eminent geriatrician andauthor Dr. Robert N. Butler coined the term “Peter PanMedicine” to describe age-denial in healthcare and med-ical education in the U. S. Training doctors and nurses totreat one disease at a time in otherwise healthy andresilient patients is relatively easy, he explained. But asadults grow older, there are complications and changes —

physiological, psychological and social— that require specialized training toprovide the best possible care andmost desirable health outcome.

Unfortunately, very few health professionals in the U.S. — physi-cians, nurses, psychologists, pharma-cists, physical and occupational ther-apists, social workers — have beenexposed to the techniques andknowledge of geriatric health care aspart of their professional training.This creates a dangerous “discon-

nect” between the education of America’s health careproviders and the aging of the population at large, andespecially their patients.

Unlike the fictional Peter Pan, the U.S. is getting older. Inless than a decade, the first members of the Baby Boomgeneration will reach age 65, and older people will growsteadily as a percentage of the U.S. population for thenext several decades. Older Americans will more thandouble in number from 35 million today to 70 millionby year 2030. Already, some 6,000 Americans turn age65 every day in our country. In just 10 years, the numberreaching that personal milestone will rise to about 10,000Americans each day. As hard as it may be for some to

admit, the very icons ofAmerican youth and theBaby Boom generation soonwill become part of thelargest Medicare generationin history. Yet, our healthcareproviders engaged in thedelivery of care to the elderlyare woefully under-preparedto meet this demographic sea change.

Older people have medical needs different from youngeradults. The average 75-year-old person has three chronicmedical conditions and regularly uses about five prescrip-tion drugs, as well as multiple over-the-counter remedies.In many instances older people are using 12 prescriptiondrugs or even more at any given time. Changes withaging can alter how the body metabolizes, absorbs andclears these drugs from the body. Also, symptoms of ill-ness can present differently in older people than in theyoung or middle-aged.

For many older people, chronic age-related conditionssuch as memory loss, depression, or incontinence, pose adirect threat to their ability to live independently. Carefulmanagement of these conditions by a multi-disciplinaryteam becomes paramount to maintaining long-termhealth, vigor and the capacity for personal growth andindependence. Often the key to effective management ofthe complex and over-lapping health challenges of olderpatients is a health care professional who has at least sometraining and orientation in geriatric health care.

Just as Peter Pan hoped to never grow up, part of the col-lective American psychology does not want to acknowl-edge aging on a personal level. This is part of the reasonwe have created a Medical Never-Never Land: denyingthe graying of the population seeking health care, andblind to the need to train all health providers in age-appropriate medical techniques. Every older personshould expect that his or her health care providers—socialworkers, nurses, pharmacists, physicians and other pro-fessionals—be trained to diagnose and treat their specialneeds. Despite decades of warnings from policymakers,physicians, social scientists and advocates, an acute short-age of geriatricians and health professionals with geriatrictraining persists in the United States.

6,000 Americansturn age 65 every

day in our country. In just 10 years, the

number reaching that personal

milestone will rise to about 10,000

Americans each day


Perhaps even more troublesome, the nation is withoutenough geriatric academic schools of medicine, nursingand the allied professions to educate the generation ofhealth care professionals currently being trained. At atime when geriatrics and health promotion for older peo-ple should be infused into the training of all health pro-fessionals, this remains a distant goal. The nation is leftwith a very real geriatric gap that could overwhelm thehealth system, increase premature death and disability,and increase the costs of health care.

It is estimated that the U.S. currently needs 20,000 physi-cian-geriatricians to care adequately care for our popula-tion of 35 million older people. Yet of the 650,000licensed physicians practicing in the U.S., fewer than9,000 physicians have met the qualifying criteria in geri-atrics. Furthermore, this number is projected to decreaseto as few as 6,100 by 2004. The U.S. will fall far short ofthe 36,000 geriatricians needed by 2030 unless effectivesteps are taken to train new providers. Many non-physi-cian health professions are just as far behind.

It is estimated that the U.S. currently needs 2,400 geri-atric academicians to train new providers, integrate geri-atrics into medical practice, and develop standards of carefor older people. However, there are currently fewer than600 academic geriatricians in the U.S., and only a hand-ful of medical schools require students to take any geri-atric courses. The same holds true in dentistry, nursing,pharmacy, and other health professions.

The human benefits of improving the health and inde-pendence of older people are obvious. The financial ben-efits are enormous. If proper geriatric care resulted in aconservative reduction of hospital, nursing home andhome care costs of just 10 percent a year, the nation wouldhave saved $50.4 billion in health care costs in the year2000. The potential savings by the year 2020 of such amodest reduction would be $267.4 billion in that yearalone. Beyond direct savings in heath costs, a healthier

more independent older pop-ulation would contributeimmeasurably to the nationby easing the cost growth ofMedicare, Medicaid, andSocial Security and bydecreasing the need for nurs-ing home and long-term care.

Significant, but still inadequate, research dollars aredirected at serious conditions, such as Alzheimer’s disease.But we may be falling further behind in support forresearch aimed at less dramatic but critically importantconditions of aging that prevent older people from per-forming daily activities of living.Small reductions in the prevalence offalls or incontinence could extend theindependence and activity of manyolder Americans and realize billionsof dollars in health care savings.

Bridging the geriatrics gap inAmerican medical education andpractice will take leadership,resources and national will. A start-ing point is examining what factors have blocked our way until now. This report focuses on 10 reasonsAmerica’s health professionals are not being adequatelyprepared for the coming Age Boom. Recognizing andaddressing these barriers is the key to escaping fromMedical Never-Never Land:

• Age Denial

• Older Patients Marginalized

• Lack of Public Awareness of the Geriatrics Gap

• Scarcity of Academic Leaders

• Lack of Academic Infrastructure in Geriatrics

• Geriatric Medicine Not Valued

• Inadequate Reimbursement

• Lack of Coordination within Medicine

• Clinical Trials Do Not Include the Aged

• Little Research on the Aging Process

Little time remains to overcome these 10 barriers beforethe Baby Boom becomes the Age Boom of the early 21stCentury. The U.S. must take immediate steps to developproperly trained medical professionals to manage the careof older people. The most immediate need is to increasethe number of qualified academic leaders to train the nextgeneration of providers. Greater numbers of primary carephysicians, pharmacists, psychologists, nurses, socialworkers, and other providers must receive formal trainingin geriatrics, and specialists who treat large numbers of

Bridging thegeriatrics gap inAmerican medicaleducation andpractice will takeleadership, resourcesand national will.


By 2030, the U.S. willneed up to 36,000geriatricians and will fallfar short of that figure byas many as 25,000 unlesseffective steps are taken totrain new providers.

older people must receivegeriatric certification.Students in virtually everyhealth field must receive geri-atric training as part of theircourse work, residency train-ing and field placement.

America has run through itsreasons for staying mired in Medical Never-Never Land— there are no good excuses left. Aging is not a statisti-cal abstraction. It is a reality driving the future of healthcare in America. Evidence already shows that a lack ofgeriatrics-trained health professionals and standards ofcare is eroding the quality of health care afforded olderAmericans. For example, a recent article in The Journal ofthe American Medical Association focused on the wide-spread inappropriate medication use among the elderly.

Unless action is taken soon, this geriatric disparity willwiden as older people increase in number and as a shareof U.S. population. America must end this shortage ofgeriatrics-trained health professionals, and the academicleaders needed to train them, or remain trapped inMedical Never-Never Land, where the appropriate careneeds of older people are unmet and the consequencespossibly tragic.


A77 year old man in good health notedbreathlessness for a day or two thencollapsed from what appeared to be a

massive stroke. He was taken to a hospitalwhere he was treated by doctors withoutspecial age-related training. The man didpoorly and became, essentially unresponsive.He was put on large doses of medication toblock acid production in his stomach and thepotential of stress related gastric ulcerbleeding. He ate little and a feeding tube wasplaced. He continued to do poorly and wastransferred to a nursing home where familyfelt he would die. In the nursing home, thegeriatrician noticed that his mental status wasfluctuating, more consistent with delirium, areversible condition, than a stroke. Thegeriatrician discovered that the patient’searlier heart failure had been too aggressivelytreated and that the patient was dehydrated.From the high doses of the ulcer preventivemedication, drug toxicity developed. Themedication was discontinued and fluids wereadministered. The patient improved andeventually, the feeding gastrostomy tube wasremoved; a Foley catheter, which had beenplaced to collect the urine, was removed andthe patient ultimately was able to eat andeventually go home and ambulate slowly.After several months he had only partialdependencies. Often delirium is missed byphysicians with no geriatric training withpotentially adverse outcomes.

The Demographic Imperative

The American population is getting older. Every day inthe U.S. some 6,000 people celebrate their 65th birthday.In less than a decade nearly 10,000 a day will reach thatmilestone. By the year 2020 there will be 50 million olderAmericans, and 70 million by 2030. Then almost one inevery four Americans will be over age 65. This shift willaffect every part of society and life: from work to leisure,transportation to housing, and from corporate strategiesto family relationships. The graying of America will haveits most dramatic consequences on health care. OlderAmericans, currently 13% of the U.S. population,account for 36% of hospital stays, 49% of all days of hos-pital care, and 50% of all physician hours. In the foresee-able future, older Americans will account for half of allhealth care expenditures.

Longevity can be a blessing and most people are gratefulfor longer lives. More Americans are celebrating their75th birthdays, their 85th birthdays, and their 100thbirthdays. Those over age 85 years—the oldest of theold—will increase from 4 million today, to nearly 19 mil-lion by 2050. This group will include more than 1 mil-lion centenarians.

The Medical and Social Necessity

The seismic shift in demographics alone should warrantgreater medical focus in geriatrics. New medical chal-lenges that come with the age-wave present compellingreasons to adjust health education and practice. While ahealthy youth is often a good predictor of a healthy olderperson, longevity often increases the complexity of a per-son’s medical and social needs. On average, people age 75years or 80 years have more ailments and often moremultiple ailments than people age 65 years. The average75-year-old person experiences three chronic conditionsat any given time. Some report as many as 10. The aver-age person at age 75 years uses more than 4.5 prescriptionmedications at any given time. More than one in fourpeople at age 75 years report at least one disabling condi-tion. At age 80 years, three out of four people report a dis-abling condition. In addition, age-related social and psy-chological factors, such as retirement, widowhood,bereavement and isolation, can compound the healthcare challenge for older adults.

Health care professionals not only will be treating moreolder patients, they will see far greater incidence of thediseases that affect older people, such as dementia, cancer,bone and joint diseases, and vision impairment. Theincidence of many illnesses riseswith age. For example, there are agreater percentage of men withprostate cancer at age 85 years thanat age 75 years, according to theMayo Clinic. The number of peoplewith Alzheimer’s disease is expectedto double from approximately 4million today, to more than 8 mil-lion by 2020, and could reach 14million by 2040. The Centers forDisease Control and Prevention(CDC) estimates that arthritis willaffect more than 60 millionAmericans in 2020 and limit thedaily activities of nearly 12 million.

There will be a rise in diseases that affect older people,and in the medical conditions associated with older age.The number of hospitalizations for hip fractures in peo-ple age 65 years and older rose from 230,000 in 1988 to

Health careprofessionals notonly will be treatingmore older patients,they will see fargreater incidence of the diseases thataffect older people,such as dementia,cancer, bone andjoint diseases, andvision impairment.

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1010

00

9090

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34.734.7

20102010

39.439.4

20202020

53.253.2

20302030

69.469.4

20402040

75.275.2

20502050

78.978.9

The Senior BoomThe Senior Boom

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4.34.3

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6.56.5

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8.58.5

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13.613.6

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18.218.2

The Oldest OldThe Oldest Old


340,000 in 1996. The num-ber is expected to reach morethan 500,000 per year by2040, according to the CDC.

Nearly all geriatric hip frac-tures are fall-related. Eachyear, approximately one inthree people age 65 years or

older experiences a fall-related injury. Of these people,approximately 20 to 30 percent suffer a reduction inmobility and independence. Half of all people hospital-ized for hip fractures cannot live independently after theirinjuries. In the U.S., women sustain approximately 80percent of all hip fractures. Osteoporosis-related fracturesare the most common fall-related injuries in persons overage 65 years.

Older people experience conditions associated withadvancing age, such as hearing loss, vision loss, loss ofbone density, loss of mobility, and other age-related func-tional declines that hinder ability to perform activities ofdaily living. Many of the conditions associated with age,such as memory loss and loss of cognition also mimic thesymptoms associated with serious illness. These symp-toms manifest differently in older people and medicalprofessionals must be trained to distinguish what is dis-ease and what is not.

Older people have two goals in their health management.The first goal, like that of young people, is to prevent ill-ness and maintain good health. The second is to managethe changes associated with aging, sometimes managingdegrees of disability, in order to prolong their independ-ence and activity. Too many older people fail to distin-guish between these two goals. A medical workforce lack-ing in geriatric training will also lack the training to helpthe older population differentiate between aging relatedhealth promotion and disease prevention and suggest thenecessary health strategies that will preserve independ-ence.

Too many older people are conditioned to accept asinevitable the decline that accompanies aging . Moretroubling is that too many health professionals unfamil-iar with geriatrics, perpetuate this notion. Conditionsthat can be treated, such as loss of cognitive function or

incontinence, often are viewed as the first step toinevitable decline and institutionalization. This need notbe the case. Memory and other cognitive losses can beimproved, or their declines slowed, through appropriatepharmaceutical and non-pharmaceutical interventions.Incontinence is a significant contributing factor to theloss of independence, affecting nearly 50 percent of peo-ple in nursing homes. Yet, many types of incontinencecan be treated, delayed or managed with low-cost andnon-embarrassing methods that empower older people tomaintain active, public lives.

Different Diseases/Different Conditions

Changes in the body that accompany the aging processcomplicate the diagnosis and treatment of many diseases.The fact that many older people experience more thanone chronic condition complicates the diagnosis of theirother health problems. Depression is now considered acommon illness among older people, yet it is under-diag-nosed and under-treated. Often, it is confused with theonset of cognitive impairment, which affects 5 to 15 per-cent of people over age 65 years and approximately 40percent of people age 85 years or older. However, thecause of depression can often be something as simple ashearing loss, which affects one-third of people age 65years, two-thirds of persons over age 70, and three out offour people over age 80 years.

Geriatric training and treatment targets these often-com-plex overlapping factors. Like peeling an onion, the geri-atric approach helps move through each layer of healthand social issues impacting the well being of a patient.Geriatric assessments are often interdisciplinary encoun-ters, requiring physicians, psychologists, nurses, andother members of the health team to assess physical andemotional states, as well as living arrangements, whichcan accelerate physical and mental decline. Also, the careof older people can vary greatly from that of younger peo-ple. Caregivers, such as family members, friends, andneighbors, are often called to play crucial roles in main-taining the independence of older people. Care mustoften be coordinated between the geriatric trained spe-cialist and several providers, such as primary care physi-cians or cardiac specialists. Geriatric specialists, who aretrained to foster cooperative team care, are needed inevery aspect of the care of older people, from physiciansto social workers.


The Geriatrics Gap

Despite a general consensus that a core group of trainedgeriatricians is necessary to maintain the health and func-tioning of older people, a critical shortage of geriatrictrained professionals persists in the United States. Thereare currently only 9,000 physicians with geriatric certifi-cation in the U.S. However, the U.S needs 20,000 to pro-vide adequate treatment to its older population. TheAlliance for Aging Research estimates the U.S. will needapproximately 36,000 geriatricians to treat 70 millionolder people by the year 2030. Unless a significant com-mitment is made to geriatric medical education, the U.S.will fall short of this projection by as many as 25,000 doc-tors. In addition, many of the nation’s 650,000 physi-cians in current practice will require continuing educa-tion with significant infusions of geriatric training.

This geriatrics gap applies not only to physicians, but alsoto virtually every field of health care. Less than one per-cent of nurses in the U.S. are certified in geriatrics andonly three percent of advance practice nurses specialize inthe care of older people. Less than one-third of one percentof physical therapists is board certified as a geriatric clin-ical specialist. Of nearly 200,000 pharmacists in the U.S.,only 720 have geriatric certifications, in spite of the factthat the elderly are by far the largest users of pharmaceu-tical products.

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20,00020,000

15,00015,000

10,00010,000

5,0005,000

00

40,00040,000

202020201995199519901990 20102010 203020302005200520002000

PROJECTED NUMBER OF NEEDED GERIATRICIANSPROJECTED NUMBER OF NEEDED GERIATRICIANS

ACTUAL AND ESTIMATED NUMBER OF GERIATRICIANSACTUAL AND ESTIMATED NUMBER OF GERIATRICIANS

The Geriatric GapThe Geriatric Gap


Mrs. H is a 94 year-old African-Americanfemale who lost her balance andbroke her hip in April, 2000. Until that

time, she cared for herself in a two-storytownhouse she had lived in for 50 years. She had cooked her own meals, includingThanksgiving family dinners, and enjoyed herfavorite television shows.

Mrs. H was hospitalized for the broken hip andsurgeons, who had not received any specificgeriatric training, recommended bedrest for 8-10 weeks. The results were catastrophic. Shesuffered from bedsores, confusion, and bladderinfections after spending three months in ahospital and nursing home. The bedrestweakened her muscles, so her knees could nolonger bend, and she became permanentlybedbound.

When she returned home in August 2000, herdaughter, Mary, moved in to care for her on a 24-hour basis. The “den” off the kitchenbecame a studio apartment, where a hospitalbed used up half the floor space. Care isextensive, and the daughter’s only relief iswhen a home health aide comes each day forfour hours. Wounds must be dressed, inaddition to all other daily physical functions andfeeding. In February 2001, her family decided toenroll her in a house call geriatric care program.

During the next eight months, Mrs. H. hadseveral medical issues which were handled bythe geriatric professionals without any trips tothe emergency room or doctor’s office. In time,the geriatric care healed her bed sores, urinarytract infections, and pneumonia. Hermedications were reduced, both improving hermental status and allowing her to finallyconverse with her family once again.

Compounding the gap is an acute shortage of academicleadership to expose all U.S. health providers to geriatriccontent as part of their professional training. Academicgeriatricians are needed to provide training, guidance,and role models, yet the U.S. has fewer than 600 medical

school faculty that list geriatrics astheir specialty—out of a total of100,000 faculty members.Academic geriatricians are needed toconduct research on the conditionsof aging. Geriatricians compriseapproximately 0.5 percent of allmedical educators in the U.S., rep-resenting the largest educationaltraining gap in any field. This short-age dwarfs the lack of other educa-tional shortages, including the lownumber of primary and secondaryschool math and science teachers.

The Gap is WideningThough some progress has been made over the pastdecade, we are likely to lose ground in the coming years.The Association of Directors of Geriatric Academic

Programs (ADGAP) has projected that the number ofcertified geriatricians would actually fall to near 6,100 by2004 because the number of certified geriatricians notseeking re-certification is greater than young physicianscompleting their geriatric fellowships. The shortagereflected in the ratio of providers to patients is expected toincrease further as the size of the older population grows.It is currently projected the U.S. will have only one-fourththe geriatricians needed to care for older people as thegrowth of the Baby Boom generation reaches it crest.

This applies to all health-related disciplines. Accordingto the John A. HartfordFoundation, “The rate ofincrease in geriatrics trainingand research capacity in thenation’s medical, nursing,and other health professions’schools continues to lag farbehind need; indeed the number of geriatricians appearsto be diminishing. At every level (undergraduate, gradu-ate, post-graduate) and in every sphere (medicine, nurs-ing, physical/occupational and other therapies, socialwork, pharmacology, etc.) of health professions educa-tion, the gap between need and supply is widening.”

By no means does every older person have to be treatedby a geriatrician, simply due to age. However, everyphysician, psychologist, pharmacist, nurse, physical ther-apist, or social worker that treats older people should havesome training in geriatrics. Geriatricians are needed forconsultations on difficult cases and to develop curriculafor professional schools and standards of care for thetreatment of older people. A critical mass is needed tostimulate the field and to permeate proper medical care.However, the current ratio of approximately 2.5 geriatri-cians to every 10,000 elderly patientsis insufficient to meet these mostbasic needs.

If geriatrics does not penetrate thecurricula of American medicalschools, it will not permeate main-stream medical practice. Withoutthe leadership of medical schools,the U.S. cannot create the coregroup of providers needed to care forolder people. And while it is not necessary that everyprovider treating older patients be a geriatrician specialist,it is necessary for providers to understand the logic, goals,and some of the techniques of good geriatric care. Forexample, one study has shown that exposing providers tothe principles of communicating with geriatric populationsimproves the health outcomes of older patients.

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8,0008,000

7,0007,000

6,0006,000

4,0004,000

3,0003,000

2,0002,000

00

10,00010,000

5,0005,000

Internal Medicine & Family Physician Certified GeriatriciansInternal Medicine & Family Physician Certified Geriatricians

Geriatricians compriseapproximately 0.5percent of all medicaleducators in the U.S.,representing thelargest educationaltraining gap in any field.

Of nearly 200,000pharmacists in the

U.S., only 720 havegeriatric certifications,

in spite of the factthat the elderly are by

far the largest usersof pharmaceutical

products.

A L L I A N C E F O R A G I N G R E S E A R C H 1 0

There are good models to follow. Great Britain maintainsa full-time Department of Geriatrics at nearly every med-ical school. Japan has full departments of geriatrics in halfof their schools of medicine. In the U.S. only threedepartments exist out of 144 medical schools. A good casecan be made that strong divisions of geriatrics and adult

care within departments of medicineand its sub-specialties, as well as nurs-ing and other fields, is also an effec-tive way to create critical masstowards improvement.

Without a consistent and persistenteffort to integrate geriatrics into U.S.health professional education and todevelop academic leadership, Americawill remain stuck in its MedicalNever-Never Land. The shortfall in

geriatricians training will perpetuate itself. If fewer med-ical students are exposed to geriatrics, there will be fewergeriatricians to assume academic teaching posts. If thereare fewer geriatric academicians to train new profession-als, there will be fewer professionals in all disciplines tomeet the special needs of older patients.

A Crisis That Is Already Here

Beginning in 2011, the largest generation ever inAmerica will begin to move onto the rolls of SocialSecurity and Medicare. This will exacerbate any problemsnot addressed earlier regarding the health outlook forolder people. There is ample evidence that the geriatricsgap among American health professionals already isundermining the health outcomes of older Americans.

A L L I A N C E F O R A G I N G R E S E A R C H1 1

Every physician,psychologist,

pharmacist, nurse,physical therapist, or

social worker thattreats older peopleshould have some

training in geriatrics.

If more consistent and widelyavailable geriatric care couldresult in a reduction of hospital,nursing home and home carecosts by just 10 percent ayear—a reasonable and realisticpublic health goal—the U.S.could have saved $50.4 billionin the year 2000.

Human CostsResearchers estimate thatmedication problems areinvolved in as many as 17percent of all hospitalizationsof older people and that 35percent of people over 65experience adverse drug reac-tions. A study published in

the December 12, 2001 Journal of the American MedicalAssociation shows more than one out of every five olderpatients receive prescriptions of inappropriate drugs.Worse, physicians are often reluctant to prescribechemotherapy or cardiac drugs to older people becausethey mistakenly believe the benefits will not outweigh thepains of treatment. Yet, studies indicate many older peo-ple benefit from such treatment as well as or better thanyounger patients. Just one example:

William Bergman, an 85-year-old Californian wasdenied pain medication in the final stages of lung cancerbecause his physician was reluctant to prescribe addictivedrugs. His case led to changes in California law requiringphysicians to take classes in both pain management and

end of life care. Mr. Bergman is notalone. A study in the June 2001Gerontologist suggests, “Pain is preva-lent and often goes untreated innursing homes.”

The marginalization of a patient onthe basis of age undermines the careof older people. Physicians whowould not hesitate to prescribe exer-cise regimens, smoking cessationprograms, or cholesterol loweringstrategies to 45-year-old patients,often hesitate to prescribe such ther-apies to older patients, though evi-

dence shows they would benefit. Advancing age reinforcesthis disparity in treatment. Studies suggest people age 65years are far more likely to receive cholesterol loweringdrugs than people age 75 years. There is a well-docu-mented tendency for physicians to under-prescribe bloodthinners, beta-blockers, ACE inhibitors and other cardio-vascular drugs to older patients after coronary incidents.

Cost in DollarsThis inability to guarantee effective standards of care notonly undercuts the health and independence of olderpeople, but also increases the costs of caring for olderAmericans. This accelerates Medicare costs and affects theeconomic health of all Americans. If more consistent andwidely available geriatric care could result in a reductionof hospital, nursing home and home care costs by just 10percent a year—a reasonable and realistic public healthgoal—the U.S. would have saved $50.4 billion in theyear 2000.

There are numerous economic benefits to delaying theillnesses associated with aging and prolonging the func-tional activity and independence of older people. TheU.S. realizes $5 billion in savings for every month thatthe physical independence of older people is extended.According to the CDC and The Center for BladderControl, decreasing the prevalence of incontinence andfall-related injuries by 5% could generate more than $1.6billion savings for direct health care costs, which couldeasily reach $40 billion by 2020. Even greater savings arerealized by reducing the number of people in long-termor nursing home care.

A study published inthe December 12,

2001 Journal of theAmerican Medical

Association showsmore than one outof every five older

patients receiveprescriptions of

inappropriate drugs.


10The following barriers — cultural, educational,economic and political — help explain why theU.S. has not moved sooner to integrate geri-atrics and age-appropriate professional trainingat every level of the American health care sys-tem. Knowing these inhibitions and excuses isthe first step to overcoming them. When theBaby Boom generation begins moving past age65 at a rapid rate in less than a decade, there willbe no room for more excuses.

In the few years before that happens, the U.S.must address and reverse the reasons for ourpast complacency and inaction. It is time toconfront our attitudes toward aging and thestructural changes in both health care educationand medical research that have kept us inMedical Never-Never Land.

1. Age DenialOn both an individual and a national level, we have notowned up to the fact that we are aging. Those in the BabyBoomer generation still think of themselves as youthful,and the U.S. still thinks of itself as a nation of young pio-neers, rather than facing the fact our population is agingwith unprecedented size and speed. Age denial is at theroot of the failure to address the gap in geriatric training.

Americans also tend to deny existence of problems thatcan accompany aging. There is a stigma attached to dis-cussions of many health issues associated with older agesuch as incontinence or memory loss. Yet, such healthproblems cause a significant number of nursing homeadmissions each year, compound hospitals stays, lead toinappropriate use of medications and increase the risk ofmedical errors.

2. Older Patients MarginalizedOlder patients are seen as nearing the end of life and withsmaller chances of recovery than younger patients.Prevention programs have a youth focus and offer little tohelp older people increase their health or independence.This is too often based on age-related biases andimproper understanding of the health status and medicalcondition of older people. Pure and simple, this is a caseof ageism.

Older patients confront a prejudice prevalent throughoutthe health care system that decline is inevitable. As aresult, there is little effort to redress the problems facingolder patients. For example, potential barriers of culture,age, hearing loss, or expediency can often confuse com-munications between young providers and older patients.Since most providers lack the grounding in geriatric prin-ciples needed to understand these barriers, they perpetu-ate stereotypes that marginalize older people as difficult tomanage or treat, or, worse, destined for decline.

3. Lack of Public Awareness of the Geriatrics GapThe general public is unaware that most of their healthcare providers have never had any specific formal trainingin how to care for elderly patients. Many older people arenot aware that their doctors, pharmacists, or nurse prac-titioners overseeing their care have never had this train-ing. This lack of awareness prevents a critical mass of pub-lic opinion from forming around this issue.

Yet when made aware of this gap in training, Americansoverwhelmingly want their providers to get the necessarytraining. A survey conducted for the Alliance for AgingResearch by Opinion Research Corporation in February2002 found that 74% of all Americans feel it is “veryimportant” that their healthcare providers have someaging- specific training. The number jumps to 96% whenthose who believe the need for specific training is “some-what important” are included.


It is time to confront ourattitudes toward agingand the structural changesin both health careeducation and medicalresearch that have kept us in Medical Never-Never Land.

4. Scarcity of Academic Leaders Too few academic leaders in American schools of medi-cine, nursing, and other health professions are present tointegrate geriatrics into professional health education.The drive to initiate change in medical practice oftenbegins in academia. Academic leadership is necessary topropel an issue to prominence within the health profes-sions and creates the infrastructure for training new

providers. There are too few aca-demic leaders focusing their careerson the needs of older people in allfields of health care and socialresearch.

Of the few physicians, for example,who specialize in academic geri-atrics, most are required to devotemore than half of their time to directpatient care because there are toofew geriatricians. As a result, too fewgeriatricians dedicate their time toresearching the care of older peopleand training students. This creates a

ripple effect throughout the medical education system.There are too few academicians to define and articulatethe health needs of older people; and too few academicsto facilitate the transfer of research findings into practice.

5. Lack of Academic Infrastructure inGeriatricsThe simple fact is that while health care providers willspend much of their time caring for older patients, thereis often no required rotation in geriatrics. While this hasimproved very recently thanks to investments in geriatricsinfrastructure by a few private foundations, over half ofall medical schools still have not appropriately broadenedtheir curricula.

The current infrastructure used to train student physi-cians at most medical schools does not adequately fit thegeriatric model. Less than three percent of U.S. medicalstudents opt to take an elective in geriatrics. This, to alarge degree, can be traced to the lack of established geri-atric teaching units within professional schools, and lackof academic role models. The one-month training rota-tions some residents receive do not permit futureproviders to adequately experience and understand how

geriatric practice improves health and independence overtime. Brief and transitory exposure to sick older patientsin hospital wards without this follow-through perpetuatesthe stereotype that older patients are hopeless cases des-tined for decline.

6. Geriatric Medicine Not Valued Geriatric medicine lacks the prestige and financialrewards afforded other fields of medicine. Older patientsare perceived as more difficult to diagnose and treat.Geriatrics does not rely on high-tech procedural medi-cine or dramatic cures as much as other disciplines, whichleads to lower levels of reimbursement and relatively lesscareer glamour compared to other medical fields. This isfurther hampered by a lack of medical role models andinvestment in geriatrics education.

Limits on the number of residency slots funded byMedicare also discriminate on new fields like geriatrics.Only 450 of the 98,000 academic fellowships funded byMedicare education funds are in geriatrics. Put anotherway, the very program designed to treat older Americansdevotes less than one-half of one percent of its trainingdollars to programs specifically aimed at treating olderAmericans.

7. Inadequate ReimbursementMedicare and other health care insurers provide higherreimbursement for procedures, tests, and technology-driven medical care that are not the core of geriatric care.Also, good geriatric care runs counter to trends shapinghealth care practice, such as physicians spending fewerminutes with each patient. The appropriate time requiredfor an average office or home visit for an older person,who often has multiple health problems, is longer thanthat for a younger patient. Reimbursement does not ade-quately reflect this added provider time. This skewreduces the incentives for providers to seek certification ingeriatric practice.

The very programdesigned to treatolder Americans

devotes less thanone-half of one

percent of itstraining dollars to

programs specificallyaimed at treatingolder Americans.


Cost-saving measures byMedicare and other insurersoften demand that healthcare providers, includingphysicians, pharmacists, andtherapists receive decreasingreimbursement rates forpatient visits. Providers areexpected to compensate for

loss of income by seeing more patients in less time. Thediagnostic tools that allow professionals to reduce timespent with patients often cannot effectively discern thehealth status of older patients. For example, a suddenshift in behavior could be caused by a loss of hearing,numerous metabolic conditions, the first signs of demen-tia, or a reaction to medications. No single test could iso-late each of these possible causes.

8. Lack of Coordination within Medicine There are tremendous resources separately focusing onillnesses, such as cancer, arthritis or heart disease, that pri-marily affect older people. However, these resources oftenoperate in separate silos, missing valuable opportunitiesto better understand, prevent, treat and cure these ill-nesses, or to provide proper rehabilitation in older people.

While specialization and compartmentalization are theincreasing norms of health care, they often do not fit theneeds of the elderly. Older people often have severalchronic conditions at the same time requiring more thanone specialist. One elderly woman asking her oncologistabout painful muscle stiffness was told, “That is not asso-ciated with the condition I treat. Ask someone else.”Cardiovascular, neurological, and other conditions are partof the aging process. The health and independence of olderpeople depends not only on how well they manage eachcondition, but how they co-manage all these conditions.

Older people require a team approach to care — a teamthat understands medical conditions in the context ofaging — a team that understands how conditions such asdepression or loss of mobility influence the course of ill-nesses such as hypertension or heart disease. Isolating thetreatment of arthritis from the treatment of heart diseaseinhibits understanding of how the effects of aging influ-ence the overall health. The ability to prolong healthyactivity and positive mental outlook influences the pro-

gression of illnesses, such as heart disease. There is insuf-ficient effort by the health care community to integratethese concepts into the care of older people.

9. Clinical Trials Often Do Not Includethe Aged Pharmaceuticals are fast becoming the treatment ofchoice for many conditions of aging, but older people areunder-represented in the clinical trials of many of thesedrugs, which complicates creation of safe standardsregarding their use in older populations. It is especiallyrare for experimental drugs to be tested in populations ofpeople age 75 and above with co-morbidities, thoughincreasingly this is the largest group of consumers ofpharmaceutical care in the U.S.

Until 1990, older people were routinely excluded fromclinical trials. Despite efforts since then to enlist greaternumbers of older patients in clinical trials, they remainvastly under-represented. Older women account for 49percent of all breast cancer cases, yet they account foronly nine percent of the study populations of clinicaltrials, according to a study in the New England Journalof Medicine.

10. Little Research on the Aging ProcessLess than one percent of the entire budget of the NationalInstitutes of Health (NIH) is devoted to studying thebasic biology of aging. While tens of billions of dollarswill be spent each year on the specific study of disease, lit-tle is invested in understanding how the single largestdemographic fact of life will impact those illnesses. Thelack of such attention greatly reduces the cross-fertiliza-tion that is necessary to build the fields of aging researchand geriatrics.

There are significant resources dedicated to diseases thatlargely threaten older people — such as cancer, heart dis-ease, diabetes, or respiratory diseases — but research pro-grams in these areas often fail to focus on the specific roleof the aging process in the incidence or course of the dis-ease. As science is learning more about the aging at thecellular level, this research is not transferred to a broaderunderstanding of the diseases of aging. Too few researchdollars go to determine how chemical or metabolicchanges, which occur between ages 65 and 80, shape theprogression of illness.


The reasons the U.S.remains in Medical Never-Never Land reflect inertia.Still the nation has theability, if it has the will, tobridge the geriatrics gap.

A National Will to Act

Due to the above 10 reasons, there is little resolve toaddress the shortage of geriatric providers in the U.S.Without national leadership and sustained public sup-port, the U.S. will not adequately address this issue intime to prevent the gap from widening with serious con-sequences. It is possible this crisis will reach critical masswith tragic — and perhaps irreversible consequences —before America has the will to act. We urge the healthprofessions themselves, educational institutions, founda-tions and policymakers to prevent this from happening.The U.S. must awaken to the shortfall in geriatric healthprofessional training with the same urgency the nationnow gives to protecting the financial solvency of SocialSecurity and Medicare.

Recommendations

The lack of geriatric training in the professions that gov-ern the care and treatment of older people in the UnitedStates constitutes an immediate and continuing crisis. Itis a crisis the U.S. should have addressed by now.However, the reasons the U.S. remains in Medical Never-Never Land reflect inertia. Still the nation has the ability,if it has the will, to bridge the geriatrics gap.

End the DenialGrown up Americans should realistically accept and planfor their own aging. As a nation we should accept there isan urgent need for more geriatricians and geriatrics edu-cators in all fields of physical and mental health. The U.S.will only end its denial of aging by awakening to theurgent health needs of older people. A lack of geriatricprofessionals has already undermined the health of thou-sands of older people. A lack of awareness underminesthe health of thousands more. Too many people wronglyregard any sign of forgetfulness in older people as the firststep toward unstoppable dementia. Educating Americansto the true health needs of older people will propel thisissue to the public agenda and create a demand for geri-atric services that moves healthy policies to achieve cor-rective action.

The Health Resources andServices Administration(HRSA) of the U.S.Department of Health andHuman Services is currentlydeveloping a report on thehealth workforce implicationsof an aging America. While thisreport is a good first step, italone does not respond to thedramatic demographic shiftAmerican medicine is justbeginning to experience. Changes are needed at the fed-eral, state and local level to accelerate geriatric educationin the healthcare professions.

Develop Geriatric LeadershipThe U.S. must set goals to increase the number of geri-atric academics in all fields of the health sciences. Thesetargets should be matched with adequate funds and

The U.S. must awaken to the shortfallin geriatric healthprofessional trainingwith the same urgencythe nation now gives toprotecting the financialsolvency of SocialSecurity and Medicare.


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One Approach to Needed Growth in Academic GeriatricsOne Approach to Needed Growth in Academic Geriatrics

Dr. Robert Butler, the first director of the NationalInstitute of Aging, has proposed an algorithm toclosing the geriatric gap for academic physicians. Overa 20-year period, Butler would increase the number ofmedical schools training academic geriatriciansthrough federal support — reaching all medicalschools by the 15th year. His approach would producea cumulative total of 1,400 academic geriatricians bythe 20th year at a relatively modest average annualcost of 22 million dollars. And while Dr. Butler’s plan isambitious, it is barely enough to keep up with thepopulation growth of the elderly. It would need to beaugmented with private sector programs in order toadequately meet the need.

training resources to provide incentive for students.Improvements to the training infrastructure, includingincreasing the length of fellowship support and increasinggeriatric research and teaching time, must be achieved.

The U.S. should fund geriatric research and centers forexcellence to attract academicians to geriatrics. Thenation should also dedicate a larger percentage of govern-ment research dollars to studying the basic biology andconditions of aging. This will generate interest in humanaging and geriatrics at major universities and academicinstitutions. The government has created resources todevelop geriatric leadership, such as the Claude PepperCenters, the HRSA Geriatric Education Centers, and theGeriatric Education and Clinical Centers (GRECCs) ofthe Veterans Administration, but now must to supportsuch efforts more fully and generously.

Make Careers in Geriatric Care More Attractive The U.S. should set a goal of attracting new providers togeriatric practice, and commit programs to achieving thegoal. Targeted financial incentives, such as loan forgive-ness and continuing education funds, are needed across

all health fields and specialties toencourage exposure to geriatrics andage-related care.

The income disparities betweengeriatricians and other specialtiesshould be reduced. Loan forgivenessprograms and other financial incen-tives are necessary to eliminate thefinancial burdens of paying for med-ical education, which can dissuade

young providers from entering geriatrics. Improved reim-bursement from both Medicare and managed care organizations would help to transformgeriatrics into viable career paths for prospective younghealth professionals.

Integrate Geriatrics into Medical Education The drive to integrate geriatrics into the training infra-structure of health care providers will require governmentleadership and government funds. Geriatrics must be

infused throughout the U.S.medical school and teachinghospitals curricula . The fed-eral government shouldrequire every health profes-sional school, hospital, andteaching facility receivinggovernment training dollarsto require geriatric coursework or rotation. States, especially those with significantnumbers of older people, should examine licensingrequirements as they pertain to geriatric training and care.

Provide Incentives to Include Older Patients inPharmaceutical TrialsThe federal government should develop incentives forprivate industry to stimulate increased pharmaceuticalresearch and testing among older people. Research anddevelopment tax credits, patent extension and labelingallowances should be explored to increase inclusion ofolder people in research on new drugs.

Escape From Never-Never Land

Considerable public policy attention in the comingmonths and years will focus on the financial solvency ofSocial Security and Medicare. These two programs repre-sent vital support and necessary care to the nation’s ever-growing, ever-changing older population. These are largeand vital programs. Beyond policy changes, the outlookfor protecting Social Security and Medicare becomesbrighter if those two programs serve to increase theprospects for healthier, more vital and independent lives.Proper age-related and geriatric medical care is the onlydirection our nation can take. The time to make thisinvestment is now.

Proper age-relatedand geriatric medical

care is the onlydirection our nationcan take. The time

to make thisinvestment is now.


The U.S. should fund geriatric research and centers forexcellence to attract academicians to geriatrics. Thenations should also dedicate a larger percentage of gov-ernment research dollars to studying the basic biologyand conditions of aging. This will generate interest inhuman aging and geriatrics at major universities and aca-demic institutions. The government has created resourcesto develop geriatric leadership, such as the Claude PepperCenters, the HRSA Geriatric Education Centers, and theGeriatric Education and Clinical Centers (GRECCs) ofthe Veterans Administration, but now must to supportsuch efforts more fully and generously.

Make Careers in Geriatric Care More Attractive The U.S. should set a goal of attracting new providers togeriatric practice, and commit programs to achieving thegoal. Targeted financial incentives, such as loan forgive-

ness and continuing educationfunds, are needed across all healthfields and specialties to encourageexposure to geriatrics and age-related care.

The income disparities betweengeriatricians and other specialtiesshould be reduced. Loan forgivenessprograms and other financial incen-tives are necessary to eliminate the

financial burdens of paying for medical education, whichcan dissuade young providers from entering geriatrics.Improved reimbursement from both Medicare and managed care organizations would help to transformgeriatrics into viable career paths for prospective younghealth professionals.

Integrate Geriatrics into Medical Education The drive to integrate geriatrics into the training infra-

structure of health careproviders will require govern-ment leadership and govern-ment funds. Geriatrics mustbe infused throughout theU.S. medical school andteaching hospitals curricula .The federal governmentshould require every health

professional school, hospital, and teaching facility receiv-ing government training dollars to require geriatric coursework or rotation. States, especially those with significantnumbers of older people, should examine licensingrequirements as they pertain to geriatric training and care.

Provide Incentives to Include Older Patients inPharmaceutical TrialsThe federal government should develop incentives forprivate industry to stimulate increased pharmaceuticalresearch and testing among older people. Research anddevelopment tax credits, patent extension and labelingallowances should be explored to increase inclusion ofolder people in research on new drugs.

Escape From Never-Never Land

Considerable public policy attention in the comingmonths and years will focus on the financial solvency ofSocial Security and Medicare. These two programs repre-sent vital support and necessary care to the nation’s ever-growing, ever-changing older population. These are largeand vital programs. Beyond policy changes, the outlookfor protecting Social Security and Medicare becomesbrighter if those two programs serve to increase theprospects for healthier, more vital and independent lives.Proper age-related and geriatric medical care is the onlydirection our nation can take. The time to make thisinvestment is now.

Proper age-relatedand geriatric medical

care is the onlydirection our nationcan take. The time

to make thisinvestment is now.


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