When I'm Sixty-five

A friend of mine has a golf-obsessed mother who moved South the split second her kids were grown. Though the kids sometimes worried about how she was getting on by herself, they were strangely reassured by the long list of medical specialists she was seeing regularly and seemed to regard as fondly as her grandkids.

There was the “darling man” who replaced her knee, the “smart little gal” who handled her physical therapy, the cardiologist (“from Harvard!”) who listened to her heart, not to mention the ophthalmologist who kept an eye on her glaucoma and the sports medicine expert who made sure her arthritis didn’t get in the way of her golf game. My friend’s seventy-something mother was in such good spirits, and spoke of her diverse medical team with such happy familiarity, that the call my friend received one day informing her that her mother had collapsed during an appointment took her entirely by surprise.

“I tried to call your father first, but he didn’t answer,” one of the doctors told her.

In fact, the woman’s husband had been dead for nearly a decade—an oversight that made her children worry about what else on her medical chart may have been overlooked or misread. Family members flew to her bedside, and for a while it looked as though she would have to leave her sunny second home and move in with one of her kids. Then another specialist introduced himself. He concluded that the woman’s dizziness had not been brought on by anything malignant, but by several competing medications that shouldn’t have been taken together. He also determined that her recent weight loss—and that of her cat—was probably the result of the arthritis pain she experienced trying to operate her manual can opener while preparing meals.

My friend knew her feisty mother was back to her former self when she balked at having to add the new specialist to her list of providers. “I’m not old enough to need a geriatrician,” her mom complained.

It’s a common notion—especially in an era when no one can agree on what qualifies any of us as “old.” Fifty is the new forty, sixty is the new sexy, and menopause, a topic barely mentioned a generation ago, is the subject of a “hot” off–Broadway musical. Some of this is the healthy result of new attitudes about aging as well as social and medical advances that have extended life expectancy well beyond what it was a century ago. (The average sixty-five-year-old American can now expect to live at least another 18.7 years.) On the other hand, some of our insistence that we’re getting better not older may be old-fashioned denial. As physician and New Yorker writer Atul Gawande put it recently, “People naturally prefer to avoid the subject of their decrepitude.”

“As a nation, we don’t like to think about getting older, and we certainly don’t like to plan for it,” says Joseph Gaugler, an assistant professor at the University of Minnesota School of Nursing Center on Aging. We’re often reluctant to acknowledge a loved one’s advancing years “until,” Gaugler says, “it becomes a full-scale family crisis” like the collapse that spurred my friend’s concern. Or a national one. 

In three years, the leading edge of the nation’s 78 million baby boomers will turn sixty-five, an age that makes them eligible for Medicare and will qualify them, in the parlance of the American Geriatrics Society, as “older persons.” What they will find when they reach that milestone, according to a report released this spring by the Institute of Medicine, a branch of the National Academy of Sciences, is a health care system “woefully unprepared” for meeting the needs of an aging population.

Among the problems outlined in the organization’s report is a system more effective at offering piecemeal acute care for the problems of middle age than providing the more complex care older patients need. Medicare doesn’t pay doctors enough to manage the care of elderly patients, and with steep pay cuts coming this summer, according to an American Medical Association report, some 60 percent of the nation’s physicians say they’ll be forced to limit the number of Medicare patients they can treat.

The existing shortage of geriatricians—there’s currently one physician certified in geriatric care for every 2,546 Americans over the age of sixty-five—is predicted to almost double in the next twenty years. Last year, according to the American Geriatrics Society, nearly half of the nation’s 468 first-year geriatric training fellowships went unfilled.

Alarm over the dire predictions has resulted in the usual congressional hearings and collective handwringing about what can be done to attract more health care workers to serve the elderly. Proposals call for financial incentives for geriatric work, loan-forgiveness programs for future providers, even a “rebranding” campaign that would change the term geriatrics to something that sounds less, well, old. Steven Miles, a board-certified geriatrician and professor at the University of Minnesota Medical School, says such approaches, though well-meaning and overdue, also “reflect an undue sense of pessimism about what can be done with older folks.” Geriatrics, he says, is “one of the more interesting human encounters in medicine, between a total human patient and an engaged practitioner.”

Miles gave up a job as a primary care physician treating “yuppies with shin splints” at an HMO to work with older patients with more complicated problems, including many with dementia, at the Minneapolis Veterans Affairs Medical Center. Though the move may have struck some of his colleagues as peculiar, Miles is not alone in his praise of the work. Geriatricians are among the lowest paid of all physicians, yet their specialty enjoys one of the highest job-satisfaction rates in medicine, according to the Archives of Internal Medicine.

One reason for that satisfaction may be the patients themselves. “Old age really isn’t a time of despair and depression,” says Gaugler. “It’s a pretty consistent finding that people are happier as they get older. It’s a time in their life when they can enjoy their family and their accomplishments.”

Yet another reason may be the living proof that good geriatric care improves longevity and quality of life. A U of M study conducted in St. Paul a few years ago followed more than 500 men and women over the age of seventy who were living on their own and were at high risk of becoming disabled. Half the group was left in the care of their own physicians, while the other half was assigned to a team of geriatric specialists. After a year and a half, about 10 percent of the participants had died. Of the rest, those who had received geriatric care were found to be 33 percent less likely to become disabled, 40 percent less likely to need home health services, and 50 percent less likely to suffer from depression.

Miles notes that many of the best techniques for improving the lives of his elderly patients are the simplest—making sure they’re eating right and bathing regularly, monitoring their medications, determining which family members are involved in their lives and which aren’t. (Miles says a survey of academic medicine residents found that four out of ten didn’t know whether their patients were married or not—critical information when it comes to understanding a patient’s lifestyle, social support, and decision-making situation.) “You also want to see [your patients] move,” he says. “Stand up, twirl around, then sit down and do it again. That can tell you quite a lot.”

The low-tech interventions often provide better information about the elderly patient than expensive diagnostics, says Miles. “We seem to think we’re getting closer to and more intimately knowledgeable about a patient the more scans and complex blood tests we do,” he says. But often the tests create a “level of estrangement” from the patient. Miles tells of a recent meeting with a ninety-year-old man who’d been prescribed cholesterol-lowering drugs—medication meant to help the middle-aged reach old age.

“You can’t practice medicine with older people without engaging them where they live,” he says.

Caring for the next wave of older Americans is going to take a new way of thinking. It’s also going to take many more nurses, aides, and other health workers. One of the more troubling findings in the Institute of Medicine report is that the turnover among nurses’ aides averages 71 percent a year and as many as 90 percent of home health aides will leave their jobs within two years. The report also found that in some parts of the country, manicurists and dog groomers are required to have more hours of training than those who work with the elderly.

Minnesota seems to be in a better position than many states, thanks to the U of M Nursing School, which has one of the largest gerontological nurse practitioner programs in the country. Just this spring, the John A. Hartford Foundation, a New York–based nonprofit that focuses on improving health care for older Americans, gave the school $1 million to establish the Minnesota Hartford Center for Geriatric Nursing Excellence. The center will train faculty who teach geriatric nursing at schools in four states and at tribal colleges across the nation. “We’re directly trying to fill the gaps the IOM report is talking about, trying to increase the number of nurses in the Upper Midwest who are prepared for this aging population,” says center director Jean Wyman. “We can’t graduate people fast enough.” 

Other responses to the age crunch may include a shift toward a more primary care–centered health system in which patients would have a “medical home” with a team that manages and coordinates their care over a lifetime. The move toward electronic record-keeping should also help, giving all of a patient’s various specialists instant access to the same information. Proposed legislation in the U.S. Senate would help attract caregivers to geriatrics and create an advisory panel to figure out how to handle health care twenty years from now, when one in five of us will be over sixty-five.

Of course, retooling the system will take time, so what should we do in the meantime? “Exercise, get plenty of rest, and keep your mind active and engaged in meaningful activity,” advises Wyman, who says that such practices are already helping us age better than our parents, who have aged better than their parents before them.

Miles agrees with Wyman’s prescription and adds one more. Find a physician “who likes you—really likes you,” he says. “They need to be skilled, but you want to make sure they also really like older people.” After all, the term might not apply to you now, but, if all goes well, it someday surely will.