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Aging:Final 9/4/07 4:06 PM Page 12 In the United States, the number of people over 65—currently 35 million—will double by 2030, jumping from 13 percent of the population to 20 percent. And adults over 85 are currently the fastest growing demographic group in the U.S. It's a different kind of boom for which we're not prepared. While the elderly population is climbing, the number of doctors and nurses who treat them is declining and the population of traditional caregivers is either stagnant or falling. Studies show that conditions like incontinence, diabetes, and high blood pressure respond just as well to exercise and dietary regimes as they do to target drugs. Indeed, many times the drugs create the problems. Dr. Wendel Brunner, now director of public health in Contra Costa County, Calif., recalled that when he was working in a clinic, "Old people would come in with bags of medicine. I would throw away most of it, and they would get better." "Old people would come in with bags of medicine. I would throw away most of it, and they would get better." —dr. wendel brunner What makes addressing the aging population particularity challenging is that geriatrics, the branch of medicine that deals with the diseases, debilities, and care of older people, is an enormously complex kaleidoscope of medical procedures, government policy, and demographics. Problems or the wrong approach in any of these areas can lead to a train wreck. In the aftermath of the 1995 Midwest heat wave, researchers found that it was not so much the temperature that killed people, but poverty, isolation, and fear. Many elders were too poor to afford air conditioning, they lived alone, and were too afraid to go out into the mean streets of Chicago. Isolated behind locked doors, they baked to death. But tying together all the strands that make up the complex field of geriatrics is not a simple task. On one level, the infirmities of age like diabetes, arthritis, incontinence, and high blood pressure are medical conditions that can be treated with drugs. But as Dr. Claudia Landau, geriatric curriculum coordinator and an associate clinical professor of medicine at the University of California, Berkeley argues, when it comes to treating older people, "The medical model is not going to work." Geriatrics, she says, needs doctors and nurses to be as much sociologists and anthropologists as medical workers. "They have to know whether their patients are poor or rich, they need to know the total terrain," said Landau. "If you don't attend to all of the elements, you are not going to care for old people very effectively." Yet currently, the medical model is relentlessly pushed by an avalanche of television ads on treatments for incontinence, diabetes, and high blood pressure—what researchers Dr. Carol L. Estes and Steven P. Wallace call the "commodification" of aging by a "medical-industrial complex" whose bottom line is money. According to Joan Stanley, RN, senior director of education policy of the American Association of Colleges of Nursing, and Mathy Mezey, RN, a professor at New York University, "The care of older adults is now the number one business of the U.S. healthcare system, cutting across hospitals, home care and nursing homes." "Adult diapers and drugs produce significant profits for their manufacturers, creating incentives to promote these products," write Estes and Wallace in the book Social Injustice and Public Health. "As a consequence, behavioral therapy, which is time consuming and not very profitable, is rarely used even though it is more effective." For example, while loss of bladder control seems like one of aging's minor ailments, it is a major reason older people are institutionalized. 12 REGISTERED NURSE Treating older people takes certain skills that most general practitioners and specialists don't have. One of those skills is listening. "As we get older our homeostasis changes and doctors need to be tuned into that," said Landau. "You have to listen and take the time. You have to value communication." She calls this "cognitive medicine." Is an older patient disoriented because he or she is losing their mental faculties, or because of depression? Do they have an infection? (Infections can be difficult to spot because older people tend not to run fevers.) Or are they on the wrong medication? Doctors, for example, need to be particularly careful when prescribing drugs to elders. Diuretics are commonly prescribed for controlling high blood pressure, a chronic disease afflicting many older people. But if patients are not properly hydrated, diuretics can cause dizziness and falling. Of some 350,000 Americans who fall and break their hips each year, 40 percent will end up in nursing homes. A fifth will never walk again. Side effects can be exacerbated when different doctors prescribe drugs without any centralized monitoring. "Multiple doctors prescribing multiple medicines cause multiple problems," said Brunner. The flip side of overprescribing is the attitude among providers that there's nothing that can be done for elderly patients. Wallace and Estes found that many doctors tend to undertreat older patients, with some claiming "those over 80 should receive no curative treatments…because they have lived out their 'natural lives.'" But a Harvard study found that when 90 year olds were put on Nautilus trainers their health improved. Landau recalled advocating physical therapy for older patients when she worked in a public health clinic, only to be accused of "torturing" them by some staff members. "I told them to humor me and lo, and behold, people got better," she said. A doctor or nurse certified in geriatrics is best trained to triage the health needs of elderly patients. But out of the nation's 145 medical schools, only nine have geriatric departments, according to an April 2006 New York Times article. There is only one geriatric doctor for every 5,000 people in the United States. Fewer than 9,000 of the 650,000 doctors in the country are certified in geriatrics and fewer than 3 percent of medical students take courses in the subject. The number of U.S. geriatricians has dropped by one-third between 1998 and 2004 . "It's a problem," warned William Satariano, a professor of epidemiology and community health at U.C. Berkeley's School of Public Health and an expert on aging. W W W. C A L N U R S E S . O R G SEPTEMBER 2007