Do I need a geriatrician?
Cliff: A geriatrician is a physician who specializes in the care of older adults. There aren’t many of us around. Most seniors see general internists, family physicians, family nurse practitioners or physician assistants as their primary care providers. So I’m frequently asked, ”Do I need a geriatrician?” Or more often the question actually is, ”Does my Aunt Gracie need a geriatrician?”, since the question is usually asked by family members concerned about a relative’s functional decline and safety in the home.
To answer the question for Aunt Gracie, let me give some background on geriatrics. The specialty of geriatric medicine dates to the early years of the 20th century when the term “geriatrics” was first proposed to refer to the medical care of older adults. The American Geriatric Society was formed in 1942 as the first major medical society in the US devoted to enhancing medical care of the elderly. A state chapter of the American Geriatrics Society, called the Dirigo Maine Geriatrics Society, was formed just last year by leading geriatricians in Maine to improve geriatric education and clinical care in our state. In the early 1990’s, the national specialty boards of internal medicine, family medicine and psychiatry recognized geriatrics as a subspecialty and offered exams and subspecialty board certification that recognizes extra training and expertise in geriatrics.
Modern curricula for medical students and all medical specialties (except of course, pediatrics!) must include training and experience in geriatrics. I think that this requirement has made a big difference in the knowledge and skills of younger physicians when it comes to the basic principles of geriatric medicine. Many older physicians have gained special knowledge and skills in geriatric care through experience and continuing medical education. This extra training certainly helps, but primary care providers and general psychiatrists have a lot of other areas to keep up with and they generally don’t have the knowledge of geriatric specialists.
Advanced practice nurses also recognize geriatrics as a special area for training and certification. Interchangeably called gerontological or geriatric nurse practitioners, these nurses provide primary care to older adults in clinic, hospital and nursing home settings, just as their physician colleagues do.
Now let’s get back to whether Aunt Gracie, who is getting very forgetful and has fallen several times at home, needs to see a geriatrician? The answer is……”It depends.” It depends on how interested and knowledgeable her primary care provider is in geriatrics. It also depends on how complex the situation is. A 75 year-old who is active, healthy, takes few medications and overall functions well doesn’t need a geriatrician. An 82 year-old who is forgetful, has trouble walking and takes 12 medications may well benefit from seeing a geriatrician. We geriatricians are at our best when there are complex interactions between aging, multiple chronic diseases and several medications with lots of interactions and side effects. In those situations we can often clarify the reasons for decline in memory, energy, hearing, vision and mobility and figure out the best approach to keeping a person as active and independent as possible. We tend to focus less on specific diseases and more on improving overall function and quality of life. We take great pleasure in stopping unnecessary or potentially harmful medications. This is increasingly the focus of many primary care providers as well, so Aunt Gracie may already be in good hands. But at least one consult with a geriatrician has been shown to improve functional outcomes in older adults with multiple chronic conditions.
The answer to the question also depends on how satisfied you and she are with her current provider. How well does her provider listen to her describe the symptoms? How many questions does the provider ask? Is the provider also interested in the family’s opinion? How well do they explain the diagnosis and treatment plan? How well do they explain the potential risks and benefits of diagnostic procedures and treatments, explaining how age and functional outcome affect those decisions? Health care providers these days are under intense time pressure and they may not be able to take the time required to really assess common geriatric problems such as incontinence, balance problems, mood and memory issues. They may be too quick to attribute symptoms to “old age”. Thoughtful assessment and discussion of symptoms not only takes knowledge, but time, and geriatricians generally have a little more of both when it comes to the common problems of old age. They also generally know a little more about the options for getting help in the home or what to do when it’s no longer safe for Aunt Gracie to stay home.
To summarize, geriatricians can be very helpful in figuring out why an older person is declining when there doesn’t seem to be one simple explanation. We’re good at understanding how many little subtle things can add up to big problems in old age, teasing those things apart and developing an overall plan. We can also be helpful, when the time comes, in advising when to set limits on more diagnostic tests, more surgeries and more medications. When it come to longevity, our focus is quality, not so much quantity, and that is often just what Aunt Gracie wants for herself.
Next Month: Do I need a professional geriatric care manager?