When I'm Sixty-five

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.