Senior Health Program Streamlines the Assessment Process

The leading edge of the "Baby Boom" generation is turning 60. Many members of this population sector - estimated at more than 75 million Americans born between 1946 and 1955 - have enjoyed health advantages far beyond those of previous generations.

Good food, childhood vaccines, improved dental care, and widespread infection control have become widely available in the US. Advanced health screening techniques catch early signs of diseases such as cancer that once were considered invariably fatal.

Millions of us take advantage of medications that slow the ravages of chronic illnesses such as diabetes, arthritis, and heart disease. Quality and length of life have been increased by procedures like joint replacement, open-heart surgery, organ transplantation, and stroke rehabilitation, to name just a few.

For a generation that has received unparalleled health and medical care, there are high expectations for old age. But who will be providing that care?

"We're going to go from somewhere in the neighborhood of 13% of the US population over age 65 to 20%-25% as we approach the middle of the century," says Edmund H. Duthie, Jr., MD, Medical College of Wisconsin Professor of Medicine and Chief of the Department of Medicine's Division of Geriatrics and Gerontology. "That may not seem like a big number, but it is - it's really big. This is viewed as an impending national challenge."

According to an article in the New York Times (Geriatrics Lags in Age of High-Tech Medicine, October 18, 2006), one in a series about aging, "In 2005, there was one geriatrician for every 5,000 Americans 65 and older, a ratio that experts say is sure to worsen. Of 145 medical schools in the United States, only 9 have departments of geriatrics. Few schools require geriatric courses. And teaching hospitals graduate internists with as little as six hours of geriatric training."

The Medical College of Wisconsin has been ahead of the curve in taking care of the older population. In 1981, the Division of Geriatrics/Gerontology was established within the Department of Medicine, and today every MCW student receives training in various aspects of taking care of elderly patients.

Adult Children Watch Over "Vulnerable Elders"
"I deal with vulnerable elders," says Dr. Duthie. "A definition of that would be, generally, people 85 and over, or people over 65 who are not functioning optimally or at risk for losing function. Vulnerable elders have some frailty, they're not always able to advocate completely for themselves. Their condition is such that they're often not able to navigate the health care system and they need some help in that regard," he explains.

"When you're older and healthy, that's one thing - the non-vulnerable elderly are fending for themselves. But what are you going to do when you have multiple problems?" asks Dr. Duthie.

In many cases, the answer lies with adult children. In fact, Dr. Duthie says it's unusual for his patients to decide on their own to see a geriatrician. The most common scenario he sees is that of adult children bringing parents to the doctors - and they come prepared. They bring tape recorders, take notes, research health conditions and treatments, and question their parent's doctors. Typically, the children have already met with the parent's primary care doctor or internist, but the parent is still not functioning optimally.

Ideally, health care providers will appreciate this family involvement. For example, "Dr. Biblo (Lee Arnold Biblo, MD), Vice Chairman of our department, really makes a point about patient empowerment," says Dr. Duthie. "He says that as a clinician, he feels a lot better when there is a patient advocate in the mix. He considers it one more safety check."

The Senior Health Program
Dr. Duthie leads the Froedtert & the Medical College of Wisconsin Senior Health Program, which includes staff members from multiple geriatric specialty areas who see patients at both Froedtert Hospital and the Milwaukee VA Medical Center. "Both campuses contribute significantly to our academic mission," notes Dr. Duthie.

"At the VA, we have an inpatient geriatric evaluation and management unit, while at Froedtert we do more outpatient geriatric evaluations emphasizing memory and cognitive decline. The two programs complement each other, both for patients and from a training perspective. Our students are able to see different interdisciplinary teams caring for different patient groups."

The core team includes board-certified geriatricians (physicians who specialize in geriatric care), nurses, social workers, and geriatric care managers. They use a "bio-psycho-social model" that assesses all aspects of their patients' lives, including cognition, physical function, communication, movement, and activities of daily living (ADLs) such as dressing, eating, and toileting; and look at mood and other factors to screen for depression, which occurs fairly frequently among people with chronic illness, Dr. Duthie says.

Although patients can complete the comprehensive cognitive assessment in one day if they prefer, most choose to make several visits, since the process can be tiring.

During the first visit, patients typically meet with the nurse, who performs tests and interviews to gather initial data about medications, functional ability, cognition, and mental status.

The second visit consists of the more traditional medical history and physical; if further testing or consultation is needed - for instance, MRIs or other imaging, hearing evaluation, psychiatry - these will be scheduled. Also at this visit, there is the opportunity for a meeting with the social worker to discuss the social and community aspects of the patient's life.

For a "wrap-up" visit, the team pulls together all the information gathered about the patient, discusses results with the patient and family, answers any questions, and makes recommendations that can then be taken back to the patient's primary care physician for consideration and implementation. Depending on the circumstances, the team may refer the patient back to the primary care physician or co-manage the patient with the primary provider.

"I still believe that a vast majority of older people in this country are going to be cared for by a primary care physician, either an internal medicine specialist or family physician," Dr. Duthie says. "Our teaching programs at the Medical College of Wisconsin are aimed to help these doctors do the best job possible."

"We will continue to look for innovations in care and practice so that a small number of geriatricians can amplify their effects so we have better outcomes in geriatrics."

Eileen Early, BA, BSN, RN
HealthLink Editor

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.