Getting a Grip on Geriatrics : Older Patients Urge the Medical Profession to Prepare for the Aging of America

A common gripe among older Americans is that, too often, when they talk to a doctor, what they hear is: “It’s just old age.”

--Dr. Kenneth Brummel-Smith, USC School of Medicine

Jerald Hoover, 71, remembers that it began two years ago.

“I had been in perfectly good health, and then one day I started to write a note to my son, and I had difficulty beginning simple words. A few days later, after I had finished a round of golf, I couldn’t add up the score properly.

“I didn’t know it at the time, but they were signs of a stroke.”

Soon thereafter, Hoover, of Hacienda Heights, happened to be scheduled for his annual physical, and mentioned to his family physician of 15 years what had happened. The doctor suggested that he also see a neurologist, whose tests turned up the fact that the patient had suffered a minor stroke.

Things went downhill from there, Hoover said: “The neurologist put me on medication in addition to what my own doctor had put me on. Looking back, I was being over-medicated, but didn’t realize it.”

Over-medication is but one of the complaints of older Americans in their relationships with physicians. And doctors, for their part, justifiably feel that seniors could often do more to help at this time of their lives when health problems are so common.

And all of this happening while the nation’s population grows increasingly older.

As Dr. Edward Schneider, dean of the Andrus Gerontology Center at USC, has repeatedly told his colleagues: “Officially or unofficially, you will be in geriatrics by the end of the century. Unless you are a pediatrician or an obstetrician, the average age of your patients in the year 2000 will be 65 or over.” In anticipation, curricula at medical, dental and pharmaceutical schools are being revised to add more hours dealing with the medical aspects of aging and older Americans.

But as of now--although physicians increasingly are more sensitive to the special needs of seniors--everything isn’t what it could be. As Hoover can attest:

“There should be more communication between older people and their doctors. I was taking six different medications. If only my doctors had said: ‘Look, you’ve had a minor stroke. The consequences will be as follows. The medicine you are on will do this to you. And also you are apt to become depressed.’ ”

Instead, Hoover was confused at what ensued: “I found that I didn’t give a damn about anything. I no longer wanted to play golf. I tried to read and I couldn’t. I had insomnia. I didn’t want to talk to anybody. I just wanted to lie around the house.”

Then came two dreadful days, about seven months after he had gone for his physical, when Hoover reached the point where he went entirely without any sleep --even 10 minutes. “I told my wife, ‘I’ve gotta get some help.’ She drove me to a hospital, to the emergency section, and I overheard a nurse say: ‘This guy says he can’t sleep!’ ”

But he was admitted for two days, and sleep eventually returned. After that, his wife, Betty, enrolled him in a stroke therapy class at another hospital. It was there that he heard about the Clinical Gerontology Service of Rancho Los Amigos Hospital in Downey.

“When I went there, one of their first moves was to take me off all medicines except two--and those two were gradually tapered off and eliminated. Now I feel great.

“I learned that I had been over-medicated. Not only had my previous two doctors apparently not been communicating with each other, they certainly weren’t telling me anything, not anything I could understand. Whenever I visited them, I got the impression they didn’t want to see me.”

Hoover now has new doctors, and offers this advice to other older Americans:

“Get answers to any questions you may have. If the doctor can’t or won’t give you an answer, get another doctor. In my case, I would very much have liked to know more about my stroke, the effects of the medication, and what I could do to prevent another one.

“The older you get, the more you should question things. After all, you know from experience that diagnosis is the greatest guessing game in existence. Don’t let yourself be intimidated by your doctor.”

Most physicians, however, are aware that the fact of aging may be a stress in itself. There is also a reality: “I’m certain that the more frail and debilitated the patient, the more difficult it is to convince that person of a significant future,” said Dr. Morton Glassman of Tarzana.

Glassman, 61, who retired as an internist two years ago (“I was fed up with everything”), made another point: “Very often, older people put on the physician the disappointment they have to face for themselves.”

But, he continued, “as an internist, you really are one on one. And I always wanted to do the best for any person, regardless of age. The objective of a physician is to restore you to the best health possible--and there shouldn’t be any differentiation regarding age to achieve this medical ideal.”

Is it a factor that treating older people means facing one’s own process of aging?

“Yes, no matter what the age of the doctor, it means coming to terms with your own mortality,” Glassman said. “At times, this can lead to over-treatment. You don’t want to let go. Every death is a defeat, from the standpoint that a doctor is concerned with the maintenance of life.”

In Redondo Beach, after 61 years in the general practice of medicine, Dr. A. E. Sommer still has that on his mind when he sees his patients three days a week.

Sommer, who declined to pinpoint his own age, said he has many patients in their 80s, and has empathy for their problems:

“I may discuss with them what may be causing their anxiety or insomnia. Sometimes, with the elderly, aloneness can be the cause. Sometimes they live alone, and have withdrawn from the world.

“One of my patients is in his 80s and used to play the piano in a band. He has a piano in his home, but hasn’t touched it for years. I have been putting pressure on him to play again, to help give him an interest in keeping going.”

Sommer, who is of the “rather wear out than rust out school,” takes a daily walk, rides a stationary bicycle, and takes adult education courses in Spanish and in piano playing.

“I would hate to retire, and be reduced to meeting other people my age and telling each other of our infirmities,” he said. That, he joked, would be “an organ recital.”

He said that with his older patients, just as with the young people who come in to see him, he likes to be unhurried. “I allow time for personal conversation--about their lives, what part of the country they are from, what their hobbies are.

“After all these years, my advice to medical students would be to communicate and have empathy.”

Near the other end of the age spectrum, Dr. William Wake, 34, of Glendale, is a family physician whose practice is probably 30% to 40% patients 65 or older.

He said that, traditionally, there have been two groups of physicians who take care of older people:

* “There is the technocrat, the specialist who deals in the severe consequences of aging. They do their jobs very well, but older patients sometimes find it difficult to talk with them. The patients are intimidated. There is respect, but no rapport.

* “There are the doctors who (are willing to) hold a patient’s hand. . . . They should be able to recognize a disease before it becomes overwhelming. And there needs to be more preventive medicine. And states such as depression need to be recognized and corrected.

“In the future, what is needed is a combination of the two,” Wake added.

Dealing with older patients, he said, does force a doctor to come to terms with his own aging--even one as young as he, who has been in practice only a few years:

“Sometimes when I see these patients, my parents and grandparents come to mind. I try to be the kind of physician I would want for them.”

“Older people, by and large, were brought up in a culture where doctors were thought to be omniscient,” said Barbara Herzog, director of the Health Care Campaign of the Washington, D.C.-based American Assn. of Retired Persons (AARP).

“Seniors are, in general, more hesitant to question doctors. But they want information. It is a common complaint by them that they don’t get enough.”

Observers say the potential communication gap looms larger when one considers the problem experienced by a growing number of elderly from immigrant groups--the need to find bilingual doctors.

In a booklet entitled “How to Talk to Your Doctor,” the UCLA/USC Long Term Care Gerontology Center highlights what physicians say about the doctor-patient relationship.

“Doctors complain that older patients take more time, are difficult to get information from, are difficult to interview, and easily go off on tangents.”

The center also points out that “a doctor’s time is limited and so is his or her patience. So the more specific, direct, positive and simple the question is, the more likely the doctor is to respond.”

It advises specifics such as:

* “I get a stabbing pain in my right knee when I walk fast. What do you think that means?

* “I read about a new treatment for arthritis. Is that something you would consider using (for me)?”

* “Is there another pill I can take for this that wouldn’t have as many side effects?”

For its part, AARP has published a booklet subtitled “Communicating With America’s Fastest-Growing Patient Group,” concerning older Americans and directed at physicians. Among the statistics it mentions:

* The 65-plus group spends more than $120 billion yearly on health care needs, constituting about 15% of their per-capita income.

* People over 65 average eight visits to the doctor per year, in contrast to people under 65, who average about five visits per year.

* Most older patients have at least one chronic condition and many have multiple conditions.

* Visits to physicians account for 21% of total health expenditures for older people.

* The aging of the population will create a greater demand for physician care. The number of physician visits by older Americans is expected to increase by 47% from 1980 to 2000.

AARP suggests to physicians that caring also can be communicated through nonverbal means, such as touching a patient’s shoulder or back. Also, doctors should avoid spatial relationships in which they tower over patients, and should move from behind furniture barriers, such as desks, during conversations.

And another often-neglected consideration: “Many older patients resent being called by their first names without their permission, while respecting the custom of calling you ‘Dr. Surname.’ Ask your patient how you should address her or him during the initial visit.”

Many observers of the medical scene say that relations between older Americans and physicians are improving, but there are seniors who distinctly feel otherwise.

Cele Gonski, 69, of Panorama City, swears it happened:

“I went into the doctor’s office and said I needed something for my lupus. I told him about my fatigue and weakness. His reply was to the effect that I shouldn’t worry about it. I told him he didn’t seem to care much about senior citizens. He said, ‘I guess you’re right.’ ”

Gonski said she had been told she has symptoms of lupus, but that her family doctor died four years ago. “Since then I’ve had problems finding a family doctor I could talk to.”

She said one physician she saw gave her medicine that caused side effects: “I developed a bad sore on my leg. When I called about it, they declined to give my anything for it. I was afraid to go back there anymore. I doctored myself with Epsom salts.”

Gonski said another physician told her to write in advance any questions she had. “I did this, but I got no answers of any use. All I got was a prescription renewal, and was told to come back in a few months.

“I’m so tired of doctors,” she continued. “They keep you in the waiting rooms as if you are in a prison . . . When you see them and ask questions about side effects of medications, they brush you off.”

Gonski has concluded she is disregarded because she is an older American: “When I was younger, it seemed the doctors cared more, they took more time with me.”

Ann Sorrell, 87, of West Hollywood, had a colostomy 27 years ago after doctors found a malignancy. “If I hadn’t been able to accept it, I’d have been gone long ago,” she reflected. “I’m not a fighter, I am an accepter.”

Ten months after that operation, she recalled, cancer was found in another part of her body, and she took 41 successive cobalt treatments.

“The same two doctors took care of me both times, and they were the best. But complications developed with my colostomy, and they recommended another doctor for that. He was a nice man, but was very mercenary. It was all a matter of money with him. They all have their buddies. They send you from one doctor to another. It’s nothing but money, money, money.”

Sorrell had a complaint common among seniors: “Doctors don’t give you any time when you are old. Once, when I had an appointment, two girls came in later, and they were taken ahead of me. The doctor told me: ‘Well, they’re young.’

“And when they finally do see you, they’ll say: ‘You’re doing just fine--come back in four weeks.’ ”

She recalled that “once, after I had waited three hours after my scheduled appointment, a doctor told me: ‘If we didn’t keep a lot of patients in the waiting room, people would think we weren’t any good.’ ”

But, Sorrell added: “I’m not afraid of doctors. I think too many of the elderly are in awe of them.”

Given the relentless graying of the population, what are tomorrow’s physicians, dentists and pharmacists being taught in today’s classrooms?

“Attitudes are changing,” said Dr. Kenneth Brummel-Smith, associate professor of clinical family medicine at USC and a nationally recognized authority on geriatric education for physicians.

“Almost all medical schools now offer some training about aging. Many used to have none.”

Still, he said, while all medical schools require students to take training in pediatrics, probably only 20% require it in geriatrics. And this, he pointed out, while people age 65 or older occupy 60% of hospital beds and make up about 40% of office patients.

Brummel-Smith, also co-chief of the Clinical Gerontology Service at Rancho Los Amigos Hospital, reflected on the need for physicians to realize that, in addition to clinical medical care, older patients are greatly concerned about independence--jealously guarding the ability to “walk safely, dress themselves, feed themselves, care for themselves.”

His students also hear variations of something he recently wrote in a publication of the American College of Physicians:

“Evidence of the responsiveness of older persons to treatment is being increasingly well documented.

“From the management of hypertension to the safety of clearly indicated elective surgery to preventative interventions such as stopping smoking (even after age 70), the older person responds very well.”

However, he added, “the older person will be much more likely to suffer adverse effects from treatment if drug dosages or interactions are not carefully monitored.”

Brummel-Smith said he tells students that, with older patients, doctors often must develop consultative relationships with specialists they aren’t accustomed to using. “They will consult with social workers, home nurses, psychologists.”

And there is another area, a sensitive one:

“For the younger patient, the value of saving the life may be primary--something not always true with someone older. You have to listen to what the patient wants.” Brummel-Smith said a doctor can nearly always assume that what a young person wants is total medical intervention, almost no matter what the emotional, physical or economic cost. “An older person” he said, “may place a value on what kind of life remains.”

At the USC School of Medicine, it isn’t just lectures and books when it comes to dealing with older patients.

“In their first year, (medical students) go in pairs to homes of older volunteers to see them and talk with them,” the professor said. “Also, in a course entitled ‘The Family Life Cycle,’ we have senior citizens come to the classroom and answer questions.”

At the USC School of Dentistry, associate professor Dr. RoseAnn Mulligan said there is more emphasis at dental schools nationwide on dealing with older people: “One reason is that dentists are realizing that such patients will be a growing part of their practice.

“And, for their part, seniors now are expecting and demanding dental services, unlike in the past, when it was typical to have had all the teeth removed, and therefore never have to go to a dentist again.”

Mulligan, also chair of the school’s Section of Geriatric and Special Patient Dentistry, said today’s dental students are taught that older patients usually undergo sensory changes, as in hearing and vision:

“We tell the students to sit while talking to the patient in the chair, and at face level. A lot of the seniors use lip reading, so it does no good to sit next to that person’s ear while speaking.

“Standing isn’t advised, because if the person has arthritis, it may be hard to tilt the head and look up.

“Prescription drug dosages must be adjusted,” Mulligan added. “You don’t give the same dose to an elderly patient as you would to a young one.”

A number of drugs, such as blood pressure medications, can cause oral changes, such as a dry mouth, that may have other repercussions.

For example, “very often a dry mouth in elderly people makes them more vulnerable to fungal infections of the mouth,” Mulligan explained. “Also, when there is diminished saliva, the rate of tooth decay goes up. And if the person wears dentures, saliva acts as a cushion. If this is gone, the tissue often is abraded.

“And we dispel one of the myths of aging, that as dentists they will have difficulty getting work done with older people because they talk too much. That isn’t true. They want that work done.”

Associate professor Dr. Bradley Williams said the USC School of Pharmacy is “tripling the content of material which focuses on the aging process and how drug therapy interacts with those processes.”

Now, Williams disclosed, not only are class instructors being provided with course material, but arrangements are being made for outside speakers, such as those from the Andrus Gerontology Center.

The professor said he impresses on his students the fact that Americans age 65 and older make up 12% of the population, but receive 30% of all prescription drugs. And they are major consumers of nonprescription drugs.

“The pharmacists of the future will have to be experts in drug therapy to those who will be among their major clients.”

Williams said student pharmacists are being instructed on:

* “Counseling older clients on the proper use of the medicine being prescribed. The doctor may not have done it--and even if he has, this reinforces the information.

* “How the information is provided is as important as the fact that it is. There should be a setting of privacy, because health care is a personal matter.

* “Since some of the older clients may have hearing impairment, the setting should be in a quiet area where there are few background noises.

* “In counseling, the pharmacist needs to speak slowly and distinctly, and should allow the individual to respond or ask questions.”

As Williams emphasized: “If an older person is seeing several doctors, each of whom may be prescribing independently--and the person also may be taking non-prescription drugs--the pharmacist is perhaps the only outside individual who is aware of all this medication being taken.

“Because of the potential problems from drug interaction or side effects, it is a pharmacist’s duty to advise.”

HOW SENIORS CAN GET BETTER MEDICAL CARE

Steps older patients can take to get better care from their doctors:

Take a written list of symptoms to the doctor’s office, so nothing is forgotten.

If possible, take along a “significant other” for a major appointment.

Don’t be afraid to ask questions.

If the doctor is unwilling to answer questions, fire him or her and get another.

Steps doctors can take to give better care to their older patients:

Talk with the patient about costs.

Discuss the benefits and risks of a given treatment.

Outline what alternatives, if any, are available.

Advise the patient to bring along a “significant other” if the appointment concerns something major. The other person can listen, and later help the patient remember and discuss the situation. A lot of us don’t remember well under stress.

Provide a written explanation of diagnosis and treatment that can be taken home for further study.

Source: Barbara Herzog, director, Health Care Campaign, American Association of Retired Persons.