The Elder Boom: Caring for an Aging America

A perfect storm is brewing in the United States and threatening to exacerbate an already overtaxed health care system. The biggest—or at least most visible—factor is the “elder boom” that logically follows from the baby boom that began in the 1940s. Thanks to advances in medicine and technology, more people are living longer. But as the number of older Americans increases, experts say, the workforce to care for them will experience insufficient growth.

Consider this: In 2005, older adults represented 12% of the US population. By 2030, they could account for nearly 20%. Meanwhile, the number of geriatricians (ie, physicians certified in geriatric medicine) is expected to increase by less than 10%. The already vast disparities in the patient/provider ratio—in 2007, there was one geriatrician for every 2,456 older Americans; by 2030, there will be one for every 4,254—are only going to worsen.

Perhaps Kathy Kemle, PA-C, President of the Georgia Geriatrics Society and Cofounder of the Society of PAs Caring for the Elderly, is not entirely joking when she says one of the advantages of choosing a career in geriatrics is “You’re always going to have a job.” Kemle has reasons beyond job security for loving what she does (see “The Joys of Elder Care”), although it’s hard to argue that opportunities abound in geriatrics.

But are NPs and PAs taking full advantage of them?

Insufficient Training
Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, describes geriatrics as “high-touch, low-tech,” and every clinician knows what that means in terms of reimbursement. As in all areas of primary care, the R-word is a major issue in the recruitment and retention of clinicians in geriatrics.

In addition, misperceptions frequently discourage clinicians from pursuing geriatrics. Debra Bakerjian, PhD, MSN, FNP, President of the Gerontological Advanced Practice Nurses Association (formerly the National Conference of Gerontological NPs) observes that nurses often avoid nursing homes, thinking they are settings for unskilled workers who couldn’t cut it in hospitals. “In fact, what we need are the most skilled people in nursing homes, because we don’t have the technology in nursing homes that they have in the hospital,” says Bakerjian, who is also an Assistant Adjunct Professor of Social and Behavioral Science at the University of California–San Francisco School of Nursing. “Your clinical skills have to be much better than they would be in a hospital.”

But do most clinicians have the right skills to care for older adults in any setting? The Institute of Medicine (IOM) says they do not. In a report released earlier this year, an IOM committee concluded that “in the education and training of the health care workforce, geriatric principles are still too often insufficiently represented in the curricula, and clinical experiences are not robust.”

It is an assessment with which Segal-Gidan, an Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, does not disagree. “Geriatrics is not a required part of training for many health care providers,” she observes. “PA curricula do require some geriatrics, but it’s very vague how much. So you can graduate PA school having had a couple of lectures and seen a few older people, while other people have had required rotations.”

NP training can be just as variable; while the American Association of Colleges of Nursing has a set of competencies for older adult care, there are no specific geriatric requirements for advanced practice nursing education. “Just like anything else, there’s good geriatric education,” says Barbara Resnick, PhD, CRNP, FAAN, FAANP, a Professor at the University of Maryland School of Nursing and Secretary of the Board of Directors of the American Geriatrics Society (AGS), “and then there’s geriatric education in name only, if you know what I mean.”

As older adults become a larger proportion of the US population, and as they seek care for multiple conditions in various settings, it will be essential for all clinicians to know how to provide care to them. “Unless they’re doing pediatrics, everybody does geriatrics,” Kemle points out. “They just don’t know it.”

Need to Know
What they also might not know is that from a clinical perspective, older adults are not simply adults who are older. Every day, Resnick says, she encounters colleagues who don’t recognize the distinctions. “They’ll try to blow off a temperature of 99.5°, and I think, ‘You know, this person is this-and-this years of age and his baseline temp is normally 99.0°.’” Her response is to bring the evidence. “I’ll send or quote a reference that says, ‘In older adults, a rise of 1° above their baseline is consistent with a fever.’”

“Older adults have physiological changes that cause them to be a completely separate population from adults,” says Bakerjian, who also points out that 65 is a somewhat arbitrary age: It does not reflect the fact that such changes occur earlier or later in some individuals.

“It’s hard to describe unless you actually do it, but older adults are the most heterogeneous group,” Kemle says. “If you’ve seen one 85-year-old, you’ve seen one 85-year-old.”

Clinicians who care for older adults need to know everything from the normal process of aging to how diseases present differently at advanced ages. They need to understand the geriatric syndromes, which include dementia, incontinence, and falls.

“It’s also about understanding the health care world of aging,” Resnick adds. “Medicare and Medicaid, the dually eligible, nursing home care, assisted living care—all of those are really quite different than [in] the acute care setting or a primary care practice.”

And clinicians who care for older adults must be prepared to address multiple conditions and think outside the box. For example, if a 55-year-old presents to the emergency department with chest pain, a heart attack is a logical diagnosis.

For a 75-year-old with chest pain, however, “Maybe they had a heart attack, but maybe the chest pain is because they have pneumonia, and maybe they have pneumonia because they fell and were on the floor for an hour,” Segal-Gidan says. “It’s much more complicated, and that’s what scares people away from wanting to care for older people.”

Clinicians also need to recognize the burdens that caring for the elderly places on informal caregivers. “We need to be aware that oftentimes the middle-aged and ‘young’ old people that we’re seeing are suffering from illnesses because of the increased stress of their caregiving role,” Kemle points out. “I think sometimes people forget that it’s not just the patient—it’s the entire family and those interwoven relationships.”

Roles for NPs, PAs in Team
There are indications that PAs and NPs could make a big difference in geriatrics. Significantly, team care is considered essential for older adults and is associated with better outcomes, such as lower rates of hospital readmissions, shorter lengths of stay in hospitals, better quality of life, and higher function. “A single provider really can’t do everything older patients need,” Kemle says.

NPs and PAs already play an important role in geriatric health care. About one-third of visits to PAs are made by older adults, and 78% of PAs report treating at least some patients older than 85. Among NPs, 23% of office visits and 47% of hospital outpatient visits are made by people 65 and older.

The IOM report indicates that “health care providers of all levels of education and training will need to assume additional responsibilities—or relinquish some responsibilities that they already have—to help ensure that all members of the health care workforce are used at their highest level of competence.”

“We have so few geriatricians that we need to preserve them for the most highly complex care,” Bakerjian says. She envisions a system in which NPs provide routine primary care in nursing homes or private offices, while the geriatrician acts as a consultant—not just to the NP but also to physicians in other specialties.

“Physician time and knowledge shouldn’t be spent on managing chronic medical problems that NPs can do,” Resnick adds. “That time should go to diagnosing and managing more complicated illnesses—diagnoses that an NP may not know anything about. That’s the beauty of the team, and it’s the only way we’re going to have sufficient resources.”

Among PAs, there are mixed reviews as to how fully their role in geriatric care is being recognized. “NPs have advanced themselves as part of the solution,” Segal-Gidan observes. “PAs aren’t seen so readily as pieces of those teams. The PA profession, in my opinion, has not stepped forward and taken on a leadership role that it could—and I think should—in this area.”

Kemle, however, has had positive experiences in her role as the American Academy of Physician Assistants Liaison to the AGS. “The physician community is very anxious to embrace us, and I’m not sure you would find that in every specialty,” she says. Among the AGS’s working group on workforce issues, “there has been a lot of discussion about ‘Now, this is not physician-only. We need to be inclusive of everyone and work together to develop interdisciplinary curricula.’”

Collaborating in a team is one of the things Bakerjian finds most rewarding in her work. “We work closely with the physical therapist, the dietitian, the psychologist or psychiatrist, the pharmacist, the physicians, the nursing staff, the activities director [in a nursing home],” she says. “It’s a very interdisciplinary or multidisciplinary environment to which all of those people contribute.”

Touchy Subjects
In addition to making the best use of human (ie, clinician) resources, the US needs to face some of the tough ethical questions that arise when you must balance respect for the lives and health of older adults with a shrinking economy and limited funding.

“We definitely undervalue [older adults’] health care, because if you look at where we put our money, we put it into preserving the young person,” Bakerjian says. “We’ll put inordinate amounts of money into doing specialty procedures for young people, but we won’t put at least an equal weight [on] doing basic primary care and good comprehensive coordination of care for older adults.”

At the same time, “We are not going to be able to continue to pay for every woman in her 80s or 90s to have a mammogram, which is going to show something and then we start a million-dollar work-up that may or may not come to anything,” Resnick says, adding, “I’m not saying we should stop, but I think those are the types of issues we need to deal with.”

Even preventive measures such as vaccination may need to be reconsidered if supplies are insufficient or in the event of a pandemic. Recent research suggests that older adults’ immune systems do not respond as well to vaccination as children’s do. While vaccinating persons at high risk for death from infection makes sense, overall, Resnick says, “If we had more children who had less infections and didn’t expose older adults, we’d be better off.”

But by far, the “touchiest” questions relate to end-of-life care and dying. Segal-Gidan, who works predominantly with persons with dementing illnesses at the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center, knows from experience that most patients would rather not die in the hospital, and many do not want aggressive end-of-life care.

“A significant body of literature shows that there’s a lot of money spent in the medical system on people in their last days and months of life that is essentially wasted, because it’s spent in hospitals and intensive care units,” she says, “whereas, if there had been discussion with patients and their families months and years previously, they would be home in hospice care. That’s what people want.”

Can Americans come to terms with their squeamish attitudes toward death? If they are going to, clinicians must learn to overcome their own reluctance to speak about uncomfortable topics—just as they have in the past.

“If we talk about trying to change curricula and training, people should be trained to have a level of comfort in talking about death and dying the way they talk about sex,” Segal-Gidan says. “People don’t have any problems, in the last 10 years, in talking about sexual activity with men who are in their 60s and 70s and then prescribing Viagra.”

A perfect storm is brewing in the United States and threatening to exacerbate an already overtaxed health care system. The biggest—or at least most visible—factor is the “elder boom” that logically follows from the baby boom that began in the 1940s. Thanks to advances in medicine and technology, more people are living longer. But as the number of older Americans increases, experts say, the workforce to care for them will experience insufficient growth.

Consider this: In 2005, older adults represented 12% of the US population. By 2030, they could account for nearly 20%. Meanwhile, the number of geriatricians (ie, physicians certified in geriatric medicine) is expected to increase by less than 10%. The already vast disparities in the patient/provider ratio—in 2007, there was one geriatrician for every 2,456 older Americans; by 2030, there will be one for every 4,254—are only going to worsen.

Perhaps Kathy Kemle, PA-C, President of the Georgia Geriatrics Society and Cofounder of the Society of PAs Caring for the Elderly, is not entirely joking when she says one of the advantages of choosing a career in geriatrics is “You’re always going to have a job.” Kemle has reasons beyond job security for loving what she does (see “The Joys of Elder Care”), although it’s hard to argue that opportunities abound in geriatrics.

But are NPs and PAs taking full advantage of them?

Insufficient Training
Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, describes geriatrics as “high-touch, low-tech,” and every clinician knows what that means in terms of reimbursement. As in all areas of primary care, the R-word is a major issue in the recruitment and retention of clinicians in geriatrics.

In addition, misperceptions frequently discourage clinicians from pursuing geriatrics. Debra Bakerjian, PhD, MSN, FNP, President of the Gerontological Advanced Practice Nurses Association (formerly the National Conference of Gerontological NPs) observes that nurses often avoid nursing homes, thinking they are settings for unskilled workers who couldn’t cut it in hospitals. “In fact, what we need are the most skilled people in nursing homes, because we don’t have the technology in nursing homes that they have in the hospital,” says Bakerjian, who is also an Assistant Adjunct Professor of Social and Behavioral Science at the University of California–San Francisco School of Nursing. “Your clinical skills have to be much better than they would be in a hospital.”

But do most clinicians have the right skills to care for older adults in any setting? The Institute of Medicine (IOM) says they do not. In a report released earlier this year, an IOM committee concluded that “in the education and training of the health care workforce, geriatric principles are still too often insufficiently represented in the curricula, and clinical experiences are not robust.”

It is an assessment with which Segal-Gidan, an Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, does not disagree. “Geriatrics is not a required part of training for many health care providers,” she observes. “PA curricula do require some geriatrics, but it’s very vague how much. So you can graduate PA school having had a couple of lectures and seen a few older people, while other people have had required rotations.”

NP training can be just as variable; while the American Association of Colleges of Nursing has a set of competencies for older adult care, there are no specific geriatric requirements for advanced practice nursing education. “Just like anything else, there’s good geriatric education,” says Barbara Resnick, PhD, CRNP, FAAN, FAANP, a Professor at the University of Maryland School of Nursing and Secretary of the Board of Directors of the American Geriatrics Society (AGS), “and then there’s geriatric education in name only, if you know what I mean.”

As older adults become a larger proportion of the US population, and as they seek care for multiple conditions in various settings, it will be essential for all clinicians to know how to provide care to them. “Unless they’re doing pediatrics, everybody does geriatrics,” Kemle points out. “They just don’t know it.”

Need to Know
What they also might not know is that from a clinical perspective, older adults are not simply adults who are older. Every day, Resnick says, she encounters colleagues who don’t recognize the distinctions. “They’ll try to blow off a temperature of 99.5°, and I think, ‘You know, this person is this-and-this years of age and his baseline temp is normally 99.0°.’” Her response is to bring the evidence. “I’ll send or quote a reference that says, ‘In older adults, a rise of 1° above their baseline is consistent with a fever.’”

“Older adults have physiological changes that cause them to be a completely separate population from adults,” says Bakerjian, who also points out that 65 is a somewhat arbitrary age: It does not reflect the fact that such changes occur earlier or later in some individuals.

“It’s hard to describe unless you actually do it, but older adults are the most heterogeneous group,” Kemle says. “If you’ve seen one 85-year-old, you’ve seen one 85-year-old.”

Clinicians who care for older adults need to know everything from the normal process of aging to how diseases present differently at advanced ages. They need to understand the geriatric syndromes, which include dementia, incontinence, and falls.

“It’s also about understanding the health care world of aging,” Resnick adds. “Medicare and Medicaid, the dually eligible, nursing home care, assisted living care—all of those are really quite different than [in] the acute care setting or a primary care practice.”

And clinicians who care for older adults must be prepared to address multiple conditions and think outside the box. For example, if a 55-year-old presents to the emergency department with chest pain, a heart attack is a logical diagnosis.

For a 75-year-old with chest pain, however, “Maybe they had a heart attack, but maybe the chest pain is because they have pneumonia, and maybe they have pneumonia because they fell and were on the floor for an hour,” Segal-Gidan says. “It’s much more complicated, and that’s what scares people away from wanting to care for older people.”

Clinicians also need to recognize the burdens that caring for the elderly places on informal caregivers. “We need to be aware that oftentimes the middle-aged and ‘young’ old people that we’re seeing are suffering from illnesses because of the increased stress of their caregiving role,” Kemle points out. “I think sometimes people forget that it’s not just the patient—it’s the entire family and those interwoven relationships.”

Roles for NPs, PAs in Team
There are indications that PAs and NPs could make a big difference in geriatrics. Significantly, team care is considered essential for older adults and is associated with better outcomes, such as lower rates of hospital readmissions, shorter lengths of stay in hospitals, better quality of life, and higher function. “A single provider really can’t do everything older patients need,” Kemle says.

NPs and PAs already play an important role in geriatric health care. About one-third of visits to PAs are made by older adults, and 78% of PAs report treating at least some patients older than 85. Among NPs, 23% of office visits and 47% of hospital outpatient visits are made by people 65 and older.

The IOM report indicates that “health care providers of all levels of education and training will need to assume additional responsibilities—or relinquish some responsibilities that they already have—to help ensure that all members of the health care workforce are used at their highest level of competence.”

“We have so few geriatricians that we need to preserve them for the most highly complex care,” Bakerjian says. She envisions a system in which NPs provide routine primary care in nursing homes or private offices, while the geriatrician acts as a consultant—not just to the NP but also to physicians in other specialties.

“Physician time and knowledge shouldn’t be spent on managing chronic medical problems that NPs can do,” Resnick adds. “That time should go to diagnosing and managing more complicated illnesses—diagnoses that an NP may not know anything about. That’s the beauty of the team, and it’s the only way we’re going to have sufficient resources.”

Among PAs, there are mixed reviews as to how fully their role in geriatric care is being recognized. “NPs have advanced themselves as part of the solution,” Segal-Gidan observes. “PAs aren’t seen so readily as pieces of those teams. The PA profession, in my opinion, has not stepped forward and taken on a leadership role that it could—and I think should—in this area.”

Kemle, however, has had positive experiences in her role as the American Academy of Physician Assistants Liaison to the AGS. “The physician community is very anxious to embrace us, and I’m not sure you would find that in every specialty,” she says. Among the AGS’s working group on workforce issues, “there has been a lot of discussion about ‘Now, this is not physician-only. We need to be inclusive of everyone and work together to develop interdisciplinary curricula.’”

Collaborating in a team is one of the things Bakerjian finds most rewarding in her work. “We work closely with the physical therapist, the dietitian, the psychologist or psychiatrist, the pharmacist, the physicians, the nursing staff, the activities director [in a nursing home],” she says. “It’s a very interdisciplinary or multidisciplinary environment to which all of those people contribute.”

Touchy Subjects
In addition to making the best use of human (ie, clinician) resources, the US needs to face some of the tough ethical questions that arise when you must balance respect for the lives and health of older adults with a shrinking economy and limited funding.

“We definitely undervalue [older adults’] health care, because if you look at where we put our money, we put it into preserving the young person,” Bakerjian says. “We’ll put inordinate amounts of money into doing specialty procedures for young people, but we won’t put at least an equal weight [on] doing basic primary care and good comprehensive coordination of care for older adults.”

At the same time, “We are not going to be able to continue to pay for every woman in her 80s or 90s to have a mammogram, which is going to show something and then we start a million-dollar work-up that may or may not come to anything,” Resnick says, adding, “I’m not saying we should stop, but I think those are the types of issues we need to deal with.”

Even preventive measures such as vaccination may need to be reconsidered if supplies are insufficient or in the event of a pandemic. Recent research suggests that older adults’ immune systems do not respond as well to vaccination as children’s do. While vaccinating persons at high risk for death from infection makes sense, overall, Resnick says, “If we had more children who had less infections and didn’t expose older adults, we’d be better off.”

But by far, the “touchiest” questions relate to end-of-life care and dying. Segal-Gidan, who works predominantly with persons with dementing illnesses at the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center, knows from experience that most patients would rather not die in the hospital, and many do not want aggressive end-of-life care.

“A significant body of literature shows that there’s a lot of money spent in the medical system on people in their last days and months of life that is essentially wasted, because it’s spent in hospitals and intensive care units,” she says, “whereas, if there had been discussion with patients and their families months and years previously, they would be home in hospice care. That’s what people want.”

Can Americans come to terms with their squeamish attitudes toward death? If they are going to, clinicians must learn to overcome their own reluctance to speak about uncomfortable topics—just as they have in the past.

“If we talk about trying to change curricula and training, people should be trained to have a level of comfort in talking about death and dying the way they talk about sex,” Segal-Gidan says. “People don’t have any problems, in the last 10 years, in talking about sexual activity with men who are in their 60s and 70s and then prescribing Viagra.”

A perfect storm is brewing in the United States and threatening to exacerbate an already overtaxed health care system. The biggest—or at least most visible—factor is the “elder boom” that logically follows from the baby boom that began in the 1940s. Thanks to advances in medicine and technology, more people are living longer. But as the number of older Americans increases, experts say, the workforce to care for them will experience insufficient growth.

Consider this: In 2005, older adults represented 12% of the US population. By 2030, they could account for nearly 20%. Meanwhile, the number of geriatricians (ie, physicians certified in geriatric medicine) is expected to increase by less than 10%. The already vast disparities in the patient/provider ratio—in 2007, there was one geriatrician for every 2,456 older Americans; by 2030, there will be one for every 4,254—are only going to worsen.

Perhaps Kathy Kemle, PA-C, President of the Georgia Geriatrics Society and Cofounder of the Society of PAs Caring for the Elderly, is not entirely joking when she says one of the advantages of choosing a career in geriatrics is “You’re always going to have a job.” Kemle has reasons beyond job security for loving what she does (see “The Joys of Elder Care”), although it’s hard to argue that opportunities abound in geriatrics.

But are NPs and PAs taking full advantage of them?

Insufficient Training
Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, describes geriatrics as “high-touch, low-tech,” and every clinician knows what that means in terms of reimbursement. As in all areas of primary care, the R-word is a major issue in the recruitment and retention of clinicians in geriatrics.

In addition, misperceptions frequently discourage clinicians from pursuing geriatrics. Debra Bakerjian, PhD, MSN, FNP, President of the Gerontological Advanced Practice Nurses Association (formerly the National Conference of Gerontological NPs) observes that nurses often avoid nursing homes, thinking they are settings for unskilled workers who couldn’t cut it in hospitals. “In fact, what we need are the most skilled people in nursing homes, because we don’t have the technology in nursing homes that they have in the hospital,” says Bakerjian, who is also an Assistant Adjunct Professor of Social and Behavioral Science at the University of California–San Francisco School of Nursing. “Your clinical skills have to be much better than they would be in a hospital.”

But do most clinicians have the right skills to care for older adults in any setting? The Institute of Medicine (IOM) says they do not. In a report released earlier this year, an IOM committee concluded that “in the education and training of the health care workforce, geriatric principles are still too often insufficiently represented in the curricula, and clinical experiences are not robust.”

It is an assessment with which Segal-Gidan, an Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, does not disagree. “Geriatrics is not a required part of training for many health care providers,” she observes. “PA curricula do require some geriatrics, but it’s very vague how much. So you can graduate PA school having had a couple of lectures and seen a few older people, while other people have had required rotations.”

NP training can be just as variable; while the American Association of Colleges of Nursing has a set of competencies for older adult care, there are no specific geriatric requirements for advanced practice nursing education. “Just like anything else, there’s good geriatric education,” says Barbara Resnick, PhD, CRNP, FAAN, FAANP, a Professor at the University of Maryland School of Nursing and Secretary of the Board of Directors of the American Geriatrics Society (AGS), “and then there’s geriatric education in name only, if you know what I mean.”

As older adults become a larger proportion of the US population, and as they seek care for multiple conditions in various settings, it will be essential for all clinicians to know how to provide care to them. “Unless they’re doing pediatrics, everybody does geriatrics,” Kemle points out. “They just don’t know it.”

Need to Know
What they also might not know is that from a clinical perspective, older adults are not simply adults who are older. Every day, Resnick says, she encounters colleagues who don’t recognize the distinctions. “They’ll try to blow off a temperature of 99.5°, and I think, ‘You know, this person is this-and-this years of age and his baseline temp is normally 99.0°.’” Her response is to bring the evidence. “I’ll send or quote a reference that says, ‘In older adults, a rise of 1° above their baseline is consistent with a fever.’”

“Older adults have physiological changes that cause them to be a completely separate population from adults,” says Bakerjian, who also points out that 65 is a somewhat arbitrary age: It does not reflect the fact that such changes occur earlier or later in some individuals.

“It’s hard to describe unless you actually do it, but older adults are the most heterogeneous group,” Kemle says. “If you’ve seen one 85-year-old, you’ve seen one 85-year-old.”

Clinicians who care for older adults need to know everything from the normal process of aging to how diseases present differently at advanced ages. They need to understand the geriatric syndromes, which include dementia, incontinence, and falls.

“It’s also about understanding the health care world of aging,” Resnick adds. “Medicare and Medicaid, the dually eligible, nursing home care, assisted living care—all of those are really quite different than [in] the acute care setting or a primary care practice.”

And clinicians who care for older adults must be prepared to address multiple conditions and think outside the box. For example, if a 55-year-old presents to the emergency department with chest pain, a heart attack is a logical diagnosis.

For a 75-year-old with chest pain, however, “Maybe they had a heart attack, but maybe the chest pain is because they have pneumonia, and maybe they have pneumonia because they fell and were on the floor for an hour,” Segal-Gidan says. “It’s much more complicated, and that’s what scares people away from wanting to care for older people.”

Clinicians also need to recognize the burdens that caring for the elderly places on informal caregivers. “We need to be aware that oftentimes the middle-aged and ‘young’ old people that we’re seeing are suffering from illnesses because of the increased stress of their caregiving role,” Kemle points out. “I think sometimes people forget that it’s not just the patient—it’s the entire family and those interwoven relationships.”

Roles for NPs, PAs in Team
There are indications that PAs and NPs could make a big difference in geriatrics. Significantly, team care is considered essential for older adults and is associated with better outcomes, such as lower rates of hospital readmissions, shorter lengths of stay in hospitals, better quality of life, and higher function. “A single provider really can’t do everything older patients need,” Kemle says.

NPs and PAs already play an important role in geriatric health care. About one-third of visits to PAs are made by older adults, and 78% of PAs report treating at least some patients older than 85. Among NPs, 23% of office visits and 47% of hospital outpatient visits are made by people 65 and older.

The IOM report indicates that “health care providers of all levels of education and training will need to assume additional responsibilities—or relinquish some responsibilities that they already have—to help ensure that all members of the health care workforce are used at their highest level of competence.”

“We have so few geriatricians that we need to preserve them for the most highly complex care,” Bakerjian says. She envisions a system in which NPs provide routine primary care in nursing homes or private offices, while the geriatrician acts as a consultant—not just to the NP but also to physicians in other specialties.

“Physician time and knowledge shouldn’t be spent on managing chronic medical problems that NPs can do,” Resnick adds. “That time should go to diagnosing and managing more complicated illnesses—diagnoses that an NP may not know anything about. That’s the beauty of the team, and it’s the only way we’re going to have sufficient resources.”

Among PAs, there are mixed reviews as to how fully their role in geriatric care is being recognized. “NPs have advanced themselves as part of the solution,” Segal-Gidan observes. “PAs aren’t seen so readily as pieces of those teams. The PA profession, in my opinion, has not stepped forward and taken on a leadership role that it could—and I think should—in this area.”

Kemle, however, has had positive experiences in her role as the American Academy of Physician Assistants Liaison to the AGS. “The physician community is very anxious to embrace us, and I’m not sure you would find that in every specialty,” she says. Among the AGS’s working group on workforce issues, “there has been a lot of discussion about ‘Now, this is not physician-only. We need to be inclusive of everyone and work together to develop interdisciplinary curricula.’”

Collaborating in a team is one of the things Bakerjian finds most rewarding in her work. “We work closely with the physical therapist, the dietitian, the psychologist or psychiatrist, the pharmacist, the physicians, the nursing staff, the activities director [in a nursing home],” she says. “It’s a very interdisciplinary or multidisciplinary environment to which all of those people contribute.”

Touchy Subjects
In addition to making the best use of human (ie, clinician) resources, the US needs to face some of the tough ethical questions that arise when you must balance respect for the lives and health of older adults with a shrinking economy and limited funding.

“We definitely undervalue [older adults’] health care, because if you look at where we put our money, we put it into preserving the young person,” Bakerjian says. “We’ll put inordinate amounts of money into doing specialty procedures for young people, but we won’t put at least an equal weight [on] doing basic primary care and good comprehensive coordination of care for older adults.”

At the same time, “We are not going to be able to continue to pay for every woman in her 80s or 90s to have a mammogram, which is going to show something and then we start a million-dollar work-up that may or may not come to anything,” Resnick says, adding, “I’m not saying we should stop, but I think those are the types of issues we need to deal with.”

Even preventive measures such as vaccination may need to be reconsidered if supplies are insufficient or in the event of a pandemic. Recent research suggests that older adults’ immune systems do not respond as well to vaccination as children’s do. While vaccinating persons at high risk for death from infection makes sense, overall, Resnick says, “If we had more children who had less infections and didn’t expose older adults, we’d be better off.”

But by far, the “touchiest” questions relate to end-of-life care and dying. Segal-Gidan, who works predominantly with persons with dementing illnesses at the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center, knows from experience that most patients would rather not die in the hospital, and many do not want aggressive end-of-life care.

“A significant body of literature shows that there’s a lot of money spent in the medical system on people in their last days and months of life that is essentially wasted, because it’s spent in hospitals and intensive care units,” she says, “whereas, if there had been discussion with patients and their families months and years previously, they would be home in hospice care. That’s what people want.”

Can Americans come to terms with their squeamish attitudes toward death? If they are going to, clinicians must learn to overcome their own reluctance to speak about uncomfortable topics—just as they have in the past.

“If we talk about trying to change curricula and training, people should be trained to have a level of comfort in talking about death and dying the way they talk about sex,” Segal-Gidan says. “People don’t have any problems, in the last 10 years, in talking about sexual activity with men who are in their 60s and 70s and then prescribing Viagra.”