Focus of Geriatric Care Has Begun to Change


 
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With a growing elderly population that is living longer with fewer physicians available to treat them, the future of geriatric medicine is on the verge of transitioning from disease treatment to disease prevention, according to several medical experts.

These specialists believe a more proactive approach will address certain challenges in geriatric medicine, especially in the areas of pharmacology, patient monitoring and physician availability.

"The medical community's focus has been on the discovery and treatment of disease for decades," said Jeff Mullins, MD, a physician with MidSouth Family Medicine who specializes in geriatric medicine. "During the next 10 years, you will start to see an evolution in disease prevention, especially in geriatric medicine."


Jeff Mullins, MD

Mullins says that a key area in which prevention will be stressed is immunizations.

"I think you will see a more proactive push by the government and private insurance companies to make it mandatory for physicians to immunize elderly adults in order to prevent common illnesses, such as pneumonia," Mullins said. "Billions of healthcare dollars are spent to hospitalize elderly patients with pneumonia."

Currently, the Centers for Disease Control and Prevention (CDC) identifies the importance of pneumonia vaccinations by recommending that adults 65 and older be vaccinated against the virus twice.


Paul Hill, MD

According to Mullins and Paul Hill, MD, a geriatric psychiatrist and associate professor of psychiatry at the University of Tennessee Health Science Center (UTHSC), a common challenge for physicians is determining whether geriatric patients are taking their medicine consistently. Hill says advances in pharmacology will make the process easier.

"It's difficult for physicians to determine if the patient is actually taking his or her medication," Hill said. "If the patient misses dosages, it could result in hospitalization, which is expensive. Innovations are in the works to administer certain medications in different ways, such as through weekly or monthly injections rather than in pill form. We need to find ways for the drug to stay in the human body for longer than 24 hours."

Additionally, Hill says a future innovation is a digestible microchip, which is embedded inside of a pill capsule. When swallowed, it generates a slight voltage in response to digestive fluids, which conveys a signal to the surface of a person's skin where a patch then relays the information to a mobile device belonging to a healthcare provider. The microchip tells clinicians whether patients are taking their medications as prescribed. The U.S. Food and Drug Administration approved the device in 2012 based on studies showing its safety and efficacy when implanted in placebo pills.

"We are a long way from this becoming mainstream, but it's a step in the right direction to successfully measure when a patient takes his or her medication," Hill said.

Mullins says pharmacies address this issue now by providing mail-order prescriptions and delivering medicine directly to the patient's residence or nursing home.


Anna Rikard, Pharm.D

Anna Rikard, Pharm.D, a pharmacist with Walgreens who is board certified in geriatric medicine, takes this a step further.

"We perform adherence calls and discuss with patients directly how they are taking their medications to make sure they are taking them correctly," she said. "Also, we call patients when they are late refilling certain medications. If patients take medication which addresses conditions like hypertension, diabetes and high cholesterol on a continual basis, the more likely they will stay out of the hospital, which is the ultimate goal."

Another issue pharmacists and physicians deal with frequently is the prescribing cascade. This is when the side effects of drugs are misdiagnosed as symptoms of another problem, resulting in further prescriptions and more side effects and unanticipated drug reactions.

Mullins said this can lead to polypharmacy, which is common in geriatric patients.

Polypharmacy refers to the effects of taking multiple medications concurrently to manage coexisting health problems.

The CDC reports 76 percent of Americans over 60 use two or more prescription drugs and 37 percent use five or more.

All three geriatric experts affirm the future importance of tracking each patient's medication and any side effects that may result from drug-to-drug interactions.

"Any new symptom in an elderly patient should be considered a drug effect until proven otherwise," Rikard said. "It's important for the pharmacist and primary physician to work together to look at the side effect of each drug to see if the patient needs to change the time of day he or she takes the medication instead of prescribing a new medication."

Additionally, Hill says physicians are paid by the Centers for Medicaid and Medicare Services to track a patient's medication through medical reconciliation, which is the process of creating the most accurate list possible of all medications a patient takes. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors or drug interactions.

"It's important to review each patient's medication list to determine of all medications are necessary for the patient," Mullins said. "Once a patient is on a medication, he or she may take it for life unless a physician reviews it to determine if it is necessary."

Mullins believes another future development in geriatric medicine is electronic remote monitoring.

Electronic remote monitoring refers to when a physician monitors a patient's symptoms, such as blood pressure or weight, remotely through a device at the patient's home. Information is sent to an information center through a patient's electronic medical record.

"Parameters will be set to warn a physician's office when something isn't right," Mullins said. "For instance, a patient who gains a lot of weight during a short period of time is an indication that he or she is retaining fluid. This is a sign that a patient's medication may need to be adjusted. A warning would be sent to the physician to contact the patient to visit the office."

Mullins stresses that this could decrease the amount of times a patient has to visit a physician, which could double a physician's capacity to see additional patients, while keeping a patient out of the hospital.

"The importance of this is that there is early intervention," Mullins said. "As physicians, we need to get to a place where we prevent conditions instead of chase them, and this is the first step. We will be able to foster the elderly as they are developing symptoms and can treat them immediately. This will make it easier to keep geriatric patients out of the hospital."

All experts agree that there is a need for more physicians in geriatric medicine.

The American Geriatrics Society, a nonprofit organization that focuses on improving the health and quality of life of older adults, reports there are 7,300 certified geriatricians in the United States, which is one geriatrician for every 2,700 Americans who 75 or older. Due to the projected increase in the number of older adults and the plateauing of the number of geriatricians over the last 10 years, this ratio is expected to drop to one geriatrician for every 4,500 older Americans in 2030.

"Few physicians see themselves as geriatricians," Mullins said. "They aren't exposed much to geriatrics during residency, training is intensive and debt is high. Geriatrics can be financially unattractive for doctors carrying large medical school debt. We need to reduce the burden of debt to incentivize more students to go into primary care."

Hill agrees.

"Access to adequate healthcare decreases significantly for a person who is over 65," Hill said. "Medical students must be exposed to treating high-functioning geriatric patients in a clinical setting to learn how to care for these patients adequately and skillfully."

Many medical school programs do not require medical students to perform a geriatrics rotation.

Hill says this is about to change at UTHSC.

Starting next month, UTHSC will offer a mandatory course in geriatric medicine for fourth-year medical students. Medical students will be exposed to geriatric patients by observing a geriatrician in a clinical setting. Additionally, they will be required to perform rotations in palliative care, which is specialized medical care that focuses on providing relief from the symptoms and stress of a serious illness.

"Including geriatrics in medical school curriculum and providing an incentive to reduce debt could level the playing field and encourage more medical students to go into primary care over the next decade," Mullins said.

RELATED LINKS:

Centers for Disease Control and Prevention

University of Tennessee Health Science Center

Centers for Medicare and Medicaid Services

American Geriatrics Society

 
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