Doctors miss low-cost chances for preventive care with older adults

Older Americans may not be getting some of the basic “low-tech, high impact” care that can ward off a cascade of serious and costly health problems.

That’s the conclusion of a new survey of people age 65 and older. The John A. Hartford Foundation commissioned the poll of about 1,000 Americans to gauge health care experiences.

Problem interactions between over-the-counter and prescription drugs are common says geriatrician Sharon Brangman, yet one-third of people in the survey said doctors didn’t review all their medications.

Brangman is chief of geriatrics at Upstate Medical University in Syracuse, New York. She said one of her patients started taking a non-prescription allergy pill, hoping the side effect of drowsiness would help with sleep.

“However, in an older adult, that also can keep the blood pressure from increasing when they stand up,” said Brangman, chair of the board of the American Geriatrics Society. “We found out they were on too big a dose of a water pill and when they added the antihistamine that increased their risk for falling.”

In 2010, there were about 7,000 certified geriatricians, according to estimates from a national workforce panel convened by the American Geriatrics Society. The United States needs about 17,000 older adult specialists, the experts concluded.

Brangman said traditional medical education in the United States doesn’t expose enough would be doctors and nurses to elder care. “Every medical student has to have a rotation through pediatrics or obstetrics,” she said. “However very few of them will see children or deliver babies, but just about every medical and surgical specialty will deal with older people in their career.”

The survey also asked about Medicare’s annual wellness exam. The appointment is free to patients. Meanwhile, the government pays doctors almost three times the fee for a regular office visit.

Fifty-four percent of people in the Hartford poll said they’d never heard of the benefit.

“The whole advantage of the annual wellness visit is to step back,” said geriatrician John Bruza. “‘We’re not going to deal with managing your blood pressure or your arthritis. We’re going to talk about the big-picture issues and may be some other things that have gotten lost in the trees.'”

Bruza is an associate professor in the University of Pennsylvania’s Division of Geriatrics. Not every person over 65 needs an old age specialist, but Bruza said many people 80 and a above would benefit. There’s no specific age when a person should switch to as geriatrician, he said.

“Interestingly a lot of that has been consumer driven,” Bruza said. “It’s patients themselves self-identifying or close family members identifying that their current primary care physician has not been addressing what they are perceiving to be problems.”

The survey asked about a list of assessments that Bruza says are part of standard geriatric care including falls and depression risk as well as a patient’s ability to take care of everyday tasks.

Colleagues in primary care many miss these check-in opportunities because of a lack of training or comfort level about what to do next, Bruza said.

Doctors wonder: “‘Well what am I going to do differently about this?’ if I find early signs of Alzheimer’s in an 80-year-old,” Bruza said.

“Well, ideally what they’d be doing would be checking to see if a patient is having difficulty with higher-level functioning such as managing finances or taking and refilling medications correctly,” he said.

“We tend to identify these when a calamity has struck. It can be a functional calamity such as someone losing their house because they weren’t making financial decisions and didn’t have the capacity to do that. It may be that a patient is admitted for congestive heart failure or low blood sugar—and it wasn’t appreciated that the patient didn’t have the cognitive ability or in-home support to implement the medical plan discussed.”