Much attention has been paid to the disproportionate balance of the supply and demand of PCPs. Fewer PCPs also means fewer geriatricians, for which there is already acute demand.
The shortage of primary care physicians around the country affects more than run-of-the-mill patients who endure longer wait times and shorter doctor visits. It also affects a patients who are sick, frail, and may be at the end of their lives—the elderly. That's because the number of geriatricians, PCPs with one to two years of additional training in elder care, is also diminishing.
Caring for an aging patient presents unique challenges for physicians even when the patient is relatively healthy. And when an elderly patient has dementia, their individual needs are more acute, and they need specialized a care beyond what a PCP can give.
"Dementia is not treated in a holistic manner," says Kyle Allen, DO, vice president for clinical integration and medical director for geriatric medicine and the lifelong health division for Newport News, VA–based Riverside Health System made up of seven hospitals, a medical group, and a full continuum of care for aging patients. "Geriatricians who've had the training understand that this is a family illness. This is not just an individual."
The American Geriatrics Society estimates that there will need to be 30,000 geriatricians by 2030, that's when one in five Americans will be eligible for Medicare. There are currently 7,500 geriatricians in the U.S. The gap is so wide, that it casts a pall on the quality of care that could be available in the future.
Dementia is Misunderstood
There are several types of dementia, but Alzheimer's is the most common and arguably the most well-known type of dementia. And though dementia isn't a sign of aging, the elderly are most at-risk for developing it.
Alzheimer's received a lot of attention earlier this year when a 2014 study published in the New England Journal of Medicine named it as possibly the third leading cause of death behind cancer. But it's not enough attention, says Evelyn Granieri, MD, MPH, chief of the division of geriatric medicine and aging at New York-Presbyterian/The Allen Hospital.
"AIDS, cancer, breast cancer, colon cancer, they all have their celebrity spokespeople," she says. "There's no one really willing to stand up in popular culture and say, 'Look, this is a reality of life. If you're lucky enough to turn 85, you have at least a 65% chance of having dementia.' "
Granieri cares for the frailest of the frail at a 23-bed inpatient site that's part of The Allen Hospital in New York City. She only has about 300 patients, and they are all over 70 years of age with significant markers of frailty. She says the most consistent marker is a cognitive disorder, such as dementia.
Granieri cares for this population with an interdisciplinary team that is made up social workers, nurse practitioners, and five fellowship-trained, board-certified geriatricians. She laments the current and projected shortage of geriatricians because she believes that interferes with delivering quality care.
"Truthfully, there are so few geriatricians and even fewer geriatric psychiatrists in this country that it becomes problematic to deliver the kind of wholesale care that this coming epidemic of dementia requires," says Granieri.
Granieri identifies four barriers to caring for patients with dementia:
- Low reimbursement
- Societal dislike
- Diminished respect for aging
- Training
Medicare does reimburse for caring for the elderly, but the rates don't accurately capture the time it takes to see a patient with dementia. Depending on the stage of Alzheimer's or level of dementia, a routine office visit can take twice as long because the patient may need help getting onto an exam table, undressing, or just an extra dose of patience from the physician.
Training physicians
Allen says that at Riverside, he began integrating dementia care into the systems' medical group practices in 2011 because that's where people go. An accurate diagnosis of dementia needs a geriatrician's expertise, but often, the initial touch point is with the PCP. Allen is a trained geriatrician and created a task force to help physicians better understand dementia and the patients who have it.
"Physicians don't recognize it, or they treat dementia in a very nihilistic way," says Allen. What I mean by that is an attitude of, 'There's nothing I can do about it,' or 'I feel inept to do it,' or 'I don't have the time, I don't have the resources. This really isn't medical care, this is more social care.' " says Allen.
A first step for physicians is to use a standardized memory loss screening tool for patients. Granieri agrees with this approach, as well, and says it can be a very simple, five-minute test. It won't diagnose dementia, but it will set a baseline of memory loss for patients that physicians can measure and track.
Treating Dementia with Dignity
The amount of care a patient with dementia requires is significant and increases exponentially as the cognitive decline increases.
Kelly Blair, a 50-year old nurse in Arlington, Texas, cares for her 81-year old father, William, who has Lewy Body dementia, a common form of dementia, recently notable because it is the same disease that long-time radio personality Casey Kasem has.
Blair's father was diagnosed at age 73 and is now in the late stages of dementia. The first doctor he saw was a neurologist who suggested returning a year later. Blair's medical education and background pointed her to keep looking for another provider, and she ended up taking her dad to UT Southwestern Medical Center in Dallas, which has a memory clinic.
Blair says physicians at UTSW help coordinate care for her father when he's had to go to the hospital, which can be full of landmines for patients with dementia. Unfamiliar environments increase anxiety which can lead to difficulty care for minor issues let alone the main problem that landed the patient in the hospital in the first place, which in Blair's father case, it was cracked hip from falling out of bed.
"It would change his whole mental status if one of us was not with him," she says. "In the hospital, they can't do one-on-one. You can put him close to the nurse's desk, but that's about the best they can do."
Subsequent trips to the hospital for UTIs got easier when they found a hospital whose nurses were willing to care not only for her father, but her mother.
"They were great," says Blair, "They made arrangements for my mom to sleep in the room with my dad. They gave her a roll-away bed, they made sure she had meals. She was helping them out—when he tried to get out of bed, she could talk him back into bed. Not all facilities are willing to do that."
Geriatricians who are on the front-lines of caring for the elderly see what's coming, and the challenges associated with developing a care path for aging patients. Declining numbers of geriatricians likely portend a decline in quality of care, especially without a team-based approach at the practice level.
"It's not about specialist consults," says Allen. "It's about getting the physicians, nursing, social workers, the families… and working together as a team around these illnesses, and honoring the patients' wishes. It's burdening our society, and more importantly people are not getting the care they deserve."
Jacqueline Fellows is a contributing writer at HealthLeaders Media.