The coming tsunami of baby boomers means physicians are destined to see an increase in the number of elderly patients in their offices. Preparing to do well by them could require a change in attitude as well as office furniture.

It won't be business as usual, according to the Institute of Medicine's 2008 report "Retooling for an Aging America: Building the Health Care Workforce."

Only about 7,000 physicians in the nation are certified geriatricians, but 36,000 will be needed to provide care for the aging population by 2030, according to the report. The consensus is -- that's not going to happen.

Instead, what will occur is that more and more elderly people will turn to internists and family physicians for care, and the best course of action for these physicians is to prepare for and embrace the inevitable, say a number of geriatricians who offer a variety of pointers.

For starters, "you need to get a sense from them as to what their goals are," said Rosanne Leipzig, MD, PhD, professor of geriatrics and adult development at Mount Sinai School of Medicine in New York City. She also is an adviser to the American Medical Association on aging issues.

Dr. Leipzig works to help her patients live the life they want . She said this mind-set can lead to approaches that vary widely, because older people are a heterogeneous group. "When you've seen one, you've seen one."

Taking the time upfront to consider level of care will save time in the long run. "Is this someone you are going to think about as a robust elder, or someone who is frail, or someone who is in the last stages of life?" Dr. Leipzig asked.

"Some 85-year-olds you would treat as aggressively as you would a 65-year-old," said Jerome Epplin, MD, a family physician who cares for predominantly older patients in Litchfield, Ill.

David Mehr, MD, a professor of family and community medicine at the University of Missouri School of Medicine, in Columbia, noted that "with an 80-year-old you can have a competing athlete or someone with significant disabilities."

Regardless of the patient's level of ability, the treatment goal remains the same: "Keep them functioning independently and having a good quality of life," said Judah Ronch, PhD, professor at the University of Maryland's Erickson School in Baltimore. The school focuses on improving services for older people.

Rewards and attitudes

Caring for this population is a rewarding way to spend the day, said several physicians who do just that. "Geriatrics is going to be the fastest-growing segment of primary care practice, and this is good, because taking care of older people is one of the most thrilling experiences in medicine," said Bill Thomas, MD, also a professor at the Erickson School.

M. Mayes DuBose, MD, a geriatrician who established the first geriatrics-only medical practice in Sumter, S.C., also revels in his work. "I think I got into it for the right reasons. Otherwise I think I'd be burned out." And the right reasons? "The desire to provide high-quality care to America's older adults. And the desire comes from the recognition that they are such a vulnerable population," Dr. DuBose said.

Only about 7,000 U.S. physicians are certified geriatricians.

Caring for older people is "one area of medicine where you can practice the true art of medicine," Dr. Epplin said. The goal is maintaining a proper balance between treating enough to make a difference without overtreating, he said.

Plus, "you have to have an interest in it," Dr. Epplin said. Developing that interest may require an attitude adjustment. Some physicians may see patients older than 70 and assume they are on a downhill course, he said. A conversation may include: "Your knee hurts? You're old, what do you expect?" The biggest complaint Dr. Epplin hears from his patients is that other physicians dismiss their concerns. "Remember that these are very viable people who have a future as well as a past. Then you look at it in a more positive way."

At the same time, legitimate concerns surround the time commitment necessary to care for these complex patients. The primary care physician who is going to care for a significant number of America's elderly has to be willing to change his or her standard of practice, Dr. DuBose said. "There has to be more time taken, and it has to be a slower process than the typical office visit."

Sharpening communication skills is one way to use limited time effectively, several doctors said. Poor communication can cause the entire medical encounter to fall apart, noted John C. Houchins, MD, assistant professor in the Dept. of Family and Preventive Medicine at the University of Utah School of Medicine, and others in a 2006 article in Family Practice Management.

Their communication tips include avoiding distractions, sitting face-to-face with a patient, maintaining eye contact, listening and sticking to one topic at a time.

Patients also may be unable to hear well, whether because of a hearing loss or the loss of the ability to hear higher frequencies. Women doctors may have to enlist the help of male colleagues with lower-frequency voices to improve a patient's ability to hear them, Dr. Leipzig said.

But Dr. Thomas cautions that not all older patients are hearing-impaired, and physicians shouldn't assume they are. "I like to first speak in a normal voice to all older people."

Doctors also should be aware that their oldest patients may not be forthcoming with information because they don't want to cause the doctor any problems, Ronch said. "They might not be comfortable communicating issues that are important for the physician to know about."

Caution also should be taken to ensure that patients can read the materials they are provided. Use large font sizes and high contrast, so the letters are black and the paper is white and nonglare, Dr. Leipzig said.

The top priorities

Some concerns loom as exceptionally important when caring for older patients, and among them is the elimination of medication errors.

Geriatricians agree that all patients should bring a bag of their medications to each visit. Included should be prescription and over-the-counter items, vitamins and herbal products.

Eliminating medical errors is a top priority when caring for older patients.

Dr. DuBose likes to have patients bring the bottles, rather than a list of medications, so he can write on the bottles if a change is required. "Medication errors are very common," he said. "So a doctor or a nurse needs to make a dedicated effort to review all their medications."

Having a good, online resource to check for dosing information and drug interactions is also invaluable, a number of physicians said.

Another top priority is the ability to diagnose dementia and differentiate between dementia and delirium.

Dementia isn't always obvious at earlier stages, Dr. DuBose said. But once it is diagnosed, doctors can prescribe medications to slow its progress. Financial and health safeguards can be put in place for patients' protection.

A primary care physician doesn't need to be able to deal with every complicated patient with dementia, but they should have a good basic approach to follow if a family member expresses concern about an individual or if a patient comes in and says they are concerned about their memory, Dr. Mehr said.

Preventing falls is another area of importance. "One of the most devastating things you can help prevent is falls and resulting hip fractures," Dr. Leipzig said. An evaluation of gait, balance, vision and use of psychotropic medications is necessary.

A "get up and go test" is a fairly simple way to determine an individual's capability, Dr. Mehr said. "Ask a person to get up from their chair, walk across the room and walk back. You want to see if they use their hands to get up."

Doctors also should be sensitive to incontinence, he said, which is common in older women.

Caring for this population is a team effort. Physicians often enlist office staff to carry out many evaluations, and they should also be aware of community resources so they can help connect their patients with services such as visiting nurses, senior centers and entitlement programs. "You don't need to be a social worker, but you need to refer," Dr. Leipzig said.

Changes to the office layout also can make a difference to older patients. Ease of entry is a help to patients of all ages, Dr. Thomas noted. "People living with disabilities will thank you, as will younger people who have torn their Achilles tendons and are on crutches.

The print version of this content appeared in the May 11, 2009 issue of American Medical News.

Two physician groups are urging the federal government to update policies related to HIV infections, charging that the policies were drafted years ago when infection with the virus equaled a death sentence.

Now, with appropriate treatment, people infected with HIV can live a near-normal life span, noted Michael Saag, MD, chair-elect of the Infectious Diseases Society of America's HIV Medicine Assn. He spoke during an April 17 press briefing to introduce a joint position paper of the American College of Physicians and the HIVMA. The paper was released online April 16 and is to be published in the May 15 Clinical Infectious Diseases.

In their paper, the groups call for earlier identification of those infected with the virus, expanded access to treatment and stronger national leadership to respond to HIV's spread in the United States and abroad.

Gains on HIV diagnosis and treatment have made it more important to identify people carrying the virus as early as possible, the position paper said. Yet recent estimates by the Centers for Disease Control and Prevention say that of the 1.1 million people in the U.S. infected, one in five is unaware of his or her status.

Because of near-universal testing and implementation of effective treatments for infected mothers-to-be, transmission to infants has basically stopped, Dr. Saag said. "Now this same concept needs to be applied to the entire population."

1 in 5 of the 1.1 million people in the U.S. with HIV is unaware he or she has it.

Another reason for rapid identification and treatment is a recent finding that the AIDS virus is now more virulent, and damage to patients' immune systems is occurring earlier.

A paper published May 1 in Clinical Infectious Diseases found that 25% of patients diagnosed with HIV in recent years already had CD4 cell counts of less than 350, which is the threshold for implementing antiretroviral therapy, compared with only 12% of patients in the late 1980s.

"Unfortunately, it may no longer be true that there is a time period of several years between diagnosis and the need for treatment -- instead, this time span is shortening," said study author Nancy Crum-Cianflone, MD, MPH, an infectious diseases specialist at San Diego Naval Medical Center.

Broad screening urged

Although the CDC put out a call in 2006 urging widespread HIV screening, the response has been spotty from the nation's hospitals, clinics and physicians' offices. The AMA also recommends that physicians routinely test adult patients.

Among the changes requested by the ACP and the HIVMA are those allowing reimbursement for the screening of all patients in federal health programs. "Although the Centers for Medicare & Medicaid Services are considering reimbursing the cost for testing high-risk patients, we would recommend they expand this policy to cover all Medicare beneficiaries," said Jeffrey Harris, MD, ACP's immediate past president.

The federal government does not support needle-exchange programs.

The cost of treatment increases dramatically in later stages of infection, he noted. With early treatment, the cost is less than $14,000 per year, but that figure increases to more than $36,000 annually, he said.

The groups also request the expansion of proven prevention strategies. "It's time to support evidence-based transmission prevention efforts such as needle-exchange programs and comprehensive sexual education," said Kathleen Squires, MD, HIVMA vice chair. Despite studies showing the effectiveness of needle-exchange programs, the federal government does not support them, she said.

J. Fred Ralston, MD, president-elect of the ACP said work force issues also must be addressed.

Screening is going to be done by primary care physicians, and that network is "in critical condition as we speak," he said. "It has been shown that the collapse of primary care is going to lead to higher costs, lower quality, diminished access and decreased patient satisfaction, which is certainly not the direction in which we want to head."

The print version of this content appeared in the May 11, 2009 issue of American Medical News.

Tight control of blood glucose levels, the bedrock of diabetes care for some time, may not be the best option for all patients with the type 2 form of the disease. The burden of complex treatment regimens, risk of low blood glucose, possible weight gain and expense of reaching these goals may not always be worth it. In addition, hemoglobin A1c targets should be individualized, according to a review of recent studies in the June 2 Annals of Internal Medicine.

"It's time to look at the patient with diabetes as an individual who has more issues than just blood sugar," said Victor Montori, MD, lead author and professor of medicine at the Mayo Clinic in Rochester, Minn. "It's key that we change the emphasis from blood sugar to well-being, adequate preventive care and adequate cardiovascular risk reduction."

Researchers pooled several large randomized trials comparing effects of working toward various glycemic targets. Tight control made no impact on all-cause mortality, cardiovascular death, stroke, amputations or microvascular complications. This diabetes care strategy also increased the risk of hypoglycemia and weight gain.

Aiming for ever-lower blood glucose levels has been the emphasis of diabetes care from several organizations because of evidence indicating the approach reduces the risk of long-term complications. Most urge that the majority of patients achieve hemoglobin A1c numbers around 7% or lower.

This paper is the latest to suggest this strategy may not always be proper. Results of projects released in the past year, such as the Action to Control Cardiovascular Risk in Diabetes, the Veterans Affairs Diabetes Trial, and Action in Diabetes and Vascular Disease -- Preterax and Diamicron Modified Release Controlled Evaluation, noted that efforts to tightly control blood glucose levels may not mean lower risk of cardiovascular disease. They may even increase the risk of death for some.

"Hypoglycemia can be very dangerous in the older population, particularly for older patients who have co-existing illness and are on numerous medications," said William Duckworth, MD, director of diabetes research at the Phoenix Veterans Affairs Health Care Center and VADT's principal investigator.

In response, the American College of Cardiology, the American Diabetes Assn. and the American Heart Assn. published a statement in their respective journals last year saying most patients should still aim for an A1c of 7%. Those with a history of severe hypoglycemia, short life expectancy and advanced complications may not need such intense glycemic control. A commentary in the April 15 Journal of the American Medical Association also suggested that younger patients who have not had the disease long and do not have many cardiovascular risk factors are most likely to benefit from tight control. "The goal for the majority of people is a hemoglobin A1c as close to normal as possible," said Bruce Bode, MD, a spokesman for the Endocrine Society and associate professor at Emory University School of Medicine in Atlanta.

Response to this more recent paper varied. Some praised it for bringing attention to the fact that tight control may not be best for everyone.

"We are treating people, not numbers," said Rodney Hayward, MD, co-director of the VA Health Services Research and Development Center of Excellence in Ann Arbor, Mich. "People have different goals in their life. For them to check their blood sugar multiple times a day may come at a huge cost and may not really be valuable. It may even be dangerous."

But the findings also drew criticism. Some experts questioned the conclusions because researchers lumped together several trials focusing on very different populations. Many also expressed concern that worries about the patient burden of getting to low numbers may have been overblown.

"I agree that glucose targets need to be individualized. I don't necessarily think it's appropriate to combine all of these studies together," said Irl B. Hirsch, MD, professor of metabolism, endocrinology and nutrition at the University of Washington School of Medicine in Seattle. "I disagree with some of the conclusions about the burden of care on the patient."

The authors say tight blood glucose control is a good option for some patients but, because it is not for all, advocate that A1c numbers not be used for pay-for-performance and other quality measures.

The print version of this content appeared in the May 11, 2009 issue of American Medical News.

Weight-loss surgery may help those with less-severe obesity shed pounds, but questions remain about long-term outcomes and whether some versions of the procedure are better than others. The conclusion was the result of a data review by researchers at the University of Southampton in England. Their findings were published April 15 in The Cochrane Library.

"[This paper] is not saying that we should be doing surgery for those with a BMI between 30 and 35. It's saying that, yes, surgery results in a greater weight loss, but is it worth it? We don't know," said Caroline Apovian, MD, director of the Nutrition and Weight Management Center at Boston Medical Center. She was not affiliated with the Cochrane review.

A National Institutes of Health 1991 consensus paper stated that bariatric surgery was appropriate for those with a body mass index higher than 40. It also noted those with a BMI between 35 and 40 who had serious weight-related illnesses could be considered. But the significant number of people who carry excess pounds combined with the development of safer, less-invasive procedures is leading some physicians to ask whether these recommendations should be adjusted.

"Eighteen years ago, procedures had a higher complication rate. The [gastric] band and sleeve didn't even exist. This should be studied," said Scott Shikora, MD, president of the American Society for Metabolic and Bariatric Surgery and director of the Weight and Wellness Center at Tufts Medical Center in Boston.

A 2004 consensus statement from the ASMBS suggested that bariatric surgery for patients with a BMI between 30 and 35 who have weight-related medical conditions may be indicated and needs study. A few research projects investigating the option as a treatment for people who have diabetes and a BMI as low as 30, including one project by Dr. Shikora, are either under way or being planned.

Bariatric surgery is more effective than medical management for weight loss.

Some doctors say bariatric surgery for these patients could lower their chances of experiencing more severe weight-related adverse events.

"It means we're going to get to people earlier in the disease process," said Nick Nicholson, MD, medical director of the weight-loss surgery program at Baylor University Medical Center in Dallas and the Baylor Regional Medical Center in Plano, Texas. "[Surgery] is technically easier when they're at lower weights." On rare occasions, he has operated on patients with BMIs as low as 32 who had severe obesity-related complications.

But other physicians say unanswered questions remain on the longer-term effects. Some also feel the medical management used as a comparison in the reviewed studies was not as intensive as it could be -- giving the outcome advantage to surgery. And although the review found that surgery was more effective than medical management for weight loss, many would like to see analyses looking at differences in other factors, such as cost and adverse events.

"Surgery looks terribly promising, and I know it will play an important role. I don't think we know what the role is right now," said Tim Church, MD, MPH, PhD, director of preventive medicine research at Pennington Biomedical Research Center in Baton Rouge, La., who researches nonsurgical weight loss. "We spend 25 or 50 grand on bariatric surgery. We would never dream of committing even half that to a good behavioral intervention. Give me half that fee, and I will change someone's behavior and keep it changed."

Physicians who specialize in nonsurgical weight-loss strategies also say it is possible to lose large amounts of weight without an operation and expressed concern about patients having these kinds of procedures before exhausting other options.

"We can reverse many of the complications of obesity almost as effectively as bariatric surgery with a minimal rate of complications and cost," said Allen Rader, MD, secretary/treasurer of the American Society of Bariatric Physicians and the founder of Idaho Weight Loss in Boise. "We believe the treatment paradigm for obesity should be primary care physicians first, then referral to a bariatrician, then referral to the bariatric surgeon."

The print version of this content appeared in the May 11, 2009 issue of American Medical News.

New research that uses an innovative approach to study, for the first time, the relative contributions of food and exercise habits to the development of the obesity epidemic has concluded that the rise in obesity in the United States since the 1970s was virtually all due to increased energy intake.

How much of the obesity epidemic has been caused by excess calorie intake and how much by reductions in physical activity has been long debated and while experts agree that making it easier for people to eat less and exercise more are both important for combating it, they debate where the public health focus should be.

A study presented on Friday at the European Congress on Obesity is the first to examine the question of the proportional contributions to the obesity epidemic by combining metabolic relationships, the laws of thermodynamics, epidemiological data and agricultural data.

"There have been a lot of assumptions that both reduced physical activity and increased energy intake have been major drivers of the obesity epidemic. Until now, nobody has proposed how to quantify their relative contributions to the rise in obesity since the 1970s. This study demonstrates that the weight gain in the American population seems to be virtually all explained by eating more calories. It appears that changes in physical activity played a minimal role," said the study's leader, Professor Boyd Swinburn, chair of population health and director of the World Health Organization Collaborating Centre for Obesity Prevention at Deakin University in Australia.

The researchers started by testing 1,399 adults and 963 children to determine how a number of calories their bodies burn in total under free-living conditions. The test is the most accurate measure of total calorie burning in real-life situations.

Once they had determined each person's calorie burning rate, Swinburn and colleagues were able to calculate how much adults needed to eat in order to maintain a stable weight and how much children needed to eat in order to maintain a normal growth curve.

They then worked out how much Americans were actually eating, using national food supply data (the amount of food produced and imported, minus the amount exported, thrown away and used for animals or other non-human uses) from the 1970s and the early 2000s.

The scientists used their findings to predict how much weight they would expect Americans to have gained over the 30-year period studied if food intake were the only influence. They used data from a nationally representative survey (NHANES) that recorded the weight of Americans in the 1970s and early 2000s to determine the actual weight gain over that period.

"If the actual weight increase was the same as what we predicted, that meant that food intake was virtually entirely responsible. If it wasn't, that meant changes in physical activity also played a role," Swinburn said. "If the actual weight gain was higher than predicted, that would suggest that a decrease in physical activity played a role."

The scientists observed that in children, the predicted and actual weight increase matched exactly, indicating that the increases in energy intake alone over the 30 years studied could explain the weight increase.

"For adults, we predicted that they would be 10.8 kg heavier, but in fact they were 8.6 kg heavier. That suggests that excess food intake still explains the weight gain, but that there may have been increases in physical activity over the 30 years that have blunted what would otherwise have been a higher weight gain," Swinburn said.

"To return to the average weights of the 1970s, we would need to reverse the increased food intake of about 350 calories a day for children (about one can of fizzy drink and a small portion of French fries) and 500 calories a day for adults (about one large hamburger)," Swinburn said. "Alternatively, we could achieve similar results by increasing physical activity by about 150 minutes a day of extra walking for children and 110 minutes for adults, but realistically, eventhough a combination of both is needed, the focus would have to be on reducing calorie intake".

He emphasized that physical activity should not be ignored as a contributor to reducing obesity and should continue to be promoted because of its a number of other benefits, but that expectations regarding what can be achieved with exercise need to be lowered and public health policy shifted more toward encouraging people to eat less.


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