Aging and the Attitude of Health Care Providers

In many cultures in the world, elderly people are revered, and their advice is sought and respected. In our culture, the wisdom, the knowledge, and the social skills of the elderly are often overlooked and instead we focus on the mental and physical deficits of our older generation. Because of this prevailing attitude, older people are generally regarded as less valuable than younger people. The younger person has responsibilities of raising a family, maintaining a career, and supporting the economy. The older person generally has no responsibilities and in addition is a drag on the economy since a great part of the tax base must go towards the support of older Americans.

It is inevitable that medical care providers will unconsciously have this same attitude towards their older patients. As a result, if an older person has a medical complaint and the cause is not readily apparent, a medical practitioner is more likely to accept the condition as a consequence of old age and treat the symptoms with medication as opposed to aggressively trying to identify the underlying problem. In younger people, if the medical complaint is interfering with normal daily function, typically a more concerted effort will be made to identify and correct the underlying problem.

A 90 year old man meets with his doctor and complains about pain in his right knee. The doctor tells him,

"Well Henry, what do you expect? You're 90 years old."

Henry replies, "But doctor my left knee is the same age as my right knee, there's no pain and it feels just fine!"

Many in the health-care profession consider old age to be a disease itself. Any medical problems are inappropriately attributed to old age as if it were a medical condition. And since there is no cure for old age, appropriate tests and treatment are never performed. Thus, medical problems that may not be related to age and may just as frequently occur in younger people are often not treated. As an example, a recent survey of physicians involved in the health-care of the elderly reported that 35% of the doctors considered hypertension a result of the aging process and that 25% of them felt that treating an 85-year-old for symptoms of hypertension would cause more harm than the benefits it would produce.

Consider these real-life examples.

First Example

A 71-year-old woman has surgery on her shoulder for a bone spur that is causing her considerable pain. The surgery is successful, and she goes through several months of physical therapy to help her recover. But she is not recovering as expected. She continues to experience pain that radiates through her entire back. Her physical therapist does not know how to help her and attributes her failure to recover to old age. She visits her family care doctor at least twice over the next six months complaining of extreme tiredness and lack of energy. Her skin color is gray, and she does not look healthy. Finally, she visits her doctor and insists he check her for some problem since she is not recovering from the surgery and she feels awful. After her insistence, he does a CBC blood lab and discovers she is severely anemic. He puts her in outpatient care and gives her four units of red blood cells and puts her on iron supplementation.

Within two weeks the pain has disappeared and within a month she has recovered fully from the surgery. Numerous tests are done but there is no explanation for the anemia. Six months later she is healthy and active, and her cheeks are ruddy. When she asks her doctor why he did not suspect anemia he tells her that she has never had anemia and based on her history he would never expect her to develop it. (He obviously has no training in geriatric care.) He then tells her, in an obvious contradiction of his previous position, that older people sometimes fail to absorb iron. Ironically, she defends the action of her doctor and does not feel he acted inappropriately.

Second Example

Susan and John have been married for 46 years. Susan has always demonstrated a tendency for depression, but it has generally been kept under control with medication. John's health begins to deteriorate and within a year he is dead. Several months after her husband's death, Susan is exhibiting signs of severe depression. She is given ever-increasing levels of various Antidepressants but they have no effect. She is also exhibiting signs of a psychosis and is inflicting wounds upon herself.

The family puts her in an assisted-living facility, but the facility is unable to deal with her aberrant behavior. Her son who lives in New York decides to bring her to live with him and he admits her to a hospital in New York City . Tests indicate she is suffering from severe hypothyroidism, and she is put on appropriate treatment. Apparently, no health practitioner had to this point suspected there may be a medical condition contributing to the depression other than old age. The low thyroid undoubtedly was a significant factor in the development of her depression.

But treatment of the depression is not addressed in the hospital, and it has progressed considerably. She is transferred to a nursing home and wrongly diagnosed with dementia and placed in the dementia unit. She is deteriorating rapidly; she continues to abuse herself and she refuses to speak or acknowledge anyone. Within a few months she will probably be dead.

At this point an experienced geriatric care physician steps forward and correctly diagnoses her condition as clinical depression. She is hospitalized for six months and undergoes aggressive treatment for depression. They also discover she is severely malnourished and correct that problem as well. She has now moved back into the home of her son. She is a normal functioning person and is even volunteering to work in the local library. The geriatric health care system almost dropped the ball on this one.

Third Example

A 65-year-old woman, who has been active all her life, has a small stroke which leaves her with some discomfort and pain in her right arm but does not limit her in any other way. She is anxious and nervous about her condition and the possibility of another stroke, and the doctor prescribes pain pills and Valium to help her with her anxiety. Over a period of 15 years, she becomes addicted to Valium and does little else except sit in front of the TV all day long. She makes sure she maintains contact with a doctor who will provide her need for Valium. (No doctor or pharmacist would allow this abuse to go on with a younger person without intervention. Older people are often ignored and allowed their vices.)

Early on, her family can see the problem and they decide to intercede. On the advice of friends, they contact the geriatric care unit at a local university hospital. A geriatric care physician is alarmed at her addiction and insists they wean her off of the mood-altering drug. He is willing to treat her and help her. She refuses to cooperate and in deference the family backs off. Over a period of 15 years, she gets no exercise except for trips to the bathroom or trips to the living room to visit occasionally with her family. But family and grandchildren over the years visit less and less often.

After many years of sitting in the same position her knees deteriorate and she finds it difficult to walk. In order to avoid getting up from her chair to walk to the bathroom, she drinks very little fluid and becomes chronically dehydrated. This does not help her mental or physical condition.

She has the joints in both knees replaced but does no exercise and the combination of the invasion of muscle tissue through surgery and lack of use of her legs causes muscles around her knees to atrophy. No follow-up is done by the orthopedic surgeon to make sure she remains active, after all she is old.

She can now barely walk at all. She spends her final three years confined to one room in her daughter's house, refusing the use of a wheelchair and refusing to go anywhere beyond the bathroom.

In this case, a general lack of concern by all involved demonstrates the apathy of family and the healthcare community to making sure elderly people can experience a meaningful existence in their remaining years. Had this been a younger person, say in her 40's, everyone involved would have been more aggressive in helping her solve her addiction and in making sure she had a better quality of life.

A Hands-On Treatment Approach

Most practitioners who specialize in care for the elderly are aware of the above-mentioned problems with older patients and they take a holistic approach with the medical treatment of these people. An attempt is made not only to treat the specific condition or conditions but to make sure there is sufficient activity, proper nutrition, and family support at home.

They work closely with family members to make sure their loved ones are taking medications properly and are reporting their symptoms. They require those caring for the elderly to closely monitor health conditions and report any changes before things get worse. They meet with their patients regularly enough to monitor their health. This broad-based approach results in better health and in fewer visits to the emergency room because intervention for a worsening condition is achieved at an earlier stage.

A good example of this holistic approach is the Veterans Administration health care system. The VA system over the years has become the nation's largest geriatric care provider for older men. Almost all veterans are men and because most veterans hearken back to the Korean conflict and the Vietnam War most of them are older than age 60. Because of this the VA has found it necessary to adapt its health care to this age group.

The VA schedules regular exams at least every six months or yearly depending on available funds and personnel. A health examination almost always includes lab work. Screenings for cancer, cardiovascular problems, eye problems, hearing problems and many other conditions common to aging are a routine part of veteran's administration health care. The VA was one of the first health providers in the nation to require its local hospitals to keep their records on computer and in a central database. This allows health practitioners in the system to quickly and efficiently access all information and avoid misdiagnoses and possible drug interactions. By taking a hands-on, preventative approach to the treatment of older men the system is able to keep its patrons healthier and avoid costly medical interventions due to lack of follow-up.

A significant problem in the past with providing hands-on treatment is many health insurance providers, including Medicare, will not pay for routine office visits without an underlying medical complaint. Some private health plans are starting to use so-called "pay for performance" or "outcome-based care" where the overall health of the patient takes precedence over the procedures used to get there. Fortunately, Medicare is now providing for preventative medicine and many private healthcare plans are adopting this approach as well.