Geriatric Medicine in North America

David B. Hogan

Introduction

In this chapter we examine the history and current state of geriatric medicine in Canada (2014 estimated population 35.5 million) and the United States (2014 estimated population 319 million). Although geriatric medicine developed in response to similar demographic pressures, it evolved in differing manners within the two countries.

Demographic Imperative

As seen in other high-income nations, the absolute number and relative proportion of older individuals in Canada and the United States are increasing. Although a chronological age of 65 is typically used to demarcate the start of old age, this is arbitrary and not driven by a strong biologic or clinical rationale. If the intent is to describe the oldest segment of the age pyramid, the lower age cutoff should have been continuously moved upward over the past 50 years. Thirty years ago, those individuals 65 years or older made up a tenth of the Canadian population, whereas today it is nearly one in six.¹ Because of large post–World War II baby booms in the United States and Canada, the pace of societal aging will accelerate over the coming decades. In 2012 approximately 43.1 million Americans were 65 or older (13.7% of the population).² By 2060 the number of older individuals is projected to grow to 92.0 million. Just over one in five Americans will be 65 years or older.² Similar changes will be taking place in Canada, where by 2016 seniors will for the first time outnumber children younger than 15 years of age. In 2063 it is estimated that 24% to 28% of the population will be 65 years or older.³ In 2012 life expectancy in the United States was 79 years (76 for men and 81 for women) and 82 (80 for men and 84 for women) in Canada.⁴

Although the majority of North American seniors are in good health, their per capita health cost, on average, is three to five times higher than that of younger adults.⁵ Seniors currently account for approximately one fourth of physician office visits and one third of both acute care stays and consumption of prescribed medications.⁶ With the projected increase in the number of seniors, health care use and costs are expected to increase. Aging, though, is less important than other drivers of rising expenditures such as increases in per capita utilization rates or the introduction of promising but costly technologies.⁵ The health care workforce required to deal with the anticipated increase in demand has to be recruited, trained, and efficiently deployed.⁷^,⁸ Another issue is the financing of retirement. Rather than putting aside sufficient funds to deal with retirements that might last for 30 years or longer, Americans are now saving less for old age than in any decade since the Great Depression.⁹ The average working household has virtually no retirement savings.¹⁰ Finally, there are concerns about the potential impact on family caregiving. Already up to 40% of North American adults are caregivers to family members.¹¹^,¹² With the projected rise in the number of seniors with cognitive and functional impairments, the demand for this already strained resource will likely increase.

All of these factors have led to considerable angst about the cost and care implications of our aging population.¹³ As an extreme example of this, in 1984 the governor of Colorado, Richard D. Lamm, was inaccurately but widely reported as saying older Americans had “a duty to die and get out of the way.”¹⁴ These worries are widespread. In a nationally representative survey of middle-aged and older (45 years and older) Canadians conducted in 2014, more than one fourth stated they were caring for an aging relative or friend, 6 in 10 were concerned about their financial situation during their retirement years, most lacked confidence in the ability of the health care system to provide for seniors in the future, and nearly all (95%) agreed that a national strategy on seniors’ health care was needed.¹⁵

As will become evident, the burgeoning number of seniors hasn’t been paralleled by similar growth in the number of North American subspecialists in geriatric medicine. (Note: In North America, geriatric medicine is more appropriately viewed as a subspecialty than a specialty because it is an area of focused and advanced practice that builds on prior training and/or experience in broader disciplines such as family or internal medicine.)

Historical Development

Geriatric medicine deals with the study, understanding, prevention, and management of disease, disability, and frailty in later life. The rise in the number of older people during the twentieth century led to increasing interest in their care. In 1909 a New York physician, Ignatz Leo Nascher, coined the term geriatrics. He wrote that old age was as “distinct [a] period of life … as … childhood” and deserved “a special branch of medicine” to deal with its unique challenges.¹⁶ In 1914 Nascher authored Geriatrics: The Diseases of Old Age and Their Treatment but failed in making it an enticing field of medical practice partially because, as noted in a contemporary review of the textbook, he was “inclined to dwell on the darker lines of the picture.”¹⁷^,¹⁸

During the first half of the twentieth century, medical care in Canada and the United States was organized and financed in a similar manner, leading to a good deal of cross-border movement. A number of Canadian physicians and researchers who immigrated to the United States, such as Sir William Osler whose departure from Johns Hopkins was marred by the “Fixed Period” controversy,¹⁹ played an important role in shaping the attitudes and approaches taken by American medicine toward older persons.¹⁷ The birth of gerontology as a scientific discipline is dated from 1939 when The Problems of Ageing was published.²⁰ This book was edited by Edmund Vincent Cowdry, who was born in Canada but spent most of his professional career in the United States, principally at Washington University in St. Louis.¹⁷^,²¹ The founding of the American Geriatrics Society (AGS) in 1942 predated that of the Medical Society for the Care of the Elderly (renamed the British Geriatrics Society in 1959) in the United Kingdom.²¹ Canadian physicians joined the AGS in large numbers (approximately 400 were members of the AGS in 1970), with five serving as its president.¹⁷ One of them, Willard O. Thompson, was the founding editor of the Journal of the American Geriatrics Society.¹⁷^,²¹

Early North American geriatricians were part-time specialists with “other duties to perform from which they generally earn[ed] a living.”²² Although aging well was felt to be dependent on adhering to the advice of an experienced and sage physician,²³ no unique diagnostic or therapeutic approaches were linked to the field. The development of geriatrics as a recognized area of full-time practice in North America lagged behind the United Kingdom. As noted by John Grimley Evans, while “Nascher invented the word, Marjory Warren created the specialty.”²⁴

William R. Hazzard was mostly correct when he wrote that before 1978 in the United States, “there were no trained geriatricians … no geriatrics faculty … no recognition [of the field] as a specialty … [and] no designated training programs.”²⁵ Barriers to the acceptance of geriatric medicine as a legitimate field of practice found in a number of countries include skepticism that there is a unique body of knowledge and skills, the sense that the diseases of old age are inevitable and incurable, and the relative lack of public interest in the plight of older patients compared to other patient populations (e.g., children).²⁶ Other issues delaying recognition in the United States included organizational ones (i.e., the multidisciplinary nature of aging societies detracted from their ability to lobby effectively within organized medicine, lack of representation within the upper reaches of the power structure of academic medicine), slow development of clinical research in aging, ageism and the unspoken fear of aging, the unwillingness of established specialties and subspecialties to share resources, and the fear within these fields that geriatric medicine would encroach into their area of practice.²⁷^–²⁹ There was also uncertainty about the specific form recognition should take.³⁰^,³¹ It was not until 1988 that the first American certifying examination in geriatric medicine was held.²⁸

Things moved more rapidly in Canada. The Council of the Royal College of Physicians and Surgeons of Canada (RCPSC) formally recognized geriatric medicine as a subspecialty of internal medicine in 1977 with the first certifying examinations held in 1981.¹⁷ This took place in spite of persistent opposition from within organized medicine as shown by the reaction of the RCPSC Specialty Committee for Internal Medicine. They had not been consulted before the decision was taken to recognize the field. Once informed, they expressed strong disapproval and, on two separate occasions (1978 and 1979), passed motions “deploring” the recognition of geriatric medicine by the RCPSC. In their meeting minutes, recorded comments included “geriatrics is the business of internists… [And] segregation [of older patients is] not in their best interests.” British geriatricians were described as “curators of parking lots” with the field a “refuge for failed internists … [where] the elderly receive very indifferent care in settings apart from other medical patients.” The practice of geriatrics was stated to be “very depressing” and physicians were thought to be “more likely to perform well with a broad spectrum of patients.”¹⁷ The RCPSC committee held that geriatrics had no specific knowledge base and that advances in the care of older patients were not being made by geriatricians but by clinicians and researchers in other fields. An inescapable conclusion is that, within at least this corner of organized medicine, geriatric medicine, like its patients, was both disrespected and marginalized.⁵ Another important take-home message is to never assume support and always be able to cogently make the case for the discipline.

A particular strength of American medicine is the breadth and depth of its research activities. At the close of World War II, the federal government in the United States became the world’s leading funder of medical research, including that on aging.²⁰ Americans authored over half (53.9%) of the articles published in gerontology and/or geriatric journals in 2002.³² This compares to 9.7% and 6.7% for contributors from the United Kingdom (the nation that ranked second) and Canada (ranked third), respectively. Important contributions to geriatric medicine³³ include work on frailty³⁴^,³⁵ and the creation of innovative, effective models of care for older patients.³⁶^,³⁷

Care of Older Patients

There are important differences between older and younger adults. Seniors typically have diminished physiologic reserves. Chronic conditions such as cardiovascular disease, stroke, diabetes, cancer, chronic obstructive airway disease, musculoskeletal conditions, and dementia are common and, when present, often severe. Of even greater note is the frequent presence within an aging patient of multiple morbidities occurring in varying combinations. Geriatric syndromes (e.g., delirium, falls, incontinence, frailty), malnutrition, sensory impairments, impaired mobility, and disability are frequently encountered. The physical and social environment of the older patient is an important consideration in the planning of their care. Polypharmacy (the consumption of many drugs together) to deal with the multiple symptoms, diseases, and risk states (e.g., hypertension, hypercholesterolemia, osteoporosis) is the rule rather than the exception. This in turn can lead to problems like adverse drug effects, prescribing cascades, disease-drug and drug-drug interactions, and nonadherence. The inherent complexity of older patients all too often leads to fragmented, uncoordinated care provided by an array of practitioners working in isolation.

In 2008 the Institute of Medicine released the report Retooling for an Aging America, which warned of the need to plan for the growing number of older adults.⁸ Recommendations included increasing the number of geriatric specialists, redesigning how care is delivered, expanding the role of other providers, and enhancing the competency of the entire health care workforce in the care of older patients. With regard to the latter point, physicians without advanced training in geriatric medicine provide most of the medical care received by older patients in North America. A study of a representative sample of Medicare beneficiaries showed that general internists and family physicians are responsible for much of this care.³⁸ Specialists in geriatric medicine ranked only 38th among providers of ambulatory medical services to these patients. This will not change in the foreseeable future. The physicians (and other health care providers) providing this care require sound training about health and illness in older patients.⁸ Geriatricizing (or gerontologizing) is the awkward sounding term used to describe the introduction within the various fields of medicine the principles required to successfully care for older patients.²⁴^,²⁵ A number of medical and surgical specialties in the United States have committed themselves to defining the specific competencies needed by practitioners in their field of practice to deal with older patients and incorporating them within both their training programs and examinations.³⁹

Research shows ample room for continued improvement in the provision of care to older patients across all settings. For example, within the community, the quality of care offered for geriatric syndromes (e.g., falls, urinary incontinence, dementia, osteoporosis, hearing impairment, malnutrition) is generally worse than that provided for medical conditions (e.g., hypertension, coronary artery disease, cerebrovascular disease, diabetes, heart failure, atrial fibrillation).⁴⁰ The overall incidence of adverse events (defined as unintended injuries or complications resulting in death, disability, or prolonged hospital stay arising from the care provided) during hospitalization of adult patients in Canada is approximately 7.5/100 hospital admissions, with increasing age a statistically significant risk factor for its occurrence.⁴¹ Finally, a recent study showed widespread use of medications with questionable benefits in nursing home residents with advanced dementia.⁴²

The need to deal with the unique characteristics of seniors has to be recognized within the broader context of health care planning and delivery for the entire population. An example of this is emergency care. Hurricane Katrina and other natural disasters consistently show that older persons are at particular risk for adverse outcomes during such events. Emergency planning has to take this into account as well as the difficult ethical issues that might arise.⁴³^–⁴⁵ It is also clear that the care provided within emergency departments will have to be modified if the pending influx of aging baby boomers is to be dealt with effectively, efficiently, and humanely.⁴⁶^,⁴⁷

Given that improving the care of all older patients must be a goal of our respective health care systems, how do subspecialists in geriatric medicine contribute to this overarching aspiration?

Geriatric Medicine Today

In the United States, the American Board of Family Medicine and the American Board of Internal Medicine jointly offer a certificate of added qualifications in geriatric medicine. After completion of a residency in either family medicine or internal medicine, trainees can take additional accredited training in geriatric medicine followed by a certifying examination. About 80% of residents are from internal medicine. Few take more than one year of training in the field. It was initially thought that physicians with subspecialty training in geriatric medicine would be principally concerned with the medical care of residents in long-term care facilities. Over time this view has evolved. Some view geriatricians as consultants called on to help with complex cases, whereas others believe that geriatricians’ true calling is the provision of primary medical care to seniors.⁴⁸ Early on, and more recently as well, it has been argued that an academic model should be embraced with practitioners focusing on training other physicians, conducting research, and providing medical leadership.⁴⁸^–⁵⁰ In 2011 there were 7162 active board-certified geriatricians. This leads to a ratio of approximately 3.8 geriatricians per 10,000 individuals 75 years and older in the United States.⁵¹ By 2030 the ratio is expected to drop to 2.6 per 10,000 because of the projected increase in the number of older Americans coupled with poor recruitment (and retention) of specialist physicians.⁵¹

There are two recognized training options available for Canadian physicians interested in geriatric medicine. Physicians who have completed their training in family medicine can enroll in a 6- or 12-month residency program in Care of the Elderly accredited by the College of Family Physicians of Canada. There is no national certifying examination for this option. Training is intended to equip graduates with the skills required to provide primary medical care to older individuals, work within specialized geriatric programs, and/or function as a medical resource for their community in the care of older patients. The second training option is restricted for those with at least 3 years of prior training in internal medicine. They can enroll in a 2-year training program accredited by the RCPSC. A national certifying examination administered by the RCPSC can be taken after first passing the specialty examination in internal medicine and successfully completing a residency in geriatric medicine. Graduates function as consultants. While physicians from either option can be involved in academic activities, graduates of the RCPSC stream are the ones principally involved in research, teaching, and program development. In 2012 there were 404 (326.15 full-time equivalents [FTEs]) Canadian specialists in geriatrics (i.e., defined as physicians with advanced clinical training or equivalent practice experience in geriatrics who work as consultants).⁵² Nationally this translates to a ratio of 1.4 FTE geriatricians per 10,000 individuals 75 years or older.

It is important to mention another age-defined medical specialty, geriatric psychiatry. This field deals with the assessment and management of mental disorders in later life. Notwithstanding the field’s long history in Canada,¹⁷ the RCPSC did not recognize geriatric psychiatry as a subspecialty of psychiatry until 2009.⁵³ After completion of psychiatry training, a candidate can be accepted into a 2-year approved residency. As with geriatric medicine, a certifying examination is offered after successful completion of training. The first examination was held in 2013. In 2013-2014 there were nine residents in training nationally.⁵⁴ Based on reported professional society membership and the number of specialists listed in the RCPSC directory, there are more than 200 geriatric psychiatrists practicing in Canada. The American Board of Psychiatry and Neurology recognized geriatric psychiatry as a subspecialty in 1989. A certifying examination is offered at the end of successful completion of a year of postgraduate training. In 2011 there were 1751 board-certified geriatric psychiatrists in the United States.⁵¹ A total of 63 residents were enrolled in geriatric psychiatry training programs in 2013-2014.⁵⁵ This compares to 817 in child and adolescent psychiatry training. Unfortunately the specific issues relating to geriatric psychiatry in North America are beyond the scope of this chapter.

A critical issue on both sides of the border is the recruitment and retention of physicians. Table 121-1 shows data on the number of trainees in Canada over time. The 62 Care of the Elderly and geriatric medicine trainees in 2013-2014 made up only 0.5% of all Canadian postgraduate trainees that year.⁵⁴ Trainees in pediatrics that year numbered 669 (4.3% of the total). The problem is not insufficient training positions, as annually there are unfilled ones (e.g., 14 of 27 [51.9%] training positions were unfilled in 2014).⁵⁶ In 2013, 14 Care of the Elderly and 8 geriatric medicine trainees, a total of 22, entered practice,⁵⁴ well less than what is needed to correct the current physician resource deficit, deal with population growth, and replace retirees.⁵² Retention is a particular issue for physicians who received Care of the Elderly training, as slightly over 50% end up in a general family medicine practice rather than focusing on the care of older patients.⁵²

TABLE 121-1

Number of Trainees Enrolled in Postgraduate Training Programs in Care of the Elderly (6- to 12-Month Program) and Geriatric Medicine (2-Year Program) in Canada (2004-2014)*

	Care of the Elderly	Geriatric Medicine	Total
2004-2005	10	15	25
2005-2006	12	15	27
2006-2007	10	19	29
2007-2008	14	24	38
2008-2009	13	25	38
2009-2010	9	23	32
2010-2011	11	19	30
2011-2012	13	27	40
2012-2013	17	29	46
2013-2014	19	43	62