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Aging in Portland (Listen up Millennials, because you're next)
For all you aging baby boomers out there, here's the good news and bad news. First, the good news. A trained geriatrician as your primary care physician is likely to help you live longer and healthier as you head into what used to be called the golden years. Now the bad news. There aren't enough geriatricians to go around—about 20 in Portland. So don't count on securing one as your health care provider.
Dr. Elizabeth Eckstrom knows this better than anyone. She's the OHSU geriatrician who has been featured in the New York Times and who is constantly getting calls from seniors who want her to be their doctor. Eckstrom isn't taking any new patients, but she hopes she's found a way to spread her knowledge a little bit further.
She's spending her 8-month sabbatical traveling the globe, studying the places where people live longest and the elderly live best. Then she'll bring her new-found knowledge back to Portland where she will consult with physicians who treat the elderly and write a book about what she's learned. So far she's visited communities in Japan and Italy where people living vigorously past 100 is not considered all that unusual. Currently she's meeting with gerontology experts in Boston, Bangor and Halifax, Nova Scotia, which has innovative programs to deal with dementia. In September she's off to Denmark and Sweden, which commit more money than the U.S. to senior public health.
But first, there's this idea of geriatricians. Most doctors don't want to become them, most patients don't know they exist, and most internists and family practitioners believe they know most of what a geriatrician knows. Not true, says Eckstrom, who claims she learned more in her one-year geriatrics fellowship than in any other part of her medical training.
"The knowledge base is enormous and unfathomable to someone who has not taken that on," she says. "Most primary care physicians who are doing front end care for older adults have no clue what they don't know."
What don't they know? Before becoming a geriatrician, Eckstrom says, she had little expertise in differentiating the four different types of dementia that plague the elderly. And that's important knowledge because Lewy body dementia patients are treated with different drugs than Alzheimer patients.
Consider napping and medications, says Dr. Kathleen Drago, an OHSU geriatrician who served her residency under Eckstrom.
The average Oregonian over 65 takes 19 prescription medications a year, Drago says, citing a recent Kaiser Family Foundation study. Many seniors are taking anticholinergics for conditions ranging from sleeplessness to incontinence. But not every internist is aware that those drugs can cause mental fogginess and muscle weakness in seniors, which can contribute to falls or make a senior appear to be suffering dementia.
A geriatrician is likely to ask a senior complaining of general confusion if he or she naps a lot, Drago says. Daytime napping might be a sign of nighttime sleep problems, she explains. And sleep problems might be the result of patients taking nighttime diuretics, resulting in multiple trips to the bathroom overnight. Changing when a patient takes the drug might help them sleep through the night, and avoid some of the mental fogginess that could be misinterpreted as dementia.
What primary care physicians don't know or have time to learn about is what Eckstrom is studying in her travels. In Puglia, Italy, she learned that one of the reasons the Mediterranean Diet may be a great contributor to the health of healthy centenarians is a low-dose toxicity in the diet's vegetables, which increases the body's resilience when those veggies are eaten over a lifetime. The diet reduces the risk of frailty in seniors by 70 percent, according to researchers Eckstrom met in Europe. She also learned how to tell by taste which olive oils have higher concentrations of the chemicals which contribute to better health.
Eckstrom also spent tine in Sardinia, one of five municipalities in the world with the highest percentage of centenarians (the others are Nicoya, Costa Rica; Icaria, Greece; Okinawa, Japan, and the predominantly Seventh Day Adventist community of Loma Linda, California). In Sardinia she found that senior men were responsible for almost all the daily market shopping, and everyone walked, despite uneven cobblestone streets.
In Japan, Eckstrom saw communities where, because there weren't enough health care providers to see all the elderly in places where dementia was common, the government helped establish a system where all sorts of workers keep tabs on seniors. Grocery store clerks are trained to notice when shoppers are having trouble dealing with their money. Janitors are trained to recognize urine stains on, rather than in, a toilet. Both are instructed to call a city employee tasked with helping identify seniors who may be suffering dementia.
"That's a totally cool thing they've taken out of the hands of health care and put in the hands of regular people," Eckstrom says. What if, she continues, every barista in Portland knew there was a number they should call if elderly regular customers went a few days without showing up, or had trouble counting their change?
Also, seniors in some Japanese communities are visited nearly every day by someone who can bathe them, vacuum their homes or simply visit.
In Sardinia, an economically depressed island, Eckstrom was amazed not only at the numbers of men and women who were in their eighties, nineties and over 100 walking around, but at how active they were. Elderly women care for grandchildren during the day while the parents are at work. And the town's senior men, often in their eighties, were in charge of pruning the city's olive trees because there was no one else to do it.
"They just do so much stuff and they're absolutely relied upon," Eckstrom says of the elderly men.
The physical activity of those men, Eckstrom is convinced, helps them stay alive and vital, as does their Mediterranean Diet. But a bigger factor, she says, is that those men still feel useful to society. And that may be the toughest part to translate from what she has been observing to what she'd like to see in Portland.
"We can't put eighty-year-olds in the olive trees because they'd fall out and break their hips because they haven't done it for the last 50 years," Eckstrom says. "We have to figure out a way to get them back into some piece of our society that requires their presence, that requires their skills, and allows them to fulfill their passion."
Those tree-pruning men provide a stark contrast to most of the elderly Eckstrom treats at OHSU. "Well off seniors here go to talks and the symphony. They're always busy. They're always going to something. But they are not fulfilled and they talk about that," she says.
Geriatricians: vital and in short supply
Fifteen minutes isn't long enough to ask a senior all the questions that might reveal clues to their health care problems, says Dr. Kathleen Drago, Oregon Health & Science University geriatrician. But that's what most health insurers are allotting for most visits to internists. Geriatricians typically take 30-45 minutes for regular patient visits, and up to an hour for first-time visits.
That's a big reason there aren't nearly enough geriatricians around to fill the need, and why getting in to see a geriatrician on a regular basis in Portland is nearly impossible.
"We're not the moneymakers," Drago says.
Geriatricians' salaries are among the lowest for all physicians. OHSU offers five one-year fellowships for physicians to obtain the specialized training to become certified geriatricians. Some years they have not been able to fill all five fellowship spots, and some internists don't even let it be known that they have completed the fellowship because they don't want to attract an abundance of low-reimbursement Medicare patients who "kvetch and don't get cured," according to Drago.
"Persistent ageism" is also part of the picture, says Marcus Escobedo, spokesman for the John A. Hartford Foundation, a New York City nonprofit dedicated to improving care for elders, which surveyed medical students to learn why they weren't interested in geriatric careers. The responses? "Oftentimes it was, 'Older adults are not interesting, they are going to decline and eventually die. What can you do for them?'" It's a sort of fatalistic view," Escobedo reports.
Eckstrom says the extra time she spends with each elderly patient might cost her money, but its also the reason a 2009 study found that geriatricians have the highest job satisfaction among all physicians.
"The first three or four visits you have to get all of the complaints out," Eckstrom says. Then, she gets to hear the stories. One of her Portland patients came from an assisted living facility who asked her to do a dementia evaluation. He couldn't answer her basic memory questions, but he aced her math test. So she asked him what he did for work and learned the patient had been lead engineer for construction of Hoover Dam.
"Our thinking is it's terrible to have to take care of this old guy who's got dementia, but you haven't figured out the trigger to get him to wake up and tell his story and turn into this amazingly brilliant person again," Eckstrom says.
Nevertheless, there are fewer geriatricians per senior in the U.S. than there were 15 years ago. The alternative, pushed by nearly everybody in the field of gerontology, is to standardize a portion of the training geriatricians receive and deliver it to cardiologists, gastroenterologists, oncologists and nurses.
"Really, the entire workforce needs to be geriatricized," says Drago.
What seniors need to know
Portland seniors may not be able to find a geriatrician to serve as their primary-care provider, but they can ask their providers to approve one-time consults with geriatricians.
Here are signs that a senior should ask to see a geriatrician, according to Dr. Elizabeth Eckstrom and Dr. Kathleen Drago:
• You are starting to fall or feel unstable.
• You experience even mild dementia or forgetfulness.
• A diagnosis of Parkinson's Disease for those 60 or older
• You take multiple medications and are 60 or older
Or consult a geriatrician "any time you feel like you're being brushed off by your primary-care provider," Eckstrom says.
Next: Sardinia and Okinawa, Portland-style