Along with the well-publicized nursing workforce shortage affecting nursing centers nationally, there is a tremendous shortage of qualified medical specialists in geriatric medicine, and the gap is growing every year.

The geriatric population (usually defined as 65 and up, although some might rankle at being called “geriatric” at that age) is increasing rapidly as the baby boomers hit Medicare territory, while the number of geriatrics fellows being turned out annually is diminishing.

Those who choose to practice this specialty are well aware of its intangible rewards—the opportunity to help people who are vulnerable and ill, the privilege of walking with their patients on the path of their last months and years of life, providing care that helps optimize function, and the satisfaction of helping them explore their priorities and goals—then guiding them and their families to make informed decisions about medical treatments. Having the luxury of longer visit times helps relieve the tyranny of the packed waiting room. 

But those intangibles don’t resonate with every medical student or resident, and geriatrics will sadly never be as sexy or desirable a specialty as the much more highly compensated surgical specialties like orthopedics and neurosurgery. Indeed, as Provider’s readers know, it takes a special kind of person to choose to work with frail elders, especially in skilled nursing centers.

Need for Expertise Escalates

While not every person over 65 needs the specialized knowledge of a geriatrician, the benefits of such training and knowledge clearly are important for many nursing center residents, who have become much more complex and seriously ill in the past decade—especially in the post-acute population. Geriatricians are focused on function and treat the whole patient, not just one body system or illness.

Geriatricians think first about stopping medications (deprescribing) rather than adding additional drugs to already huge medication lists—since often the symptom that’s bothering the patient is in fact being caused by one of their other meds, or by interactions among meds.

If they are going to prescribe medication, geriatricians adhere to the mantra “start low, go slow.”
Geriatricians help create realistic expectations about prospects of medical and functional improvement in patients and their families, discussing prognosis and goals of care early and often. And they focus on what is important to patients—recognizing that something as simple and preventable as constipation can cause a host of serious problems, including urinary retention, in addition to making patients miserable. They don’t automatically believe that “more is more” when it comes to medical treatments.

These skills and philosophies of geriatric medical care are obviously of great worth to nursing center residents and their families—and they also help the centers provide appropriate levels of care and rehabilitation, while reducing facility liability by educating patients and families on expected outcomes.

Clearly, the ultimate outcome will be death—and a geriatrician can help this outcome, or others that sometimes accompany patients on their expected trajectory (such as pressure ulcers and dehydration), not feel like a surprise or the result of poor care to patients and their families.

Holdover Meds

It is common to see patients being transferred into nursing centers from acute care hospitals, having been started on multiple unnecessary, inappropriate, sometimes overtly harmful medications while hospitalized. Although prescribed with good intentions, these medications often do more harm than good, and they are prescribed by physicians who are presumably just not aware of the risks and contraindications in elders.

In many hospitals, antipsychotics are prescribed for insomnia, benzodiazepines are prescribed for anxiety or agitation, unnecessary and risky proton pump inhibitors are instituted even in the absence of any gastrointestinal symptoms, ill-advised anticholinergic medications are used for overactive bladder, and the antiquated and dangerous “sliding scale” insulin is still routinely used.

Antibiotics may be inappropriately started for “urinary tract infections” that in fact are just a colonized bladder, or asymptomatic bacteriuria. Many of the medication categories listed above are on the Beers List —a list of medications that are generally felt to be inappropriate for use in older patients.

A physician with good geriatrics knowledge will make it a priority to get residents off these medications, which are likely to result in F tags for unnecessary medications if they are continued. A consultant pharmacist may be able to convince an average nursing center attending physician to stop some of these medications, but there may be a delay and actual patient harm, like falls or delirium.

A high-quality, geriatrics-savvy medical director can work with the nursing center’s consultant pharmacist to help educate less sophisticated attending practitioners in the building, both by doing just-in-time interventions on specific residents and by larger-scale efforts such as sending e-mails, faxes, or paper mail to practitioners about efforts to reduce inappropriate medications, or to improve discussion of advance care planning.

Gearing up for Increased Acuity

In these days of Patient-Driven Payment Model and the reality of extreme medical complexity, a geriatrics approach—sometimes taking a longer view and reducing rather than intensifying treatment efforts—should be a priority for every nursing center. Being mindful of both post-acute and long term residents’ goals of care should always guide the treatment plan, including rehab goals and medication management. 

Geriatricians often have overlapping skills with hospice and palliative medicine specialists, another medical specialty that is under-represented but highly valuable to the population. There are increasing numbers of combined geriatrics/palliative fellowships, but the graduates will be nowhere near the number needed to adequately cover nursing center patients in the years to come.

For this reason, engaging medical leaders—physicians, nurse practitioners, and others—who have both the knowledge and the desire to share it with other clinicians should be something that prudent, concerned nursing centers consider strongly. Their patients are not getting any healthier or less complex, and practitioners need to know how to give them the best care possible. 

Karl Steinberg, MD, CMD, HMDC, is vice president of AMDA – The Society for Post-Acute and Long-Term Care Medicine, vice president of National POLST, chief medical officer for Mariner Health Care, and a long-time skilled nursing center and hospice medical director and attending physician from Oceanside, Calif. He is also a certified health care ethics consultant and takes his dogs to work on most days.