Issue No. 14
The Age of ResilienceDate: October 12, 2011
Johns Hopkins geriatricians help seniors stay healthy, vital and fit
A year ago, a newly minted physician in his residency at Johns Hopkins found himself at the bedside of an older patient whose chart included a long list of problems. In addition to heart disease, diabetes and several other serious illnesses, the patient was depressed and hadn’t walked in six months because of weakness and arthritis.
The resident confessed to the attending physician that, given the patient’s advanced age, it seemed like a hopeless case, and that it made little sense to consider adding to the many treatments the patient had already received. In most hospitals, the attending physician might well have agreed. But this physician was Danelle Cayea, M.D., director of education for Johns Hopkins’ Division of Geriatric Medicine and Gerontology, and a strong believer that even older patients who have a range of thorny conditions can sometimes be helped in a big way by the right medical care.
Cayea prompted the intern to look into treating the patient’s depression, add in an intensive regimen of physical therapy, and consider how the patient’s many medications could be streamlined and adjusted. The intern eventually was rewarded by seeing the patient walking around, feeling better and smiling again. “That young physician learned that a patient’s problems shouldn’t simply be chalked up to old age and left untreated,” Cayea says. “There’s a lot we can do for many of them.”
Opening other doctors’ eyes to the possibilities of helping older adults regain and keep their health is just one part of the far-reaching mission of the Division of Geriatric Medicine and Gerontology, under the leadership of Johns Hopkins physician and researcher Samuel Durso, M.D. If the geriatrics division’s goals are ambitious, Durso says, it’s because the challenges are epic.
Aging patients, he notes, often face what seems like a grab bag of extraordinary challenges, including suffering from multiple major diseases and both physical and cognitive impairment. What’s more, he adds, treating them involves coordinating care among multiple practitioners, institutions and family members, trying to sort out the dozen or more potentially interacting drugs that these patients take, and overcoming resistance from patients themselves that symptoms are “part of aging.”
The sheer numbers of older patients who have these sticky problems suggest that the health care system badly needs to place more focus on geriatrics. “Older adults already make up the largest population of chronically ill people and a large proportion of those who are hospitalized,” Durso says, “and those numbers are growing.”
Addressing the Cascade into Frailty
Geriatrics is a field that was in many ways born at Johns Hopkins, and with a full-time faculty of more than 30 people, the geriatrics division is now working to extend the field’s impact and benefits on several fronts. One of these fronts is conducting lab research to identify medical conditions that may be unique to older adults, finding the root causes of these conditions, and coming up with ways to translate these insights into new drugs, better care pathways and other interventions.
Front and center among the research initiatives is a drive to figure out what’s behind the general decline in strength and resiliency that affects older adults over time, a decline often marked by weight loss, trouble walking, weakness and susceptibility to infection and other disorders. It’s a syndrome called frailty, and it remains a sharp mystery why it affects some older people much earlier than others.
“If you look at a group of 80-year-olds, it’s difficult to explain why some still have energy to exercise and baby-sit and go to the store, while others can’t get up off the couch,” Cayea says. “Disease and lifestyle play a role, but it looks as if there may be a specific biological mechanism, and that gives us hope that we can develop ways to head off that decline.”
What Can Be Done Right Now
Although this sort of research is likely to pay off down the road, Johns Hopkins is equally determined to affect the way care is delivered to older adults today. For starters, the faculty is working to help doctors do a better job of treating the older patients they see in the hospital. The biggest single challenge, says Michele Bellantoni, M.D., clinical director of the Division of Geriatric Medicine and Gerontology, is trying to cope with the multiple chronic diseases that afflict many of these patients.
“Managing one of the conditions often impacts another,” Bellantoni says. “That means we need to fine-tune the treatments to prevent making any of the conditions worse.”
She notes, for example, that after she recently placed one diabetes patient on a healthier diet, she also had to reduce the dosage of the woman’s blood-sugar-lowering medication lest the diet leave her with too little blood sugar. Then the patient began having tremors suggesting early Parkinson’s disease, leading to a medication to slow its progress. But that medication affected the patient’s blood pressure, requiring a dosage adjustment to the medication she was taking for that problem. And so it goes for many such patients.
Even a routine follow-up exam after hospitalization needs to be a lot less routine when older adults are involved, Bellantoni notes. She has her exams start in the waiting room, where she says patients may have trouble getting up from their chairs when their names are called. “Difficulty standing is a real predictor of physical frailty,” she notes.
She also schedules at least 30 minutes for any exam—more than twice the usual time allotted to younger patients—knowing that it may take 15 minutes just for the patient to get undressed, and that it may take the patient time to recall key facts about symptoms and medications. But the extra attention brings a huge payoff, she finds. “Compared to patients who don’t get this kind of follow-up care, our patients have half the return rate to the hospital,” she says, “and they’re more satisfied with the results.”
Highly Individualized Care
Part of the trick is to be ready to go beyond the standard rule book when it comes to treating specific disorders, Durso says.
“Having multiple chronic conditions means that no single problem is treated the way you’d treat it for someone who just has that one condition,” he explains. “Every older person’s care has to become highly individualized, based on good judgment and experience.” He adds that taking patients off some of the many drugs they’re on can provide more benefit than adding a new drug, because of side effects and drug interactions.
Cayea notes that doctors frequently have to work harder to explain treatments in the right terms to older patients, or else they may not adhere to them. “They may not care that it lowers their blood pressure,” she says, “but they may care that it will make them feel well enough to make it to church on Sunday or to climb the steps to their home.”
Johns Hopkins is also forging new alliances to raise the quality of care of older adults. It has linked up with psychiatrists and neurologists to create a geropsychiatric specialty for evaluating memory disorders, which often coexist with emotional and neurological disorders in older patients. And a new geriatric orthopedic service helps patients who have hip fractures get into surgery as quickly as possible, which helps reduce medical complications.
A Passion for Preventing Problems
Meanwhile, geriatricians’ strong emphasis on prevention seeks to make changes in patients’ lives before they get to the point where they need aggressive treatment. Eating healthier foods and exercising at any age makes people less likely to succumb to a cascade of problems as they age, Durso notes. For example, patients who don’t walk around much lose leg strength, putting them at greater risk of falls and hip fractures, which further reduces their mobility.
One Johns Hopkins program put a group of older people in elementary school classrooms 15 hours a week to help tutor children. “Preliminary evidence has shown improvement across a range of functions for these people,” Durso says. “And the kids are doing better in school, too.”
Bellantoni notes that Johns Hopkins’ passion for improving older patients’ health doesn’t mean there is no room to acknowledge the inevitability of death. In fact, the faculty takes a strong interest in helping those who have come to the natural end of their lives to do so with dignity and comfort.
“After we’ve done all we can to physically rehabilitate patients and help them live a good life,” she says, “we try to establish the sort of rapport with them and their families that allows us to help them prepare for a good death.” But foremost on the faculty’s minds, she adds, is embodying the hope that medical care can provide to patients whose problems so often prove to be treatable.
“We’re passionate about the care we provide,” Bellantoni says, “and we want to share that passion so that people don’t equate geriatrics with pessimism.”
Hospital Care at Home
Great medical care doesn’t have to be limited to hospitals or doctors’ offices. The Johns Hopkins Division of Geriatric Medicine and Gerontology is looking at several new models of care that meet older patients’ needs with minimum disruption to their environments and lifestyles. Some of the projects involve alternatives to nursing homes, including bringing health care practitioners to patients’ homes for exams, and transporting people several times a week from their homes to elder-care centers that provide social activities and access to health services.
But the most ambitious program seeks to provide patients who require the sort of acute care normally provided in a hospital a chance to receive that care right in their homes. Even serious illnesses such as congestive heart failure and pneumonia are being treated at home, with the care sometimes including sophisticated monitors, intravenous drips and blood tests. Nurses typically come by the patient’s home two times a day, and every few days a doctor stops in—a significant expense, to be sure, but a fraction of the cost of hospital care.
“This is one of the most novel and potentially important innovations in health care delivery,” says Samuel Durso, M.D., director of the geriatrics division. “We’re actually seeing patients come out with better results by skipping the hospital.”
For more information, appointments or consultations, call 877-546-1872.
Free Online Seminar
Tuesday, December 13, 7–8 p.m.
Join Johns Hopkins geriatrician Alicia Arbaje, M.D., as she discusses strategies to avoid common geriatric syndromes and when to seek the opinion of a geriatrician. To register, visit hopkinsmedicine.org/healthseminars.
Watch a video of Johns Hopkins geriatrician Michele Bellantoni, M.D., discussing aging and geriatric medicine at hopkinsmedicine.org/healthseminars.