“Older adults have physiological changes that cause them to be a completely separate population from adults,” says Bakerjian, who also points out that 65 is a somewhat arbitrary age: It does not reflect the fact that such changes occur earlier or later in some individuals.
“It’s hard to describe unless you actually do it, but older adults are the most heterogeneous group,” Kemle says. “If you’ve seen one 85-year-old, you’ve seen one 85-year-old.”
Clinicians who care for older adults need to know everything from the normal process of aging to how diseases present differently at advanced ages. They need to understand the geriatric syndromes, which include dementia, incontinence, and falls.
“It’s also about understanding the health care world of aging,” Resnick adds. “Medicare and Medicaid, the dually eligible, nursing home care, assisted living care—all of those are really quite different than [in] the acute care setting or a primary care practice.”
And clinicians who care for older adults must be prepared to address multiple conditions and think outside the box. For example, if a 55-year-old presents to the emergency department with chest pain, a heart attack is a logical diagnosis.
For a 75-year-old with chest pain, however, “Maybe they had a heart attack, but maybe the chest pain is because they have pneumonia, and maybe they have pneumonia because they fell and were on the floor for an hour,” Segal-Gidan says. “It’s much more complicated, and that’s what scares people away from wanting to care for older people.”
Clinicians also need to recognize the burdens that caring for the elderly places on informal caregivers. “We need to be aware that oftentimes the middle-aged and ‘young’ old people that we’re seeing are suffering from illnesses because of the increased stress of their caregiving role,” Kemle points out. “I think sometimes people forget that it’s not just the patient—it’s the entire family and those interwoven relationships.”
Roles for NPs, PAs in Team
There are indications that PAs and NPs could make a big difference in geriatrics. Significantly, team care is considered essential for older adults and is associated with better outcomes, such as lower rates of hospital readmissions, shorter lengths of stay in hospitals, better quality of life, and higher function. “A single provider really can’t do everything older patients need,” Kemle says.
NPs and PAs already play an important role in geriatric health care. About one-third of visits to PAs are made by older adults, and 78% of PAs report treating at least some patients older than 85. Among NPs, 23% of office visits and 47% of hospital outpatient visits are made by people 65 and older.
The IOM report indicates that “health care providers of all levels of education and training will need to assume additional responsibilities—or relinquish some responsibilities that they already have—to help ensure that all members of the health care workforce are used at their highest level of competence.”
“We have so few geriatricians that we need to preserve them for the most highly complex care,” Bakerjian says. She envisions a system in which NPs provide routine primary care in nursing homes or private offices, while the geriatrician acts as a consultant—not just to the NP but also to physicians in other specialties.
“Physician time and knowledge shouldn’t be spent on managing chronic medical problems that NPs can do,” Resnick adds. “That time should go to diagnosing and managing more complicated illnesses—diagnoses that an NP may not know anything about. That’s the beauty of the team, and it’s the only way we’re going to have sufficient resources.”
Among PAs, there are mixed reviews as to how fully their role in geriatric care is being recognized. “NPs have advanced themselves as part of the solution,” Segal-Gidan observes. “PAs aren’t seen so readily as pieces of those teams. The PA profession, in my opinion, has not stepped forward and taken on a leadership role that it could—and I think should—in this area.”
Kemle, however, has had positive experiences in her role as the American Academy of Physician Assistants Liaison to the AGS. “The physician community is very anxious to embrace us, and I’m not sure you would find that in every specialty,” she says. Among the AGS’s working group on workforce issues, “there has been a lot of discussion about ‘Now, this is not physician-only. We need to be inclusive of everyone and work together to develop interdisciplinary curricula.’”
Collaborating in a team is one of the things Bakerjian finds most rewarding in her work. “We work closely with the physical therapist, the dietitian, the psychologist or psychiatrist, the pharmacist, the physicians, the nursing staff, the activities director [in a nursing home],” she says. “It’s a very interdisciplinary or multidisciplinary environment to which all of those people contribute.”