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The medical profession has been troubled for years by a persistent shortage of doctors who treat the oldest and sickest patients.

By Paula Span/The New York Times

Jan. 3, 2020

Linda Poskanzer was having a tough time in her late 60s. “I was not doing well emotionally,” she recalled. “Physically, I didn’t have any stamina. I was sleeping a lot. I wasn’t getting to work.”

A therapist in Hackensack, N.J., Ms. Poskanzer was severely overweight and grew short of breath after walking even short distances. Her house had become disorganized, buried in unsorted paperwork. The antidepressant she was taking didn’t seem to help.

Her son, visiting from Florida, called his sisters and said, “Mommy needs an intervention.” One of her daughters made an appointment with a geriatrician — a physician who specializes in the care of older adults. Dr. Manisha Parulekar, now chief of geriatrics at Hackensack University Medical Center, suggested her new patient take action on several fronts. She arranged for a sleep study, which found that Ms. Poskanzer suffered from apnea. She prescribed a different antidepressant, and physical therapy in a pool to help rebuild her stamina.

And weight loss. Eventually, the geriatrician agreed that bariatric surgery made sense. Over nine months, Ms. Poskanzer lost 75 pounds; she has shed another 15 since.

Now about to turn 80, Ms. Poskanzer is still providing therapy, 30 hours each week, feels “full of spirit” and continues to see her geriatrician every four months. “She sits and talks, which a lot of doctors don’t do anymore,” Ms. Poskanzer said. “And she knows me. I feel very well taken care of.”

Testimonials like this spotlight the rising need for geriatricians. These doctors not only monitor and coordinate treatment for the many ailments, disabilities and medications their patients contend with, but also help them determine what’s most important for their well-being and quality of life.

Patients like Ms. Poskanzer often can’t easily find geriatricians like Dr. Parulekar, however. As the nation’s older population surges, the gap between need and supply has steadily widened, and a persistent shortage of geriatricians has troubled the medical profession for years.

Geriatrics became a board-certified medical specialty only in 1988. An analysis published in 2018 showed that over 16 years, through academic year 2017-18, the number of graduate fellowship programs that train geriatricians, underwritten by Medicare, increased to 210 from 182. That represents virtually no growth when adjusted for the rising United States population. “It’s basically stagnation,” said Aldis Petriceks, the study’s lead author, now a medical student at Harvard.

Moreover, geriatrics fails to attract enough young doctors to the graduate fellowships it does offer. Leaving aside geriatric psychiatry, more than a third of 384 slots went unfilled last year, the American Geriatrics Society reports.

If one geriatrician can care for 700 patients with complicated medical needs, as a federal model estimates, then the nation will need 33,200 such doctors in 2025. It has about 7,000, only half of them practicing full time. (They’re sometimes confused with gerontologists, who study aging, and may work with older adults, but are not health care providers.)

Why do so few residents choose to specialize in geriatrics? Though salaries are rising, total compensation (wages plus certain benefits) for geriatricians in 2018 averaged $233,564, according to the Medical Group Management Association. Anesthesiologists earned twice as much; radiologists and cardiologists topped $500,000.

“These are smart people looking at economic reality,” said Dr. Mark Supiano, a geriatrician and researcher at VA Salt Lake City Health Care System. Treating patients covered by Medicare, which pays less than commercial insurance, is a slow way to repay medical school loans.

Nor does the field offer much glamour or the prospect of medical heroics. “Having patience, having good communication skills, it’s a different personality than being a surgeon,” Dr. Supiano acknowledged. Yet a much-cited 2009 survey of 42 medical specialties found that geriatricians reported higher career satisfaction than most.

Not every older person needs a geriatrician, but the federal model estimates that 30 percent of the over-65 population does. This is especially true “when someone has three or more chronic conditions and is over 85,” said Nancy Lundebjerg, chief executive of the American Geriatrics Society. Nevertheless, given the numbers, “we’re not going to address this growing older population through some miraculous influx of specialized geriatricians,” Mr. Petriceks said.

Leaders in geriatrics agree, and while they continue working to bolster their numbers, they’re also adopting other strategies. Dr. Mary Tinetti, chief of geriatrics at the Yale School of Medicine, has called for geriatricians to serve as “a small, elite work force” who help train whole institutions in the specifics of care for older adults.

“The most important thing geriatricians can do is make sure all their other colleagues” understand these patients’ needs, she said, including nurse-practitioners, physician assistants, therapists and pharmacists. To some extent, this is already happening. Medical associations representing cardiologists and oncologists have begun focusing on older patients, Ms. Lundebjerg pointed out.

Health systems are adopting age-friendly approaches, like specialized emergency rooms. The American College of Surgeons’ new verification program sets standards hospitals should meet to improve results for older patients.

Last month the Senate Committee on Health, Education, Labor and Pensions voted to reauthorize a $41 million program that educates health professionals in geriatrics; it awaits a floor vote. A companion bill has already passed the House of Representatives. “It’s money very well spent,” Dr. Tinetti said.

Health professionals increasingly recognize that if they’re not in pediatrics, they will be seeing lots of seniors, whatever their specialty. A 2016 American Medical Association survey, for example, found that close to 40 percent of patients treated by internists and general surgeons were Medicare beneficiaries.

“Our medical students are living and breathing this,” said Dr. Supiano, who also teaches at the University of Utah School of Medicine. He warns them, “If you don’t like taking care of older people, find another career.”

A heart attack is one of the scariest moments in life, and it can be hard to know what to do in the midst of a panic. While ideally, we would like these traumatic events to happen while we’re surrounded by help and support, but we all know that heart attacks aren’t exactly something you can schedule. While it might be daunting or unsettling to think about, it’s incredibly important to be prepared and have a plan in place, particularly if you live alone. Here are some of our most crucial pieces of advice for the moments following a heart attack. They may seem insignificant now, but they could just save your life.

Call for Emergency Services

If you suspect that you’re having a cardiac event, the first and most important thing to do is call 911 immediately. When you’re alone, it is also recommended to yell for help (if you have neighbors) while you wait for the paramedics to arrive. Ideally, this will help reduce the amount of time you spend alone, which greatly increases your chances of survival. There are Medical Alert devices for those who may not be able to get to the phone quickly enough, and these can come in the form of necklaces, bracelets, mobile devices, and more.  

Chew an Aspirin

If you are someone who is able to take aspirin, take one immediately if you feel yourself having what you suspect is a heart attack. Chewing the aspirin is better than simply swallowing it as usual. Chewing breaks it down a bit before it hits your stomach. This allows the medication to get into your system more quickly and provide a more effective relief during this emergency.

Unlock Your Door

Since we established that you’ve already called for emergency assistance, they need to be able to reach you. This is something you may not be thinking about in the chaos of an emergency, but it’s extremely important. If you’re locked inside your home, that can greatly affect the time it takes for your medical team to get to you and provide the help you need. Make it as quick and easy as you can to receive assistance.

Lay Down Near the Door and Wait

As established in previous points, the best thing you can do to help yourself when having a heart attack alone is to get help as quickly as possible. While it’s usually a good idea to lay down during a cardiac event, you’ll want to avoid laying down somewhere difficult to find, like a second floor or a bedroom. Paramedics will have to waste precious time looking throughout the house if you’re not waiting in an obvious location, and this is especially dangerous if you can’t verbalize your location. Lay down near your door so that they can immediately find you and get you to the hospital. Try to wait patiently for help and don’t exert yourself too much. Physical activity can cause a heart attack to progress more quickly due to blood pumping more quickly.

How to Know if You’re Having a Heart Attack

It can be difficult to differentiate a heart attack from chest pain. While severe chest pain is indeed one of the main symptoms of a heart attack, there are other signs as well. Look for pain in the left arm, upper neck or jaw, as well as profuse sweating. Any combination of these symptoms is cause for immediate medical assistance.

If you’re concerned about the possibility of a heart attack or other cardiovascular issues, Greg Says highly recommends that you visit a cardiologist. Your primary care physician can refer you to one who will keep your PCP in the loop regarding any diagnosis and treatment.

By Kate Kelland / HEALTH NEWS / September 3, 2019

LONDON (Reuters) – Cancer has overtaken heart disease as the leading cause of death in wealthy countries and could become the world’s biggest killer within just a few decades if current trends persist, researchers said on Tuesday.

Publishing the findings of two large studies in The Lancet medical journal, the scientists said they showed evidence of a new global “epidemiologic transition” between different types of chronic disease.

While cardiovascular disease remains, for now, the leading cause of mortality worldwide among middle-aged adults, accounting for 40% of all deaths, that’s no longer the case in high-income countries, where cancer now kills twice as many people as heart disease, the findings showed.

“Our report found cancer to be the second most common cause of death globally in 2017, accounting for 26% of all deaths. But as (heart disease) rates continue to fall, cancer could likely become the leading cause of death worldwide, within just a few decades,” said Gilles Dagenais, a professor at Quebec’s Laval University in Canada who co-led the work.

Of an estimated 55 million deaths in the world in 2017, the researchers said, around 17.7 million were due to cardiovascular disease – a group of conditions that includes heart failure, angina, heart attack and stroke.

Around 70% of all cardiovascular cases and deaths are due to modifiable risks such as high blood pressure, high cholesterol, diet, smoking and other lifestyle factors.

In high-income countries, common treatment with cholesterol-lowering statins and blood-pressure medicines have helped bring rates of heart disease down dramatically in the past few decades.

Dagenais’ team said their findings suggest that the higher rates of heart-disease deaths in low-income countries may be mainly due to a lower quality of healthcare.

The research found first hospitalization rates and heart disease medication use were both substantially lower in poorer and middle-income countries than in wealthy ones.

The research was part of the Prospective Urban and Rural Epidemiologic (PURE) study, published in The Lancet and presented at the ESC Congress in Paris.

Countries analyzed included Argentina, Bangladesh, Brazil, Canada, Chile, China, Colombia, India, Iran, Malaysia, Pakistan, Palestine, Philippines, Poland, Saudi Arabia, South Africa, Sweden, Tanzania, Turkey, United Arab Emirates and Zimbabwe.

As Greg Says wants to help protect clients from the risk of financial hardship associated with serious illness, we recommend consideration of Critical Illness insurance coverage.  The tax-free lump sum cash benefit paid directly to the policy owner upon diagnosis of a critical illness such as cancer, heart attack, and stroke removes financial and emotional stress which can improve treatment outcomes. And such coverage is one of the least expensive forms of health insurance available.

By Sharon Jayson – Kaiser Health News

Oct. 21, 2019

AUSTIN, Texas — Dennis and Chris Cavner, in their early 70s, are preparing to move less than two blocks away into a 2,720-square-foot, ranch-style house they bought this year. But first a renovation is underway, taking the 45-year-old property all the way back to its studs. When the work is finished, these baby boomers are confident the move will land them in their forever home.

“We wanted to find a house that we could live in literally for the rest of our lives,” Dennis Cavner said. “We were looking specifically for a one-story house and one that had a flat lot, to age in place.”

For most of American history, people have moved in with relatives or gone to a care facility to live out their final years. Baby boomers don’t want either, and those with resources have generally created the modern idea of remaking old age to fit their lifestyle and retrofitting their homes for aging in place. Design and construction firms are coming up with safety features that look good as well. Think of it as the age-defying home.

Aging in place is a major financial commitment, one that may be at odds with retirees’ plans to downsize their lives and budgets and squirrel away cash in anticipation of rising health care costs. The Cavners are rebuilding this house — assessed at $700,000 around the time of the sale — from a shell. The remodel could easily cost $300,000 in the hot Austin market.

Leaving nothing to chance, the Cavners are paying for a number of modifications they might never need. For instance, neither uses a wheelchair, but contractors are making all doorways 3 feet wide — just in case. The master bath roll-in shower, flat and rimless, will provide room to maneuver. In the kitchen, drawers, rather than cabinets, will allow easy access in a wheelchair.

The Cavners are closely watching details of the renovation, but this dramatic late-life relocation wasn’t a hard decision.

For some seniors, aging in place might amount to simple modifications, such as adding shower grab bars or replacing a standard toilet with one that sits taller. But many seniors anticipate a financial crunch as they try to plan for their future on a fixed income, uncertain how far their savings and retirement funds will stretch.

Yet many houses aren’t suited to “aging in place,” said Abbe Will, associate project director of the Remodeling Futures Program at Harvard.

“Currently, a lot do not have single-floor living — especially in certain parts of the country. There are lots of stairs and multistory homes when land is more valuable,” she said. And “many homeowners don’t necessarily have the funds to do aging in place.”

Home modifications and costs vary widely — starting with those simple safety features in the bathroom or lever doorknobs throughout the house — to more extensive changes, such as widening doorways or lowering light switches to wheelchair height. Will said simple retrofits, such as grab bars, “could be several hundred dollars,” but a “whole bathroom remodel would be in the thousands or tens of thousands.”

In a recent survey of 1,000 people age 65 and older by the California-based nonprofit SCAN (formerly the Senior Care Action Network), 80% of respondents were concerned about their ability to age in place. The driver appears to be financial: About 60% said they have less than $10,000 in savings (including investments and retirement plans).

“We don’t know what’s coming down the pipeline as we age,” said sociologist Deborah Thorne of the University of Idaho, lead author of a study that found skyrocketing bankruptcy rates among those 65 and older.

The research, recently published in the journal Sociological Inquiry, finds the share of older Americans filing for bankruptcy has never been higher. “And bankrupt households are more likely than ever to be headed by a senior — the percent of older bankrupt filers has increased almost 500 percent since 1991,” the study found.

The Harvard report also cited the burden of debt among those ages 65 to 79, with nearly half of those homeowners carrying a mortgage in 2016. And people are carrying substantially more student loan and credit card debt into retirement as well.

James Gaines, an economist with the Real Estate Center at Texas A&M University, attributes the increase “to the labor market and employment downsizing and letting older people go first. It can force them into retirement whether they’re ready for it or not. Retirement income may not be enough to carry their debts, and they don’t have enough savings.” 

“The leading edge of baby boomers has not hit 75 yet,” said Jennifer Molinsky, lead author of the Harvard report. “When you think about the next five, 10 or 15 years when they’re in their 80s, you’re really going to see the needs shift.”

Molinsky said just what financially challenged seniors should do about housing “is a good question and is a tough question.” Many states have loan and grant programs for home modifications if individuals have a documented disability, she said, yet “what we need more of are programs that help you do this before you need it.”

Molinsky said communities need to create housing near city centers so seniors don’t have to drive. And in the suburbs, communities need to offer more multifamily options, including condos and apartments to buy and rent.

“We just need options,” she said. “It’s important to think about housing options that help people stay in that community. Low-income people need housing that’s affordable. Some people want to trade that single-family home for a condo. Others want to reassess their money and sell their home for a rental. Not everybody wants the same thing.”

Don and Lynn Dille, both 75, built their Austin home with the intention of staying there for a long time. After living in California, Virginia and elsewhere in Texas, they moved to Austin in 2012 and, within a year, began drawing plans with an architect for an energy-efficient home to age in place. Their home was featured this summer in Austin’s annual Cool House Tour for its design making the most of natural light, cross-ventilation and solar panels, as well as wider-than-normal doorways and level floors for wheelchair use.

One key feature of the construction acknowledges that they might need live-in help down the road to avoid long-term nursing care. Just as the Cavners may convert a bedroom and bath on the opposite side of their new home into caregiver quarters, the Dilles constructed a second floor above their detached garage that could convert into living space.

“We think having a separate apartment where we could have a caretaker or part-time help to maintain our property makes us able to stay where we’d like to be and be independent,” said Don Dille, who retired from the federal government.

The renovations are meant to meet very personal needs, but that doesn’t mean they wouldn’t appeal to others and even add to the resale value down the road.

For his part, Cavner, an investment adviser and co-founder of a new health care startup, said he believes what they’re spending to renovate the house for the years ahead will prove a sound investment: “The modifications we’re making are not going to make it less desirable. It will feel more spacious.”

By Sabrina Tavernise and Abby Goodnough

The New York Times

Jan. 30, 2020

WASHINGTON — Life expectancy increased for the first time in four years in 2018, the federal government said, raising hopes that a benchmark of the nation’s health may finally be stabilizing after a rare and troubling decline that was driven by a surge in drug overdoses.

Life expectancy is the most basic measure of the health of a society, and declines in developed countries are extremely unusual. But the United States experienced one from 2015 to 2017 as the opioid epidemic took its toll, worrying demographers who had not seen an outright decline since 1993, during the AIDS epidemic.  An uptick in what have become known as “deaths of despair” (younger people dying from overdoses, suicide and alcoholism) has drawn considerable attention from politicians and policymakers.

The 2018 data, released in a recent report, confirmed the first decline in drug deaths in 28 years, an important improvement after decades of rises.  The increase in life expectancy it helped produce was small, just over a month, and demographers cautioned that it was too early to tell if the country had turned the corner with opioid overdoses, which have claimed nearly 500,000 lives since the late 1990s.

“It’s good news, but we don’t know yet if it’s the beginning of a new trend,” said Elizabeth Arias, a demographer at the National Center for Health Statistics, which released the report.  Still, the rise was welcome news in states like Ohio, which in 2018 had the biggest decline in overdose deaths in the country.

The last time life expectancy in the United States flat-lined for several years was in the 1960s, when the mass habit of smoking, particularly among men, began showing up in the mortality statistics, said Dr. Samuel Preston, a demographer at the University of Pennsylvania. But from 1968 to 2010, life expectancy went up by an average of about two years a decade, he said, a substantially slower rate than in European countries, but twice as fast as the increase in 2018.  Life expectancy at birth rose to 78.7 years in 2018 from 78.6 the previous year. It peaked at 78.9 in 2014, but has fallen or been flat since then.

Dr. Preston pointed out that the small rise in 2018 merely put the country back where it was in 2010, amounting to nearly a decade of stagnation, rare for a wealthy country.  Improvements in cancer mortality rates represented the single largest share of the life expectancy gain in 2018, about 30 percent. Next came the decline in so-called unintentional injuries, which include deaths from car accidents and drug overdoses. That category accounted for about 25 percent of the gain, a change that was driven almost entirely by a decline in drug deaths, Dr. Arias said.

Recent widespread efforts to expand access to opioid addiction medications, clean needles and naloxone — the drug used to revive people overdosing on opioids — may be having an impact.  “Good things are happening that hadn’t before, like sheriffs, hospitals and others who now use naloxone telling me, ‘We saved a life,’” said Shane Hudson, president and chief executive of CKF Addiction Treatment in Salina, Kan. His clinic is treating 117 people with medication for opioid addiction, up from 35 two years ago.

Deaths from overdoses dropped by 4.1 percent in 2018, to 67,367 from 70,237 in 2017. The decrease was largely driven by a dip in deaths from prescription opioid painkillers, which set off the opioid epidemic in the late 1990s before heroin and, later, fentanyl moved in. Provisional data suggests those deaths continued to fall in 2019, likely in part because of restrictions on prescribing.

But the death rate from fentanyl rose by 10 percent in 2018, and early data suggests it kept rising last year, though not as sharply as before. There were more overdose deaths in 2018 than in any year on record except 2017, and nearly 70 percent involved opioids.

A separate federal report, also released Thursday, found that the rate of drug overdose deaths dropped in 14 states in 2018, climbed in five and stayed about the same in the rest. The five states whose rates climbed were California, Delaware, Missouri, New Jersey and South Carolina. Ohio saw the biggest drop, to 3,980 overdose deaths in 2018 from 5,111 in 2017.

Another bright spot in the data was cancer mortality. The overall cancer death rate dropped by 2.2 percent in 2018, a substantial decline. Rebecca Siegel, the scientific director of surveillance research at the American Cancer Society in Atlanta, said the new data appeared to extend gains from 2017, when the overall cancer mortality rate drop was the largest since record-keeping began around 1930.

These improvements were driven largely by a decline in the mortality rate for lung cancer, the leading cause of cancer death. Continued drops in the country’s smoking rate and advances in treatment, such as more precise tumor classification, better surgical techniques, and improved drug therapies, contributed to the progress, Ms. Siegel said.

Despite this good news, the United States lags far behind most European countries in life expectancy. John Haaga, a demographer who retired from the National Institute on Aging in December, said that when he first started his job in 2004, life expectancy in the United States was about equal to that of Portugal, a much poorer country. Over his career, Portugal gained four years while the United States gained only one. He pointed out that life expectancy was longer in Costa Rica, Cuba and Slovenia.

The increase in life expectancy might have been greater if not for rising mortality due to influenza and pneumonia — the death rate grew by 4.2 percent — as well as suicide and nutritional deficiencies. But while there has been increased concern about suicide as a public health crisis, the growth in reported cases — to 48,344 in 2018 from 47,173 in 2017 — was relatively small. The suicide rate grew by 1.4 percent overall, with a larger rise for men than women.

Jill Harkavy-Friedman, a vice president at the American Foundation for Suicide Prevention, said the nation needed to invest far more in research to understand emerging patterns. “I’ve been a researcher in this area for 30 years and I can tell you the conversation and the funding has definitely changed,” she said, “but it’s still nowhere near the level of funding for any other public health problem of this scope.”

A federal report last fall found that the suicide rate among adolescents was at its highest level in 20 years, although the total number of teenagers who died by suicide in 2017 was fewer than 2,500. Jane Pearson, chairwoman of the Suicide Research Consortium at the National Institute of Mental Health, said there was no definitive explanation as of yet for the climbing suicide rate.