Geriatrics: The Grim Good Magic of Setting Priorities in Old Age
Economics is about tradeoffs. People want many things and care about many things. Indeed, we want so many things and care about so many things that it is extremely unlikely we will ever get them all. We have to choose.
Professionals in any area become enamored of the particular outcomes they focus on improving. This is as true of medicine as any other professional area. Because death, despite its inevitable, seems like the ultimate defeat to doctors, they face the temptation of pushing people toward prolonging life at the expense of other things people value. This can steer doctors wrong toward the end of patients lives, when patients often value the freedom to do some things they want to do in their remaining time more than a few extra months.
Atul Gawande’s wonderful book Being Mortal is on this theme: people rightly rebel at being told they must always play it safe and always put medical concerns first in their final years. (All the quotations in this post are from that book.)
There are other issues with medical judgment for older patients. Even within strictly medical outcomes, doctors not trained in geriatrics (old-age medicine) often have trouble setting clear priorities. For example, avoiding falls is crucial. Atul Gawande writes:
Each year, about 350,000 Americans fall and break a hip. Of those, 40 percent end up in a nursing home, and 20 percent are never able to walk again. The three primary risk factors for falling are poor balance, taking more than four prescription medications, and muscle weakness. Elderly people without these risk factors have a 12 percent chance of falling in a year. Those with all three risk factors have almost a 100 percent chance.
I think often about the danger of falls in my future; I regularly do balance exercises. (See “Learning to Do Deep Knee Bends Balanced on One Foot.”)
Specialized training in geriatrics helps doctors do a much better job in making the lives of older patients better:
Several years ago, researchers at the University of Minnesota identified 568 men and women over the age of seventy who were living independently but were at high risk of becoming disabled because of chronic health problems, recent illness, or cognitive changes. With their permission, the researchers randomly assigned half of them to see a team of geriatric nurses and doctors—a team dedicated to the art and science of managing old age. The others were asked to see their usual physician, who was notified of their high-risk status. Within eighteen months, 10 percent of the patients in both groups had died. But the patients who had seen a geriatrics team were a quarter less likely to become disabled and half as likely to develop depression. They were 40 percent less likely to require home health services.
These were stunning results. If scientists came up with a device—call it an automatic defrailer—that wouldn’t extend your life but would slash the likelihood you’d end up in a nursing home or miserable with depression, we’d be clamoring for it. We wouldn’t care if doctors had to open up your chest and plug the thing into your heart. We’d have pink-ribbon campaigns to get one for every person over seventy-five. Congress would be holding hearings demanding to know why forty-year-olds couldn’t get them installed. Medical students would be jockeying to become defrailulation specialists, and Wall Street would be bidding up company stock prices.
Instead, it was just geriatrics. The geriatric teams weren’t doing lung biopsies or back surgery or insertion of automatic defrailers. What they did was to simplify medications. They saw that arthritis was controlled. They made sure toenails were trimmed and meals were square. They looked for worrisome signs of isolation and had a social worker check that the patient’s home was safe.
Unfortunately, geriatrics gets low reimbursement, low pay and little respect. The government has mismanaged its price. This puts us in a crisis as the population continues to age. Here is the situation and remaining hope:
I asked Chad Boult, the geriatrics professor, what could be done to ensure that there are enough geriatricians for the surging elderly population. “Nothing,” he said. “It’s too late.” Creating geriatric specialists takes time, and we already have far too few. In a year, fewer than three hundred doctors will complete geriatrics training in the United States, not nearly enough to replace the geriatricians going into retirement, let alone meet the needs of the next decade. Geriatric psychiatrists, nurses, and social workers are equally needed, and in no better supply. The situation in countries outside the United States appears to be little different. In many, it is worse.
Yet Boult believes that we still have time for another strategy: he would direct geriatricians toward training all primary care doctors and nurses in caring for the very old, instead of providing the care themselves.
In dealing with older folks, what doctors with no geriatrics sensibility is to try to fix everything. But every fix has potential side effects. Tradeoffs mean that patient preferences have to be consulted. But, interestingly, experience Atul recounts in Being Mortal by those who are especially good at working through decisions with patients makes it clear it is better to ask people about their preferences in general terms (“What is important to you?”) before talking in detail about the particular decision a patient faces. Indeed, the recommended type of interaction with patients sounds for all the world like what I do (totally non-medical contexts) as a part-time Co-Active Coach. (See “Co-Active Coaching as a Tool for Maximizing Utility—Getting Where You Want in Life” and the other links at the bottom of “Zen Koan Practice with Miles Kimball: 'I Don't Know What All This Is')
Optimizing-subject-to-constraint needs the right objective function, which for most people is much more complex than simply maximizing lifespan. Optimizing-subject-to-constraint also needs a clear recognition and understanding of the constraints. Admitting to ourselves the doom of mortality that hangs over our flesh-and-blood bodies—and the bodily breakdown likely to presage that end—is an important part of seeing the constraints clearly.
For organized links to other posts on diet and health, see: