EDITORIAL: The Silver Tsunami

I first became interested in geriatrics in the early 1990s, when I took the job of medical director at the Villa Marin retirement community in San Rafael. The facility includes independent living condominiums and common areas on the upper levels, along with an assisted living unit, a skilled nursing facility and a medical office on the lower level.

My practice there was similar to today’s concierge practices: I had a limited panel of patients that I cared for in different settings, including inpatient hospitalization at Marin General Hospital. We had an onsite team of nurses, physical and occupational therapists, and a social worker, along with a visiting geriatric psychiatrist and a podiatrist. In 1994, I passed a CAQ exam that allowed me to “grandfather in” geriatric certification. My income was not solely dependent on Medicare reimbursement, so I was able to spend more time with patients and was enriched by hearing the stories of their accomplishments. I was inspired by their zest for life and their attitudes towards illness and the end of life.

Fast forward 20-plus years. Now I practice at Kaiser Permanente Petaluma, where I care for patients of all ages, including many seniors. Some are lifelong local residents and others have moved to the area in retirement. Some live in their own homes or with family; others in mobile-home parks, senior apartments and retirement centers; still others in assisted-living or skilled-nursing facilities. Many have limited incomes and struggle to find transportation to the office and to afford copayments and prescriptions. A number of them still work into their 80s, some as ranchers, others in retail or light manufacturing, in wineries or in hospitality. Though their circumstances may be different, they all face the same issues of normal aging and of diseases more common in the aged.

The last 20-plus years have brought many changes in geriatric practice. We have made advances in treating heart disease and strokes, diabetes, cancer and arthritis, and there is a bigger focus on prevention: both by encouraging healthy lifestyles and by screening for osteoporosis and urinary incontinence, as well as reducing fall risk through exercise and balance training and avoiding prescription medications that cause dizziness or drowsiness. There has always been a concern about polypharmacy in the elderly, particularly when there are several prescribers not necessarily communicating with one another. It’s a good idea to ask patients to bring in all their medications (or at least a current list), and to review them at each visit to check for duplications or medications that are no longer needed. Though there is a risk in overprescribing--especially drugs with potentially harmful side effects or interactions--there is also danger in underprescibing beneficial medications.

Team-based care and chronic disease management programs have done a great deal to improve outcomes through social support and better adherence to medical regimens. Some programs use electronic devices to monitor patients remotely. There is a growing interest in palliative care to allow patients the option of comfort and dignity near the end of life, in lieu of aggressive treatments. Advance directives are being promoted to encourage patients to consider various treatment alternatives before they are faced with a life-threatening illness.

The demographics and financing of elder care are changing as well. The number of seniors keeps growing, and their average age is increasing, which drives up the cost of care and strains the Medicare budget. Over the years, Medicare has tried several ways to reduce costs, including DRGs, SGRs, and now ACOs, which have physicians and hospitals working together to provide quality, cost-effective care. The patient-centered medical home pilot programs are also showing promise.

Thanks to our tireless advocates in the California Medical Association, Congress is on the verge of fixing the flawed SGR formula for physician payment as well as the GPCI, so payment for fee-for-service Medicare may soon be more equitable. The silver tsunami (aging baby boomers) is fast approaching, and it will usher in a new age of technologic innovations in elder care. We can already email and video-chat with patients, and there are lots of medical smartphone apps. Soon we may have robots helping with activities of daily living and perhaps even driving, and there are new treatments being developed, such as stem-cell therapy for degenerative diseases. It will be interesting to see what the next 20 years will bring!

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Dr. deFischer, a family physician and geriatrician at Kaiser Petaluma, is president of MMS.

Email: irina.defischer@kp.org