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After recovering from life-threatening illnesses, Dorothy B. Sting is able to work in the garden at her daughter’s home near the Rappahannock River in Lancaster. Lucy Hottie photo
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Bob Wendell and his wife, Bess, who has Alzheimer’s disease, attend a church service together at The Towers. Chris Smith photo
Dr. Peter Boling paints a bleak picture of health care for the elderly. A lack of communication between specialists, too few geriatricians to serve the growing number of aging patients and inadequate tracking of prescribed medicine add up to a dangerous situation, says VCU Medical Center's director of geriatrics.
"I have seen people die as a result," Boling says. "I have seen people institutionalized unnecessarily."
In addition, mental health care for older patients is often overlooked, says Dr. Danny Felty of Chippenham Family Medicine, part of HCA Virginia.
Without a strong advocate to push for answers and seek additional opinions, Dorothy B. Sting might not be alive. And Bob Wendell would be getting all of his nourishment through a feeding tube rather than enjoying some of his favorite foods.
Sting, a 97-year-old retired school principal, lives with her daughter and son-in-law, Lucy and Warren Hottle, who have a home on West Avenue in the Fan and a second residence just off the Rappahannock River in Lancaster. A former Michigan resident, she moved to Richmond five years ago when her health deteriorated after a surgery for spinal stenosis, the narrowing of her spinal column.
"Up [until] that surgery, she was driving herself places, living alone and taking care of her very large garden," Lucy Hottle says, adding that the garden was such a horticultural treasure that it was the topic of an article in the local paper.
Hottle took her mother to Fort Myers, Fla., where Sting owned a small trailer, to recuperate after the surgery, but she became ill with what they later learned was a staph infection and was hospitalized.
"It might have gone south right then and there," Hottle says. "If we had not advocated for trying the different doctors at VCU, my husband and I think that she would have died."
Sting's health was deteriorating, and her doctors in Florida couldn't seem to identify the cause. After about a month, she took her mother to VCU Medical Center, where she was cared for by a team, including Boling. The VCU medical team diagnosed Sting's staph infection, which had progressed to the point that it was eating away at her spine. By the time the infection was gone, her height had dropped by 2 inches, Hottle says; her mother is now 4-foot-10.
"She says she is a tough old bird," Hottle says with a laugh. "But it left her immune system very weak."
As a result, Sting moved in with her daughter permanently as she battled pneumonia and C. diff (Clostridium difficile), a condition in which toxins attack the lining of the intestine after the body's good bacteria is destroyed, often in conjunction with the use of antibiotics, as well as a severe case of shingles (a painful skin rash), Hottle says.
Today, Sting has recovered, but she remains frail. She reads avidly and continues to work with plants, though using a walker.
Navigating her mother's health care "was a learning curve," Hottle says. "As the increase in elderly continues, we are going to have to assume our responsibilities because the system cannot handle it. Everybody has to have an advocate."
A Second Opinion
The need for an advocate is becoming more critical, geriatric-care experts say.
Every day, 10,000 Americans reach age 65 and become eligible for Medicare and Social Security, says Dr. Dick Lindsay, former head of geriatrics at the University of Virginia Medical Center. That means that by 2050, more than 78 million people older than 65 will be in the nation's health care system.
Elderly patients often have multiple illnesses, requiring them to see a variety of specialists. Lindsay says that 80 percent of Medicare patients suffer from more than four chronic conditions. Boling adds that most of his patients have between five and 10 health problems and are on as many as 20 medications when he first sees them.
But there is no system in place to ensure communication between various physicians and coordination of prescriptions, the doctors say.
Felty has made outreach to area geriatric patients the focus of his private practice at Chippenham Family Medicine. He says fragmented communication is particularly dangerous at times of transition. These patients "are transitioning regularly from their homes to the emergency rooms, to recovery rooms and to assisted living," Felty says.
To complicate matters, the three major health systems in greater Richmond (HCA, VCU and Bon Secours) work independently of each other, creating a silo effect, Boling says.
"The system, as it is, is only OK if you are mobile and have a family member to advocate for you," he says.
Bob Wendell fits into that category. Wendell, who just turned 92, lives in The Towers assisted-living community near Chippenham Hospital. "I drive myself to all my appointments," he says, chuckling. He even drove himself to a hospital for testing in October 2010, when he noticed strange bleeding around his thumbnail.
Wendell has suffered five mini strokes, which resulted in nerve damage to the muscles involved in swallowing, making it easy to aspirate food or liquid into his lungs. Because he also has congestive heart failure and was taking blood thinners, he knew that the bleeding around his nail meant something was wrong. After blood testing, Wendell was diagnosed with cancer in his stomach and colon.
"I ended up with half a stomach and half a colon," Wendell says, a result of the surgery to remove the cancer.
Wendell's swallowing condition was exacerbated by the surgery, and after some testing, he was told that he would never swallow food again. He had a second major surgery in November to insert a feeding tube into his stomach for liquid nutrition.
"They had told me locally that I had half my food going into my stomach when I swallowed," he says. "My son questioned that and arranged for me to go to Johns Hopkins."
In April, Wendell had a series of swallowing tests done at Johns Hopkins Hospital in Baltimore. The tests were life-changing for him.
"I love Italian spaghetti, and that day I was really craving it," Wendell says with a broad smile. "And after those tests, the doctor put his hand on my shoulder and he said, ‘You can go have your spaghetti.' "
Wendell says that his hospitalization and the months that followed, when he temporarily lost the ability to eat by mouth, were difficult for him. "I went through a period of saying, ‘Take me, God,' because I did not see that when I got out, that I would be of any value." Wendell says he could not imagine a life in which he could not interact with people during meals.
As president of The Towers' residents association, he talks daily with other residents, who reinforce his understanding of the need for an advocate. "The person that is sick may not have a clear understanding of the total picture," he says.
Not Enough Manpower
Geriatricians, who specialize in caring for the elderly, are trained to see the overall picture. But they are in short supply.
In the Richmond region, there are about 20 geriatricians, Boling says. But in a metropolitan area with more than 1 million residents, there should be close to 100 specialists in this field, he notes.
"You could have the best health-care system in the world, but unless you have adequate people to deliver the care, the system is no good," Lindsay says.
According to recent estimates, there are a little more than 7,000 certified geriatricians nationwide, out of more than 660,000 physicians and surgeons.
Although geriatricians find their work rewarding, the field doesn't appeal to medical students because of the relatively low compensation compared with other specialties, Lindsay says. He explains that geriatric doctors are reimbursed based on the procedures they do, not the time spent with patients. "You are not going to be reimbursed to call a family and discuss [someone's] problems with wandering at night."
One way to attract students to the field would be to increase the amount of time spent in medical school on geriatrics, Lindsay says. He cites a University of Cincinnati study that states that in a three-year family-practice residency, only 20 days must be spent on geriatrics.
An innovative model used by Mt. Sinai Medical Center in New York, he says, is to assign a medical student to work with a healthy older person.
"[Students] never see older people who are well and still playing tennis. You see people who are completely dysfunctional and die," Lindsay says. "You work with them while they are well. When they are sick, you are part of the team that takes care of them. ... That kind of experience begins early and you stand a chance to recruit people."
But just increasing the number of geriatricians may not be enough.
Boling suggests another solution: "gerontologizing" as many physicians as possible. That means all doctors in fields that touch geriatric health care would receive training to treat older patients. Among others, those include physical therapy, urology, pharmacology and optometry.
Locally, there are two major training initiatives, Boling says. The Virginia Geriatric Training Center is a five-year statewide program that focuses on training a core group of educators. The second project, funded by the Donald W. Reynolds Foundation, trains students in various health-related fields to work in interdisciplinary teams. For example, students in pharmacy, nursing, physical therapy, social work and medicine programs could cooperate on geriatric case studies. The project is also going to expand to a Web-based training system.
The interdisciplinary team model has great potential to address fragmentation in care for the elderly, Boling says. "The really complex patients need someone dedicated to their case who is essentially going to direct all of their care and bring together specialists in the health system and the silos and keep cohesion to the plan."
Lindsay agrees. He describes a system in which a geriatric team would work together from the time a patient enters the hospital. When the patient's condition improves, the team would propose a discharge date and pass along to the person's family doctor or primary-care physician what his new prescriptions are, he says.
"There would be a nurse practitioner or a member of the team calling to check and talk to the wife or patient ... to make sure that the medications prescribed were received by the patient and are used correctly," he says.
Boling says that following up is imperative. VCU tracks elderly patients through the entire system, he says, from hospitalization to rehabilitation and back home if necessary, with VCU's House Calls program, which has been in place since 1984.
Asking the Right Questions
Improved communication is also needed about medication, says Dr. Patricia Slattum, associate professor of geriatric pharmacotherapy at VCU.
"No one is the keeper of the list," she says, adding that when there are several pharmacies involved as well as a number of physicians and specialists, what patients should be taking becomes a little murky.
Slattum says elderly patients often misunderstand what medicine to take or how much to take. Other issues include patients not taking their prescriptions because they cannot afford them or because they choose not to, or because they find it less expensive to take their spouse's medications. Patients also self-medicate at times, which creates dangerous health situations.
"To really help patients, it means really taking time [to talk], and sometimes it takes more than once," she says, to find out, for example, what is keeping a patient from taking proper medications.
And rather than putting responsibility on the elderly patient to remember his or her medical records, she would like to see a system based on "credit card" charting, where a patient carries a card with all of his or her medical information. Lacking that, Slattum encourages patients to keep an accurate list of what they are taking at what time of day. She also suggests that they bring a friend or family member to appointments to help them keep medications straight.
In the area of mental health, Felty says that physicians need to be better trained in how to ask questions while meeting with patients to help them see if they are struggling.
"The mental health system is treating two generations simultaneously," he says. "You are talking about people who have lived in their homes for 40 or 50 years and are going to assisted living or a nursing home and perhaps their spouse has [died]. And then you are talking about the caregiving population ... who are caring for their adult or older kids and they are caring for their parents and a lot of them are working full time. So their mental health really becomes strained."
Another issue is that elderly patients are unlikely to bring up mental health or general health problems, Felty says, so their caregivers need to speak up for them. "You are talking about the World War II population, and those are some tough folks."
Grateful to Be Alive
Wendell reminisces tenderly about the days when Bess, his wife of more than 30 years, began to show signs of Alzheimer's disease — such as turning the wrong way when driving home and forgetting how to play Solitaire, her favorite card game. He was aware of the symptoms only because of a friend who had been diagnosed, so he knew what to look for. And, he says, he did not want to be the one to tell Bess.
"If I had told Bess that she had Alzheimer's, I think she would have been devastated," he says. "I asked the doctor to examine her for that and she accepted [what he said]." Bess now lives at The Towers but in a different room down the hall from her husband where she receives constant care; she is unable to communicate except by a sudden smile or chuckle, he says.
For his part, Wendell began to find purpose again, after regaining his ability to eat soft foods (he still gets two pints of water per day through his J-tube). He is an active part of The Towers community, where he has lived since 2003, helping to improve the residents' quality of life by suggesting changes to the staff.
"There is tremendous value in living for a purpose," he says.
Sometimes that means adapting to new circumstances. About two years ago, Wendell had to give up playing the standing bass after 17 years in the Richmond Philharmonic. Instead, he taught himself the harmonica, and six pieces he composed have already been recorded.
"Scripture says to rejoice in all things, and I think I would do that," Wendell says. "I am very thankful. I count my blessings daily."