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Introduction

A Call for Leadership in Aging


Improving Care for Older Adults: Who Will Lead the Way?


Dr. David Reuben, University of California, Los Angeles, addresses participants at the 2009 ADGAP Geriatrics Leadership Scholars Retreat.

Shifting Demographics Create Imperative for Leadership

The United States rests on the brink of an unprecedented surge in the number of older adults, propelled by the aging of the baby boom generation. In 2011, those born in 1946—the first year of the baby boom, which continued until 1965—will turn 65. By 2030, 71 million Americans will be over age 65, double the number in 2005. The impact on the health care system will be huge.

Older adults are the core business of American health care. They have more complex care needs than younger adults, take more medications, utilize more services, and account for a disproportionate share of health care expenditures. The baby boom generation, our country’s emerging older Americans, is unique. They have longer life expectancies than previous generations, and they are more educated, more racially and ethnically diverse, and have more widely dispersed families.

Even as older adults enjoy longer lives, they rarely escape the physical effects of aging. Over 80 percent of adults over age 65 have at least one chronic health condition, such as high blood pressure, arthritis, or heart disease, and two-thirds have two or more chronic conditions.1,2 Chronic conditions are the primary reason older adults seek medical care.3 Although adults over age 65 currently make up only about 12 percent of the U.S. population, they account for over 20 percent of visits to family practice physicians, over 35 percent of all visits to general internists, and over 50 percent of visits to cardiologists and urologists.4 Older adults constitute 50 percent of hospital occupancy and they use 34 percent of all prescriptions. They also account for 70 percent of home health services and 90 percent of nursing home use.

In addition to coping with chronic health problems, some older adults experience conditions that affect their ability to care for themselves. Conditions such as osteoporosis, susceptibility to falls, hearing and vision impairments, depression, incontinence, and delirium may necessitate assistance with daily activities. While most older people are able to live independently, almost all eventually need at least some specialized care due to illness or difficulty caring for themselves.

“Leaders are visionaries with a poorly developed sense of fear and no concept of the odds against them.”
Robert Jarvik, MD,
inventor of the first permanent artificial heart

nursingJoyce Chan, MS, RN, Hartford Building Academic Geriatric Nursing Capacity Scholar with patient at Laguna Honda Hospital, San Francisco, CA

Health Care Workforce Lacking in Geriatrics Training

Unless fundamental changes take place in the coming years, the demand for greater health care services will fall upon an inadequately trained health care workforce. Even though most nurses, social workers, and physicians spend a large percentage of their professional lives working with older adults, few health professionals obtain the specialized skills and particular knowledge needed to care for the complex needs of older adults.

Nurses are the health professionals with the most frequent contact with patients, and they play a critical hands-on role in caring for sick and frail older adults. In hospitalized older patients, high quality nursing care can prevent functional decline, reduce disability, and keep people out of nursing homes. Yet, within the context of the general nursing shortage, there exists an even greater shortage of nurses with geriatric skills. Less than 1 percent of registered nurses are certified in geriatrics. Only about 2.6 percent of advanced practice nurses (such as nurse practitioners and clinical nurse specialists) are certified in geriatrics.

Geriatric social workers also play a vital role in maximizing the independence of older adults. Among health professionals, they are unique in their ability to assess the social, psychological, environmental, and economic situation of patients. With their extensive knowledge of systems of care, community services, and other available resources, geriatric social workers are in a position to coordinate care effectively and cost efficiently. Today, less than 4 percent of social workers specialize in geriatrics, which represents just one-third the number needed, as projected by the National Institute on Aging.

Geriatricians—medical doctors with advanced training in treating older patients—also are in short supply. The Alliance for Aging Research predicted that by 2030, the United States will need about 36,000 geriatricians. Currently, only about 7,100 physicians are certified in geriatric medicine and 1,600 are certified in geriatric psychiatry. The mismatch between supply and demand is unlikely to be remedied soon, if at all. Issues of compensation and prestige play a role in limiting interest in geriatrics. Geriatricians, who must do a residency in internal or family medicine and a fellowship in geriatrics, generally earn less than general internists in primary care and far less than those who become subspecialists in internal medicine.

Since too few health professionals choose to specialize in geriatrics, its core principles must be taught in all specialties. Yet the subject of geriatrics often is not well-represented in the curricula of many schools of nursing, social work, and medicine. According to the Institute of Medicine, only one-third of baccalaureate nursing programs require a course in geriatrics, and only 29 percent of baccalaureate programs have a faculty member who is certified in geriatrics. Eighty percent of social work students in undergraduate programs have no coursework in aging. While most medical schools require some exposure to geriatrics, much of this is “inadequate.”5 The Association of American Medical Colleges accredits 130 medical schools in the United States, but only 9 have departments of geriatrics.

In summary, too few nurses, social workers, and physicians specialize in geriatrics and the disciplines of geriatrics and gerontology lack prestige and visibility. Reversing these trends requires inspired leadership. Health professionals in key leadership positions must promote geriatrics within their institution, recruit quality students to specialize in geriatrics, infuse geriatric content throughout the curriculum, conduct research to develop and disseminate innovative models of care for older adults, and have a seat at the table of public health policy.

1. MedPAC (Medicare Payment Advisory Commission). Report to the Congress: Increasing the Value of Medicare. Washington, DC: MedPAC. 2006.
2. Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Archives of Internal Medicine. 2002. Vo. 162, Number 20, pp. 2269-2276.
3. Hing E, Cherry DK, Woodwell BA. National ambulatory medical care survey: 2004 summary. Advance data from vital and health statistics; no 374. Hyattsville, MD; National Center for Health Statistics. 2006.
4. Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey. National Center for Health Statistics. 2005.
5. Institute of Medicine. Retooling for an Aging America: Building the Health Care Workforce. Washington DC; The National Academies Press. 2008.

Next: Leaders in the Field of Aging Respond