ARTICLE IN BRIEF
Geriatric neurologists discuss the unique challenges of caring for an elderly population, and the changes at multiple levels that will be needed in order to optimize care.
The United States Census Bureau estimates that by 2050, there will be nearly 84 million Americans aged 65 and over, including nearly 18 million over age 85. The number of Americans living with Alzheimer's disease alone is projected to be nearly 14 million by then, according to the Alzheimer's Association.
For geriatric neurologists, the statistics cut to the core of a looming crisis: How will this specialty — already stretched by the demands of an increasing volume of patients and a system of medical reimbursement that does not account for the many hours it can take to care for a single geriatric patient — prepare for the future?
In interviews with Neurology Today, leaders in the specialty discussed the unique challenges to caring for an elderly population, and the changes at multiple levels — financial, structural, and educational — that will be needed in order to optimize care.
“All neurologic diseases — not just those typically associated with older age, like dementia and stroke — increase in prevalence as people get older,” Gregory A. Jicha, MD, PhD, chair of the AAN Section on Geriatric Neurology, a professor of neurology, and the McCowan endowed chair in Alzheimer Research at the Sanders-Brown Center on Aging at the University of Kentucky in Lexington, told Neurology Today. And geriatric patients may have more than one such condition, he noted.
“That complexity taxes neurologists and other geriatric medical professionals to treat them in the time allotted,” he said. “If we were dealing with a young, very healthy person who suffered from, say, migraine headaches, we might have exactly the same amount of time to perform that physician encounter as we would with a geriatric patient who had a stroke and is now developing an Alzheimer-type dementia, [who also has] a peripheral neuropathy and an associated seizure disorder.”
These patients, by virtue of the complex nature of their medical needs, require a multidisciplinary team that includes nurse practitioners, physician's assistants, and social workers, among others, Dr. Jicha said. Neurologists may also need to coordinate with a patient's primary care physician, who may not be well trained in issues pertaining to neurologic conditions in elderly patients — or who may be too pressed for time themselves to address potential neurologic problems on top of all the other ailments a geriatric patient might face.
“It's not at all uncommon that I have someone come into office with a diagnosis of dementia who has never undergone a workup to figure out why they have memory problems,” Dr. Jicha said. “I find several subdural hematomas that are completely fixable every year, [as well as] normal pressure hydrocephalus, hypothyroidism, B12 deficiency.” These common, potentially reversible medical problems may masquerade as dementia to a primary care physician, he said.
A geriatric patient's other ailments — diabetes, say, or hypertension — may further complicate their neurologic presentation, said Ronald C. Petersen, MD, PhD, a professor of neurology at the Mayo Clinic in Rochester, MN, and director of the Mayo Clinic Alzheimer's Disease Research Center. “For example, if I'm seeing somebody with cognitive difficulties, I have to keep their medical problems in mind. Might the medical problems, like diabetes or hypertension, impact cognitive function in and of themselves? A person's neurologic disorder might be compounded by their medical problems, and vice versa.”
Reimbursement is a sore spot for many, if not all, neurologists, but it may be felt even more keenly in geriatric neurology. Most geriatric patients are covered by Medicare or Medicaid, and reimbursement prioritizes procedures over long, thoughtful conversations with patients about diagnosis and prognosis or counseling families and caregivers about their loved ones' care.
Although Medicare did announce a new policy to reimburse clinicians for counseling patients and their caregivers, relatives, and surrogates on preferences for end-of-life-care — effective January 1, 2016 — geriatric neurologists say that addressing the complex health needs of an elderly population requires more time than is allotted under current policies. [For more on the Medicare policy on advance care planning, see the Neurology Today article, “Medicare Plans to Reimburse Physicians for Advance Care Counseling: Neurologists Weigh in on Next Steps,” http://bit.ly/Medicare-advancedcare. For more on chronic care management coding and other reimbursement changes, see the AAN analysis of the Physician Fee Schedule for 2016: http://bit.ly/pfs-2016-aan.]
“The current system is not set up to reimburse physicians for taking time to talk to patients, which is what a lot of neurology is about, and geriatric neurology even more so,” said Joy Snider, MD, PhD, a professor of neurology at the Washington University School of Medicine in St. Louis and vice-chair of the Geriatric Neurology Section. “I'm in an academic practice; we're supported by an institution. But we lose money seeing patients, which is not a viable business model in the real world.”
Deniz Erten-Lyons, MD, an associate professor of neurology and director of the Clinical Care and Therapeutics Program in the Layton Aging and Alzheimer's Disease Center at Oregon Health and Science University in Portland, agreed. “We do a lot of counseling with our patients and their caregivers, which is a lot of time we spend with them without reimbursement, essentially,” she said. “Just relying on our clinical practice, I don't think any of us could actually make a living, unfortunately.” Her institution supports the costs of the clinic through its research programs, she said.
The result is that “many of us spend a lot of our time in research rather than patient care, and people in practice are forced to spend their time doing procedures,” said Norman L. Foster, MD, FAAN, a professor of neurology, director of the Center for Alzheimer's Care, Imaging and Research, and chief of the Division of Cognitive Neurology at the University of Utah in Salt Lake City.
These issues are compounded by the fact that neurologists-in-training aren't flocking to the field — or even being exposed to it during their medical education. There are several reasons for this, the experts said. For one, few fellowships around the country offer subspecialty training in geriatric neurology. In fact, there are only three such fellowships currently active in the US, Dr. Jicha said.
For another, geriatric neurology is not recognized for certification by the Accreditation Council for General Medical Education, said Dr. Snider. The United Council of Neurological Subspecialties (UCNS) offered certification for specific geriatric neurology fellowships for a time, but the program was discontinued due to lack of interest. Currently, there are only 18 geriatric neurologists in the US with UCNS certification. “The Geriatric Neurology Section is trying very hard to find a way to continue that certification,” Dr. Snider said.
Within the medical establishment, “many neurology training programs don't have geriatric neurology rotations,” Dr. Foster added. “This is doubly damaging. If residents are not exposed to geriatric neurology, then they never consider it as a career, and we as academics don't have the opportunity to use residents to accomplish our clinical care. Residents assist in the success of a clinical program, and when clinical programs in geriatric neurology are starved of any residents, that puts us at a disadvantage.”
The dearth of trained geriatric neurologists is linked to the issue of reimbursement, said Dr. Jicha. “Students and residents coming out of training in the United States are left with tremendous debt. This moves many younger doctors into fields that may be more lucrative.”
Ultimately, Dr. Erten-Lyons said, the way to attract young neurologists to the field is “to improve the support for the entire spectrum of needs for this population, both research and clinical care.”
THE WAY FORWARD
How can the field overcome these challenges? The answer likely rests in a reimbursement structure that accounts for the way geriatricians and geriatric neurologists provide care, combined with robust education initiatives, the experts said.
They emphasized that these education initiatives must exist on several fronts: within neurology training, by ensuring that medical residents are exposed to geriatric patients; in medical education more broadly; and at the public level, by educating patients and caregivers about the kind of care that geriatric patients need and deserve.
“Some people think it is normal that as you get old, you get dementia, you sit in a wheelchair, and you have no interaction with the world,” said Dr. Snider. “We know now that healthy aging, including healthy brain aging, is possible, and even though we cannot cure a lot of the disorders that affect older adults, we can improve their quality of life. That's important for folks to know.”
In terms of medical education, one way to better educate physicians, regardless of subspecialty, might be to initiate a continuing medical education (CME) requirement for geriatric medicine, Dr. Jicha said. “We have to look as a nation at what the major health care issues are, and we have to make sure that our health care system is trained to address those issues.” As the Baby Boomers age, Dr. Jicha anticipates that they will spearhead grassroots initiatives to lobby state licensing boards to require CME for geriatric care.
Dr. Snider agreed that education must reach beyond residents already interested in geriatric neurology. “There will probably never be enough geriatric neurologists to care for all these folks, so we need to continue to reach out and educate general neurologists, as well as primary care doctors,” she said. “I think we are going to have to depend more on mid-level providers — nurse practitioners and physician's assistants — as well, and getting better training for them is important. We've got to have everybody on board to make this work, because the demographics [of our aging population] are really scary if you start looking at them.”
It's a challenging time for geriatric neurology, to be sure. But Dr. Jicha also sounded a positive note for the field.
“I believe the day will come when we are treating Alzheimer's the same way that we might treat breast or colon cancer, with diagnostic tests and medications in the very early or even asymptomatic stages of the disease,” he said. “We are just starting to tap into our ability to address the complexities of cognitive decline in the elderly. What an exciting time to potentially be part of the discovery of a cure for Alzheimer's and other diseases that plague the geriatric population.”