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EW YORK — Checking in at the front desk of the geriatric clinic, I suddenly felt I had made a ghastly mistake.

At 68, I was the only one in the waiting room not accompanied by a caregiver — and one of the few not using a walker or a wheelchair.

“What was I thinking?’’ I asked myself.  Looking around, I saw my own feeble future spread out before me, a tableau of what the next 20 years would bring. The exhaustive intake form that I’d filled out at home — it asked (among other things) what I ate in a typical day, whether I needed help bathing, and whether I’d had my bone density tested — suddenly seemed more ominous than reassuring.

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But I couldn’t just leave. A spate of new health problems, requiring a gaggle of doctors with no connection to one another, had persuaded me to find the right person to quarterback my care, now and in the years to come.

Plus, I had experienced nagging memory issues since a concussion last year. I wanted an Alzheimer’s test. The idea terrified me. But I had to know.

Rationally, I knew this geriatric clinic at Mt. Sinai Hospital was the place to do all that. So I swallowed hard and sat down.

That intake form had taken hours to fill out; in one section, I had to review a catalog of 88 symptoms and say whether I’d had any of them in the past three months. (Among those I checked: weight change, blurry vision, excessive thirst, and fatigue.)

My appointment was just as thorough as the form.

At recent appointments with my internist, she began looking at her watch after 10 minutes and abruptly dismissed me after 15, the average length of a doctor’s visit these days. By contrast, my geriatrician, Dr. Christine Chang, spent two hours with me, most of it talking.

The sense that Dr. Chang had all the time in the world was a first for me. So, too, was the participation of a nurse practitioner and a social worker, both part of her team. They asked questions I had never been asked before, but surely should have been: Was I sexually active? Did I have any mental health issues? Had I always been so skinny?

The contrast in approach and attitude highlights much of what is wrong with the American health care system. It also explains the dire shortage of geriatricians, who typically serve patients in their 80s and beyond, providing primary care and coordinating among necessary specialists.

There are only about 7,000 geriatricians practicing in the US, and their numbers are dwindling even as the need increases, with 20 percent of the population projected to be elderly in 2030.

Sad to say, in America’s fee-for-service system, it’s procedures and prescriptions that are reimbursed, not discussion that may lead to a decision to do nothing. Thus, the better geriatricians do their jobs, the less they are paid, a problem compounded by the low rate of reimbursement from Medicare. The median compensation for geriatricians is $200,000 a year, the lowest of all medical specialties, although their reported job satisfaction is among the highest.

While I’m sure Dr. Chang would treat me aggressively when appropriate, her default approach was less-is-more — simple remedies before complicated ones and the less medication the better.

When I reported slight hearing loss, Dr. Chang suggested a week of drops to soften ear wax before considering a hearing aid that costs thousands of dollars and is not covered by Medicare. Knowing I had recently taken a terrible fall on my head, and still had dizzy spells, she tested my balance by having me walk heel-to-toe, first with my eyes open and then with eyes closed. Tai chi would help, Dr. Chang said, and the clinic offered free weekly classes (along with meditation and yoga) to patients, their caregivers, and clinic staff.

Dr. Chang actually “did’’ only three things aside from routine measurements: administered a pneumonia vaccine; checked my vitamin D levels, protective against broken bones; and conducted a mini-mental state examination, a short cognitive test that helps diagnose Alzheimer’s disease in its early stages.

Luckily, she had taken my blood pressure before the test because anxiety about the results must have sent it soaring.

Who among us, past a certain age, doesn’t lose our glasses or walk from one room to next only to forget what we’re doing there? That’s normal aging, the experts say, but it always sets my heart pounding.

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Now I would find out if those worries were justified.

I wasn’t sure I actually wanted to know.

Identifying drawings of a lion, a rhinoceros, and a camel was easy. Drawing a clock with its hands set at 11:10 went fine (after a slight pause to remember whether 11 is to the right or the left of 12).

Counting backward from 100 in intervals of seven (100, 93, 86, etc.) was daunting but doable. Listing as many farm animals as possible in 20 seconds was a snap; so was hearing words and then spelling them backwards.

The killer part was the recall test. I was given a list of half a dozen words at the start of the test. About 20 minutes later, after the animals and the numbers and whatnot had distracted me, I was asked to recite them. I remembered four (although damned if I know what they are now, more than a week later) but went blank on the other two.

Dr. Chang offered cues: “A kind of building?” Castle! “A flower?” Tulip!

The fact that I could respond to cues was reassuring, she said. It meant the words were stored in the file drawer of memory. If I’d had Alzheimer’s disease, they would already be lost.

Was I relieved? Of course. But it took a while before I stopped trembling, before the bath of cold sweat subsided.

I stopped twice on the six-block walk home, sitting on a bench and trying to calm down. I told myself over and over that everything was OK.

And that if the time ever came when it wasn’t, I’d be in good hands.

Jane Gross is a journalist in New York City.

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  • I felt as if I was in the Doctor’s office with you. I am the same age as you and a very fixed income. You spoke to the fears of so many.

  • Thanks for this story. Being a geriatrician, I read this with great interest. I am of course a fan of my specialty but one of many problems is that most people who would like to see a geriatrician cannot find one available.

    Virtually all geriatrics practices are subsidized by some other mechanism, such as academic centers, philanthropy, or a special funding mechanism such as Program of All-Inclusive Care of the Elderly (PACE) which has a waiver to combine Medicare and Medicaid funding and is often restricted to older adults who would be eligible for nursing home care.

    There is no easy answer to this problem but I think part of the solution is to encourage people to pursue geriatrics care even when geriatricians are not available to directly provide the care. Geriatrics is the art and science of modifying healthcare so that it works better for older adults and their families. It’s a knowledge base. It can and must be applied by people who are not board-certified in geriatrics.

    Older adults and families can help encourage this by learning the geriatric approach to common problems and asking their usual providers for some of this care. This is basically a variant on people becoming savvier about their healthcare and learning to ask for what’s good for them.

    You can’t assume a non-geriatrician will remember to avoid prescribing medications that are known to be risky for older adults. You CAN learn that there is a list of such medications (the Beer’s criteria, and it is publicly available at healthinaging.org) and you CAN ask your doctor or your older parent’s doctor if any of the prescribed medications are on the list. Or you can ask about alternatives.

    To support the health and wellbeing of an aging society, everybody who helps care for older adults needs to learn at least a little geriatrics. That includes patients and families.

    Obviously this isn’t ideal, but given the shortage of geriatricians and the current health quality problems that plague the system, this approach has to be part of the solution.

    Journalists might be able to help by encouraging the public to be proactive and learn about geriatrics. To date, I find that most stories conflate geriatrics with geriatricians: the message is that to get healthcare that is suitably modified for older adults, you have to see a geriatrician in person. But that will be impossible for the vast majority of older adults, so it would be nice to point people towards a plan B.

    To improve access to geriatrics care, there are other approaches to take re policy and medical education as well, and it would be great for the public to learn about those and advocate for them. But in the short term, I encourage older adults and families to try to learn more about the best known ways to manage health in late-life. There are good resources at HealthinAging.org, curated by geriatricians, and I write a fair bit for the public as well. There are also good books written by geriatricians.
    LK
    ps: FWIW the office-based cognitive test you describe is the Montreal Cognitive Assessment (MOCA), not the Mini-Mental Status exam. The MOCA is considered a better test by many. You can ask a non-geriatrician to do it but best to ask ahead of time and plan to devote an entire visit to it, as it takes 15-20 min, esp if an older person is impaired.

    • Leslie, This is so helpful. I know how lucky I was to find a geriatrician with room in her practice, but many people have written saying they been unable to do this. For all of them, you correctly note that many non-geriatricians incorporate the concepts of geriatrics in their approach. My thanks. —Jane

  • The geriatrician who treated my mother after she entered the memory-care unit of the”Eden alternative” Westminster Thurber community in Columbus, Ohio, made a world of difference to her quality of life–first, by getting rid of the medications she no longer needed, and secondly, by discussing treatment options at length with the family–letting us know when invasive procedures weren’t warranted. As you say, for most docs, ” procedures and prescriptions are reimbursed, not discussion that may lead to a decision to do nothing.” I’m trying to find a geriatrician in time for my upcoming Medicare birthday, but there are none where I live–I’m more than happy to swallow my pride and go to one, believe me. BTW, your book The Bittersweet Season is one of the most useful I found in navigating care for my elderly parents–thanks for writing it.

    • how very kind of you re my book. to have helped anyone is a privilege. geriatricians are hard to find and i’m blessed to be in NYC where there are many academic medical centers. that’s the place to start.

  • Well, I just tried to make an appointment with a Geriatrician in my city — and she’s not accepting new patients! LOLOLOL Oh well. I’ll keep looking. I’m sure I’ll find one. A good one. I hope. 🙂

  • I understand, Jane. I really do. And thanks for giving me the nudge to make an appointment with a geriatrician in my city (which has too-few MDs — period). Just a word: I have had numerous MDs say that if we walk into a room and can’t remember why we walked into the room — we are just fine. However, if we walk into a room and don’t recognize the room, we’re in trouble. I sometimes think that’s too simplistic — I would think that, by the time we walk into a room in our home and don’t recognize it, we have more than just the beginnings of dementia. But it makes me feel better anyway. And lastly, life is so short and so precious — please don’t live with the fear of getting some kind of dementia.

    • of course. my later mother used to say the same re keys. that losing them all the time was no big deal; the only big deal was if you didn’t know what a key was. whenever i walk into a room and can’t remember why, i have the same thought that has become sort of a private existential joke: what am i doing here???? hmmmmm.

  • Thanks, I am going to be 75 in June and my Mom was lost to a vascular dementia for 4 years before she died last year. Your book and this new article are so helpful and true…I worry that my varied aches (osteoarthritis), heel pain???, names that come and go..are related to some genetic issue. I go to a doctor whose patients are older..read over 65, he usually goes to the wait and do little route. Now as I review my specialists that is another story.

  • Hello, I am a little concerned because the four symptoms you checked off on the form are classic symptoms of Type 1 diabetes. I suppose it would be very unusual to develop that in your sixties, but you don’t memtion how your geriatrician responded to this information. I would have wanted to know more.

    • Thanks for concern but I’m not a diabetic. Some symptoms result of current meds (thirst), some lingering effect of concussion (dizziness) and some just who I am (skinny).

  • Such a test should be routine and free for all to reduce the cost of hospitalisation, medication and care later in life. You’d think government and all authorities would see the sense of this.

    • Our’s is not a “sensible” medical system in any sense of the world. And if I were in charge, I’d see to it that Medicare paid for hearing, vision and dental care, which most elderly people will need if they don’t already. The Mini Mental exam is a nice add on, and this was a geriatrician after all. The others should be routinely paid for regardless of what kind of doctor.

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