The average young or middle-age person probably finds a hospital stay stressful, uncomfortable, and inconvenient. The experience can be strikingly more disruptive for a geriatric patient.
A frail elderly person can easily succumb to delirium, a fall, dehydration, polypharmacy, and deterioration in basic life skills, quickly turning even a routine hospitalization into a catastrophic downhill slide. But if a patient is lucky, she will be treated by a geriatric hospitalist—a physician who by training and temperament is uniquely suited to care for her.
Geriatric hospitalists bring heightened sensitivity and experience to treating and preventing the common syndromes that can overwhelm the elderly during hospitalizations. Fredrick Sherman, MD, FACP, medical director of Senior Health Partners and professor of geriatrics at the Mount Sinai School of Medicine in Manhattan, has been a geriatrician since the 1980s. He sees a great opportunity for hospitalist geriatricians to improve the metrics by which hospitalist programs are judged: reduced length of stay, bounceback, and morbidity. They do this, he says, with a unique blend of skills, mindset, and temperament.
“In one or two minutes at the bedside, a geriatric hospitalist can do a basic functional assessment of an elderly patient,” he says. “We can understand their ADL [activities of daily living] skills, mental status, and what resources we have to mobilize during the hospital stay and for a safe discharge plan. We don’t want to turn hospitalists into social workers, but geriatricians can teach them a body of knowledge to help them better understand and develop a holistic approach to elderly patients.”
How geriatricians work best, though, can be somewhat out of synch with hospital medicine’s fast pace. “Many hospitalists are younger and have been trained very recently,” Dr. Sherman says. “They quickly learn to take care of a 55-year-old with a [myocardial infarction], but they sometimes lack a global view of geriatric patients that is more a frame of mind than about the physician’s technical skills.”
As hospital medicine groups integrate geriatricians into their ranks, they will have recruited major players invested in improving the care of hospitalized elderly patients. There’s a lot at stake in caring for them.
The Healthcare Cost and Utilization Project’s (HCUP) most recent figures of what hospitalizations of the elderly cost is staggering. Medicare patients account for 76% of public spending on hospital care. The costliest diagnoses for Medicare-paid hospitalizations are coronary arteriosclerosis ($44 billion), acute myocardial infarction ($31 billion), and heart failure ($29 billion). Further, 90% of elderly patients with osteoarthritis are hospitalized for elective hip or knee joint replacement therapy.
The expertise of board-certified hospitalist geriatricians will be hard to disseminate throughout the corps of hospitalists. Only a tiny fraction of the nation’s hospitalist programs claim special expertise in geriatrics. Researchers from the University of Colorado Health Sciences Center and the Mayo Clinic College of Medicine conducted a cross-sectional survey of the hospitalist community in 2003-2004 to determine the impact of the hospitalist movement on acute care geriatrics. They found: