Crisis of age requires cure

By Lauren Foster

When Mark Lachs, an internist who specialises in the care of the elderly, looks into the not-so-distant future, he sees millions of retirees and not enough doctors. The baby boomers are moving through the belly of the beast and are coming out 65, he says. The numbers are just overwhelming; about 7,000 geriatricians for millions of older people.

Every day an estimated 6,000 Americans turn 65. Four years from now, that figure will swell to 10,000 people a day so that by 2030, one in five Americans will be 65 or older. At the same time, geriatrics programmes across the US are shrinking, the number of certified geriatricians is falling relative to the population, physicians are disenrolling from Medicare, and fewer medical students are choosing careers in geriatrics.

We are in a significant crisis it is no longer looming, says Lachs, a professor of medicine and a chief of the division of geriatrics and gerontology at Weill Medical College of Cornell University. The manpower deficit extends from the physician level to the frontline workers and everywhere in between.

The consequences are dire; unless systemic changes are made, the silver tsunami of retiring baby boomers will cripple the country’s health systems. Consider this: there are 7,128 board certified geriatricians in the US, or one geriatrician for every 2,546 Americans 75 or older, according to the American Geriatrics Society. By 2030, that ratio is expected to drop to one geriatrician for every 4,254 older Americans.

Usually, when public and private resources fail to address a societal problem, philanthropy is the answer. Yet ageing, for the most part, is ignored by foundations and donors. Why think about old people when there are glamorous causes with star-studded fundraisers and celebrity spokespeople? (Think malaria or the plight of refugees in the developing world.)

Ageism is alive and well in our society, says Corinne Rieder, executive director and treasurer of The John A. Hartford Foundation, the largest private foundation in the US focused exclusively on ageing and health. We really live in a youth culture. This is also true for medical education.

This age-defying quest is fuelled by best-selling books with titles such as How Not to Look Old and a society that celebrates the virtues of Botox parties and plastic surgery. For many, thinking about old age means confronting uncomfortable topics such as dementia and Alzheimer’s disease. But as Atul Gawande put it in an article last year in The New Yorker, people naturally prefer to avoid the subject of their decrepitude.

Some believe this aversion affects funding decisions. Older people and ageing are not seen as sexy topics and oftentimes the people on [foundation] boards are ageing and this can be painful to think about. They are in denial themselves, says Brian Hofland, head of the international ageing programme at The Atlantic Philanthropies, the world’s largest private funder of ageing issues.

Yet ageing is a universal issue. Gara LaMarche, Atlantic’s president and chief executive, says any foundation that does not take this into account in its strategies is not seeing the whole picture.

Ageing is not a niche funding area or a special interest group. The number of funders with a primary focus on ageing, like our close friends at The John A. Hartford Foundation, will always be finite, though it too needs to grow, he told the 2007 annual meeting of Grantmakers in Aging (GIA), a national membership association. But the number of foundations which ought to be concerned with ageing is almost infinite, for no funder ought to get away, in this day and, well, age, with saying ‘we don’t do ageing’.

A small group of US foundations has embraced funding programmes to prepare for the dramatic ageing of the population.

Through their grants, foundations are tackling issues that range from researching and treating elder abuse to changing how society views older people and helping more doctors, nurses, psychiatrists, social workers and other health professionals receive the necessary training.

For The Donald W. Reynolds Foundation, a private philanthropy that funds journalism, ageing care, and cardiovascular research, the way to improve the quality of healthcare for elderly people across the US is to strengthen all physicians’ geriatrics training. To help achieve this goal, it provides geriatric training grants of up to $2m each to medical schools.

We are not in the business of training people to become geriatricians. We are in business of training all physicians, no matter what field they enter, to better care for frail older people, so it includes both faculty and practising physicians, says Rani Snyder, a senior programme officer for Reynolds.

This skills shortage was highlighted in a 2002 report Medical Never-Never Land: Ten Reasons Why America is Not Ready for the Coming Age Boom by the Alliance for Aging Research, a non-profit advocacy group in Washington, DC. It warned the US would fall far short of the 36,000 geriatricians needed by 2030 unless effective steps were taken to train new providers.

Six years on, the outlook remains bleak. For academic year 2006-07, 468 first-year fellowships in geriatric medicine were available, and only 253, or 54 per cent, were filled, according to the American Geriatrics Society. For the same year, there were 136 geriatric psychiatry fellowship first-year training slots, and half went unfilled.

The population numbers clearly point to older patients dominating the healthcare delivery in the US and most of the developed world but we have been rather phobic about geriatrics, geriatric medicine and ageing, says Daniel Perry, executive director of the Alliance for Aging Research.

An ageing population is a triumph of medical science, but longevity has downsides that extend far beyond wrinkles. Having enough geriatricians and geropsychiatrists as well as primary-care doctors trained in caring for the elderly is one way to ensure that older people have access to a better quality of life.

This is because caring for older adults is not simply a matter of treating older versions of middle-aged patients. Many common diseases of adulthood, such as depression, have different characteristics in the elderly than in younger people. And the elderly tend to have multiple problems: the average 75-year-old has three chronic medical conditions and regularly uses about seven prescription drugs, as well as over-the-counter remedies.

The internal medicine is really complicated and really interesting. Rarely is it just heart failure. It could be heart failure plus diabetes, plus depressive disorder, plus cataracts, says Lachs, who is also director of geriatrics for the NewYork-Presbyterian Healthcare System.

He spends much time encouraging doctors to become geriatricians. But it is difficult; the pay is a lot lower than most other medical specialisations and the field lacks prestige. Geriatric medicine remains an under-subscribed field for people coming out of medical school, he says. Yet if you do anything other than paediatrics you will be seeing mostly older people.

The Hartford Foundation is working to change this. One of its initiatives centres of excellence in geriatric medicine and training was designed to address the shortage of geriatric faculty members in US medical schools. The centres are a network of 26 medical schools at which about 70 per cent of the future professors of geriatric medicine receive training. Hartford also funds similar initiatives in nursing and social work.

Funding geriatric medicine is just one area where philanthropy can make a big difference. To achieve wider impact, however, ageing needs to move from an orphan to a mainstream issue. More big funders also need to emerge as Atlantic and Reynolds are limited-life foundations, spending themselves out of business.

To help raise awareness, GIA, in partnership with Atlantic, has launched EngAGEment, a two-year pilot programme to introduce new community, family and private foundations, as well as corporate grantmakers and wealthy individuals, to philanthropy focused on the many issues facing the elderly.

Carol Farquhar, GIA’s executive director, says ageing is coming into its own and the organisation’s membership has swelled from fewer than 60 foundations eight years ago to 115 today. Still, this is minuscule considering there are about 70,000 private foundations in the US.

It is important to note that there is a seat for everyone at the table, Farquhar says. There are more needs and issues than funding resources. Ageing can be meals on wheels; an elaborate research project; or taking a national model and bringing it to the community for less than the cost of the original grant. There are many opportunities for partnering and collaboration. Ageing is very broad you can pick your issue and really make an impact.”