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Ask a Doc: Caring for Older Adults

In our Ask a Doc series, we sit down with physicians and other clinical experts across Highmark’s health plan networks, including at Allegheny Health Network (AHN), for a chat on an important health topic. In this post, AHN’s Dr. Lyn Weinberg discusses her work with older adults.

We’re getting older in the U.S. The nation’s median age rose from 28 in 1975 to 37.9 in 2016, and the number of people 65 or older grew from 35 million in 2000 to 49.2 million in 2016.

As our population continues to age, it’s vital that health care systems adapt to meet the needs of older patients. To start, Dr. Lyn Weinberg of Allegheny Health Network (AHN) stresses that preconceived notions of what aging looks like must be discarded.

“Older adults are heterogeneous,” she says. “I see 85-year-olds who are in great shape and working or volunteering in their spare time. I also see 85-year-olds who are in hospice. One treatment might work well for one patient, but not for the other. It’s so important to treat each patient personally and individualize their care.”

Dr. Weinberg was recently named the new Division Director for Geriatrics at AHN. In her position, she’ll work to operationalize and standardize geriatric care across the network while also continuing to practice.

During our conversation at the cafeteria of West Penn Hospital, Dr. Weinberg discussed her work with AHN, how she approaches geriatric care, and her vision for geriatric care delivery.

The Next Generation of Care

Nikki Buccina (NB): Being a younger doctor, what’s it like to provide cross-generational care?

Dr. Lyn Weinberg

Dr. Lyn Weinberg, Division Director for Geriatrics at Allegheny Health Network

Dr. Lyn Weinberg (LW): I get a lot of comments about how young I look, but it’s in good faith. There’s a special bond between younger and older generations. I had my first baby at the beginning of last year and I could see that it definitely brightened my patients’ days to share that with me. I had patients bring me gifts, knit things for me — it made that connection even closer.

NB: Are health care providers who specialize in geriatric care in high demand?

LW: I would say geriatricians are in high demand, but there may never be enough geriatricians to meet that demand. In my role, I like to focus on educating clinical trainees and other primary care doctors on quality geriatric care, because it’s going to be delivered by almost all health care providers.

I believe that as a geriatrician, it’s also my responsibility to be an educator. I want to help all health care providers better understand care delivery for older adults and the nuances within that — it’s why I’m so passionate about incorporating geriatrics education into residency training. We have a very robust geriatric curriculum for our resident trainees here at AHN and I’ve gone through a formal fellowship as part of my training.

NB: Can you talk more about what a fellowship in geriatric medicine entails?

LW: A fellowship in geriatric medicine is a year of training beyond internal medicine. It focuses on issues that affect older adults, and the curriculum that falls outside of typical medical training, dipping more into the psychosocial area.

In particular, it looks at how to navigate an older adult through the health care system and place a focus on available resources as well as issues that affect older adults like low vision, hearing or even urinary incontinence. I know it’s not very glamorous. But it’s important.

Another important part of this training focuses on how to best manage polypharmacy in older adults. One way to define polypharmacy is any patient who is taking more than four medications, which is pretty much everybody in geriatric populations. It can be a major factor in health-related complications, so in a training program someone may cover how to ask questions in practice like “how can we cut this down?” or “is there something we should be using instead?”

Lastly, providers learn more about the best methods to manage end-of-life issues and dementia.

Caring for Older Patients

NB: What drew you to working with older adults?

LW: I just have a soft spot for older adults; I don’t know what else to say. I love the complexity of care in older adults. There are standardized guidelines in medicine about how to take care of heart attacks, hypertension, you name it, but many of those guidelines came out of research and studies which didn’t include real-world geriatric patients. So, when I’m working with older patients, it’s really about individualizing their care and going one step beyond the guidelines.

I also enjoy working with families to meet end-of-life goals for the patient, and the way caring for older adults relies heavily on multidisciplinary teams. It’s not just what I think, it’s also the professional opinions of therapists, social workers, pharmacists and more.

NB: What is your perspective of palliative and end-of-life care?

LW: The word palliative in medicine means to relieve suffering, and that should be part of practice — I don’t know if we necessarily need to send someone to a different doctor. As for end of life, I find it rewarding to work alongside a patient and their family to make sure the patient dies with dignity. If they have goals to die at home without pain, it’s crucial that we do everything we can to meet those goals.

I have had to personally change the way I think about palliative and end-of-life care because I have my own idea on what a good death looks like, but that’s not the same for everybody. There are some patients who need to feel that they’ve tried every aggressive measure at the expense of what I would consider to be a good quality of life. Over the last five years, I’ve learned to meet people where they are and support them through whatever they decide for themselves.

NB: You were instrumental in standing up the HELP program at AHN. Can you tell us more about why you thought it was important to implement this national program and where you’re going with it?

LW: Throughout my residency, fellowship and beyond, I saw some of the hazards of hospitalization for the elderly. When they are admitted, the process is normally that they’re put to bed, restricted from walking (which stems from a fear that they will fall), and they can quickly become deconditioned. Especially when you take into account the new faces, new sounds and alarms, interrupted sleep patterns and even different medications, all of this can cause older adults to become extremely disoriented, which can cause delirium, or acute confusion.

Personally, I think that’s just heartbreaking. Someone comes to the hospital to get better, but there’s this risk with older adults that they may leave better on paper but with more disability than when they came into the hospital.

The HELP program is great because it focuses on the prevention of delirium and acute confusion in older adults. It’s a common-sense approach. We have volunteers who help seniors stay awake during the day so they can sleep better at night, give them a newspaper so they can read the date, have conversations with them — it’s a strategic approach to keep their minds active and engaged throughout their stay. It’s just good care.

We started HELP here at West Penn, and we also introduced it at Allegheny General Hospital (AGH) in June. It’s been going extremely well — we’ve already seen 160 patients at AGH, and at West Penn we’ve seen more than 2,000 patients since its launch in May 2016.

NB: What program or initiative, outside of HELP, are you excited about in terms of AHN’s care for seniors?

LW: We have a formalized program with the trauma surgeons at AGH. When patients who are 75 years or older are admitted to the hospital for trauma service, they are also now seen by one of our geriatric practitioners who will then follow them throughout their entire stay.

The majority of trauma-related admittance for older adults is caused by falling. The trauma surgeons are amazing at managing the injury, but always appreciate further guidance on managing the cause of the older adult’s fall.

Our geriatric practitioners are able to talk to the patient about their health goals, or if the situation is severe enough, their end-of-life goals. This has been an extremely successful program and we’re hoping to introduce it at Forbes Hospital in the near future.

Elderly woman seated with a female doctor standing behind her

Improving Care for an Aging Population

NB: Is there ageism in the U.S. health care system?

LW: It’s huge. Ageism can be found mostly at the hospital level, especially if the patient develops delirium. To take just one example, if a patient is a little confused one day during his or her stay, some doctors may quickly jump to dementia. If a chronic condition like dementia is on your chart — it doesn’t just go away.

So a year later, I may see that same patient who has dementia written all over the chart and they’re completely fine, but if dementia is on the chart, the patient might not be a candidate for certain treatments or surgeries because of that.

It’s important that clinicians take their time with older adults and be patient. It can be difficult, especially when working with a patient who may have low hearing or other challenges, but it’s important to ensure the highest quality of care.

NB: Is there an area where providers could focus more when it comes to improving care for older adults?

LW: I hope to guide other providers to keep the big picture in mind. Older adults have a lot of different medical issues going on and some of them see a variety of specialists. I think clinicians have the best intentions but can sometimes solely focus on their “organ system” or area of specialty, and then a patient’s care can quickly become fragmented.

We need to ensure that with geriatric patients we’re focusing on the person, and we’re looking at the whole person and the whole picture. It’s a rewarding thing to work with these patients and their families in this season of their lives and to look beyond just the medical aspects of their care, but also care for their psychosocial needs as well.

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