Ask Dr. Bob: Saddle River Magazine, January Issue 2024

Ask Dr. Bob

We have had questions from older people regarding aging, diseases, and conditions like dementia.  In this column I would like to concentrate a bit on an area called geriatrics.

What is Geriatrics?

Geriatrics is the branch of medicine that deals with the health and care of old people.  This is not palliative care or hospice.  Both of those areas deal with alleviating pain and discomfort or end of life care respectively.

Are there specialists who do this kind of work in practice or in hospitals?

Yes, Geriatrics is a medical specialty and growing by the day.  People who are geriatricians often refer to the gradual narrowing in an elderly person’s life. It is not easy to define the specific age group.  In other words, is a 65-year-old a geriatric patient or is a person who is 90 a true geriatric patient?  You can find the appropriate geriatricians in any large hospital.

What constitutes elderly?

According to the United States social Security Administration, anyone over age 65 is considered elderly.  But not everyone agrees. A 2014 research review found limited guidance on what defines “elderly”, Describing an older adult as elderly should be based on physical health and medications rather than chronological age.  Defining the word elderly may be a feeling and not a number.  In my practice I have patients who are in their 50s, who look frail and in poor health. This is fun to debate and could take up this entire column, but we will not do that.

What is gerontology?

This is different than the specialty of caring for older people.  Gerontology is the scientific study of old age, the process of aging and all the problems of older people.  A patient would want to be cared for by a geriatrician and not a gerontologist.

What are superagers?

Even at an advanced age, superagers have the memory of people who are 20 to 30 years younger than them.  In superagers, the shrinkage of certain areas of the brain called age-related atrophy of the grey matter (especially in areas responsible for memory) develops much slower than the normal aged person. The question is whether such patients are resistant to memory loss or develop coping mechanisms to offset normal aging.

There were studies of large numbers of patients in Europe (Leibnitz Institute on Aging, Jena Germany). The overall conclusion was that superagers indicated that they have been more active than control subjects in their middle years.  Going for a daily walk or taking the stairs instead of the elevator was a major way to be a superagers.  Such patients also suffered less from depression or anxiety disorders.

One interesting finding was that superagers exhibited lower concentrations of biomarkers for neurodegenerative diseases than the control groups.  This means that the superagers were not likely to get Alzheimer’s or other forms of dementia.  The curious aspect of the study was that the presence of the APOEe4 allele, which predicts Alzheimer’s disease was present in both the control normal aged patients and the superagers and seemed to have no predictive effect for the superagers. The research teams say that genetics certainly plays a major role in who gets demented with age and not simply lifestyle.

We have all seen people of advanced age who look great, and we have seen very old people who look terrible but have great minds.  Why is that?

Neurodegenerative diseases are largely genetically driven.  Some do not depend on aging and occur at a relatively young age and others are a given once patient goes into the late 80s or 90s. Diseases like fronto-temporal dementia, vascular dementia, Alzheimer’s, and others generally run in families. There are many markers for these diseases like certain proteins in the spinal fluid or the APOEe4 gene that have been found in people with these diseases.

What is palliative care?

Prevention and the relief of suffering in advanced illness is the basis for palliative care. It is an interdisciplinary specialty of medicine that focuses on improving the quality of life for people with increased illness and their families.  It is not hospice. Palliative care is called for someone who has suffered major stroke, a failing heart, someone with new onset cancer, how to manage during chemotherapy, or caring for someone with dementia. Patients go on and off palliative care.  It is not usually “end of life” care, but it can be.  Families are usually intimately involved in palliative care.

Doctor-patient communication and communication with family members is the cornerstone of palliative care.  There are four stages in the temporal progression towards death: 1) advanced care planning, 2) communicating bad news, 3) negotiating the goals of care (as examples, whether there is a living will, or should the patient go into hospice) and 4) whether care should continue or be withdrawn.  The spiritual realms and the psychosocial issues are dealt with in palliative care as well.

What is Hospice?

This is a subset of palliative care. Those in hospice get palliative care, but not all palliative care is receiving hospice. Generally, patients in hospice require four levels of care and these are often dictated by something called Medicare Hospice benefit. There are four levels of care:  inpatient care (hospitalized patients), needs for continuous care, home care, and finally respite (rest or relief from something difficult).  The doctor must certify a six month or less prognosis of the disease process. However, the patient might continue beyond the certified time.  The patient in hospice is always under the direct care of a doctor.  Patients can be continually recertified in hospice. Ninety percent of hospice care occurs in the home setting, either a private residence or a nursing home.

Psychosocial and spiritual care is part of both palliation and hospice.  The latter is because suffering may not be physical.  I think of jimmy Carter the 39th president who lost his wife at the age of 99. No doubt while at hospice his loss of Roselyn Carter was more than physical pain. Nevertheless, his condition required palliative care, respite, and all of the psychosocial and spiritual needs.

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These are important topics to discuss in this brief but important column.  All of us will someday require palliative care and maybe even hospice.  It should be comforting to know that these vehicles exist to quiet pain and suffering at any time in life when personal chaos exceeds one’s ability to cope.