Dr. Louise Aronson says the U.S. doesn’t have nearly enough geriatricians — physicians devoted to the health and care of older people: “There may be maybe six or seven thousand geriatricians,” she says. “Compare that to the membership of the pediatric society, which is about 70,000.”
Aronson is a geriatrician and a professor of medicine at the University of California, San Francisco. She notes that older adults make up a much larger percentage of hospital stays than their pediatric counterparts. The result, she says, is that many geriatricians wind up focusing on “the oldest and the frailest” — rather than concentrating on healthy aging.
Aronson sees geriatrics as a specialty that should adapt and change with each patient. “My youngest patient has been 60 and my oldest 111, so we’re really talking a half-century there,” she says. “I need to be a different sort of doctor for people at different ages and phases of old age.”
She writes about changing approaches to elder health care and end-of-life care in her new book, Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life.
On how people’s health needs become more complicated as they age
While old age itself is not a disease, it does increase vulnerability to disease. So it’s the very rare person over age 60 … and certainly over age 80, that doesn’t tend to have several health conditions already. So when something new comes up, it’s not only the new symptoms of potentially a new disease, but it’s in the context of an older body of the other diseases, of the treatments for the other diseases.
If somebody comes in with symptoms and they’re an older person, we do sometimes find that single unifying diagnosis, but that’s actually the exception. If we’re being careful, we more likely find something new and maybe a few other things. We add to a list [and], we end up with a larger list, not a smaller one, if we’re really paying attention to everything going on in that person’s life and with their health.
On how the immune system changes with age
Our immune system has multiple different layers of protection for us. And there are biological changes in all of those layers, and sometimes it’s about the number of cells that are able to come to our defense, if we have an infection of some kind. Sometimes it’s about literally the immune reaction. So we know, for example, that responses to vaccines tend to decline with age, and sometimes the immunity that people mount is less. It also tends to last less long. And that’s just about the strength of the immune response, which changes in a variety of ways. But our immune system is part and parcel of every other organ system in our body, and so it increases our vulnerability as we get older across body systems.
On the importance of vaccines for older people
Older people … are among the populations (also very young children) to be hospitalized or to die as a result of the flu. The flu vaccine, particularly in a good year, but even when the match isn’t perfect in a given year, [protects] older people from getting that sick and from ending up in the hospital and from dying. … That said, we have not optimized vaccines for older adults the way we have for other age groups. So if you look, for example, at the Centers for Disease Control’s recommendations about vaccinations, you will see that there are, I believe, it’s 17 categories for children, different substages of childhood for which they have different recommendations, and five stages for adulthood. But the people over age 65 are lumped in a single category. … We’re all different throughout our life spans, and we need to target our interventions to all of us, not just to certain segments of the population, namely children and adults, leaving elders out.
On how medications can change in how they affect the patient over time
Researchers have traditionally said, “Well, we’re not going to include older people in our studies because their bodies are different and/or because they have other ailments that might interfere with their reaction to this medicine.” But then they give the medicine to those same older people … and so very frequently with a new medicine we will see all sorts of drug reactions that are not listed on the warnings. So message number one is just because it’s not listed doesn’t mean it’s not the culprit. Another key point is really any medicine can do this. And it can do it even if the person has been on it a long time. … We think of medicines as sort of fixed entities, but in fact what really matters is the interaction between the medication and the person. So even if the medication stays the same, the person may be changing.
On the importance of doing house calls in her work
What got me into medicine and what keeps me there is the people. And when you do a house call, you see the person in their environment, so they get to be a person first and a patient second, which I love. I also can see their living conditions, and more and more we’re realizing and paying attention to how much these social factors really influence people’s health and risk for good or bad outcomes.
Roberta Shorrock and Seth Kelley produced and edited the audio of this interview. Bridget Bentz, Molly Seavy-Nesper and Deborah Franklin adapted it for Shots.