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Elder care: What lies ahead? Some day your parents could be your ...

Date Added: 16-08-2005

MY father is 86 years old. He was never a big man, except perhaps to me when I was his little boy. At most, he was 5-foot-2 and weighed 160 pounds. Today he weighs barely 120. He teeters on spindly legs, a parched blade of grass in the wind, refusing the walker his doctor recommends or the arm extended by those who love him. He doesn't know what day it is. Shaving exhausts him. His clothes hang like a scarecrow's. He is nearly deaf but won't wear his hearing aids or loses them as often as a kid might misplace his marbles. He drives my mother — five years younger — crazy to tears.

My only sibling, an architect, asks me every time we are together (which is often since we all live in San Antonio) and every time we speak on the phone (which is almost every day): "What are we going to do with Dad?" As if there must be a definitive answer, some fix — say, putting a grab bar in the bathroom.

He asks me not just out of fear and frustration, but because he figures that his older brother, the physician, should know the answer. I do not know the answer. I do not have a pat solution for my father or yours — neither as a son, a man past middle age with grown children of his own, nor as a specialist in geriatrics who is also a credentialed long-term care medical director.

In the United States today there are 35 million geriatric patients — defined as over 65. Of these, 4.5 million are older than 85, now characterized as the "old old." Yet the American Medical Directors Association, which credentials physicians in long-term care, has certified only 1,900 such doctors in the nation; only 2 percent of physicians in training say they want to go into geriatric care. As we baby boomers go about our lives, a vast inland sea of elders is building. By 2020, there will be an estimated 53 million Americans older than 65, 6.5 million of whom will be "old old." America will be inundated with old folks, each with a unique set of circumstances, medical and financial.

Compounding all of this is the sad and frustrating fact that our government appears to have no policy vision for long-term elder care. It's as if our leaders wish — perhaps reflecting our collective yearnings as a youth-worshiping society — that when the time comes, the elderly will take their shuffling tired selves, their drooling and incontinence, their demented ravings, their drain on family and national resources, and sprawl out on an ice floe to be carried off to a white, comforting place, never to be heard from again.

For the past nine years, I have been the medical director of my hospital's skilled nursing unit. It receives patients from other parts of the hospital who no longer need acute care services yet are unable to return home. But more and more, as our patients grow older and more frail, it becomes clear that the attending physicians have referred their patients to the SNU because they don't know what else to do with them.

Each week I attend the SNU team care conference. The nurses provide up-to-the-minute reports on each patient's medical progress; the therapists discuss whether the patient is meeting set goals; we hear about the situation at home, what help we can expect from family or other caretakers, and what the patient's insurance may or may not provide. Our main goal is to answer one question: What are we going to do with this patient? Where can we safely send him — given his medical, social and financial circumstances — and expect him to maintain his highest level of functioning, his remaining dignity? Very often, we don't know.

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