Geriatricians: The Super Specialists.

Who is going to care for the growing population of older persons, especially those with multimorbidity, who are responsible for over a quarter of physician office visits? Many of my primary care physician colleagues tell me that they look after older people all the time and that they are excellent geriatricians. It is only when the child of one of their older patients brings her to me that I realize just how dangerous their belief is. As an example, about a year ago I saw an 88-year-old male with prostate cancer and brain metastases. He came to me because he was fatigued. He was on 26 medicines and his physician had told him that if he stopped any of his medicines he would die instantly. I sent him home on one medicine and he phoned me a week later telling me he was no longer fatigued. He died peacefully 8 months later. Another example was a 68-year-old lawyer whose colleagues had suggested his legal practice was not as good as it should be. His primary care physicians suggested he was getting old and should consider retirement. He was clearly cognitively impaired (Saint Louis University Mental Status (SLUMS) score of 16/30) and after asking his wife if he stopped breathing at night, I referred him for a sleep test. Six months later he returned on continuous positive airway pressure with a SLUMS of 30/30. Finally, 2 African American women in their mid-80s came to one of our screenings. They both complained of fatigue. Their home systolic blood pressures on three antihypertensives ran between 90 to 100 mmHg! Unending stories like this make the geriatrician the super specialist for older persons. No other specialty has developed as many wide ranging, successful programs that have improved the quality of life of older persons. As illustrated in Figure 1, the geriatrician is the peripatetic clinician and administrator who is responsible to care for and respond to the older person’s viewpoint. Geriatricians have demonstrated improved care for older persons in hospitals (Acute Care for the Elderly (ACE) units, Delirium Intensive Care Units orthogeriatric units, postacute care (geriatric evaluation and management units), and outpatient evaluation). In addition, geriatricians have developed programs to decrease falls, to improve outcomes post hip fracture, to delay the rate of cognitive impairment (the FINGER trial), and to reduce frailty and sarcopenia. Geriatricians have also been leaders in top quality programs in nursing homes and calling for increased research in nursing home care. At the basic clinical care level geriatricians have focused on recognizing and treating a variety of predisability syndromes—The Modern Giants of Geriatrics (Table 1). These syndromes represent the Pandora’s box of predisability conditions and the ideal focus for prevention of disability. They are virtually never recognized by primary care physicians and subspecialists. The physical phenotype of frailty as developed by Fried et al., coupled with the recognition of sarcopenia, provide treatable conditions that can prevent or delay the onset of disability. Polypharmacy and the use of newer, expensive medicines represent a situation where physicians are costing their older patients large amounts of money, with negative outcomes. There are numerous treatable causes of the anorexia of and weight loss in older persons. Early recognition