Inside Duke Medicine

Inquiry: Caring for an aging population

Writing in a recent issue of the journal Virtual Mentor, second year Duke resident Jeanne Lee echoed many of the sentiments of clinicians and researchers throughout Duke who are actively engaged in caring for elderly people:

“Physicians are frequently the ultimate advocates for their patients’ autonomy…[They] must learn how to preserve quality of life even as they prolong it.”

By the year 2020, 60 percent of hospital patients nationwide will be age 65 or older. Many of these patients will struggle with multiple ailments. Lee isn’t alone in thinking about how physicians should best treat older patients so that they don’t lose their independence.

“It is important for physicians to think beyond the disease paradigm,” said Harvey Cohen, M.D., chair of the Department of Medicine and chief of the Center for the Study of Aging and Human Development. “We have to focus on the consequences of aging and look for ways improve function in old age.” Duke has a long history of focused geriatrics research, hallmarked by the nationally renowned, university-wide Center for Aging and Human Development. Created 50 years ago, the center has more than 30 core faculty and more than 100 affiliated faculty interested in the physical and mental well being of the elderly.

Kenneth Schmader, M.D., division chief of geriatrics and director of the Geriatrics Research Education and Clinical Center at the Durham Veterans Administration (GRECC), oversees a number of translational and clinical care research efforts. “Within the division of geriatrics, we’re investigating long-term and end-of-life care, transitions from hospital to home, adverse drug events, osteoporosis and fractures, just to name a few. Our work is very collaborative and very extensive.”

Duke’s efforts for improving the function of older persons were acknowledged in 1992 with its designation as a Claude D. Pepper Older Americans Independence Center, a program administered by the National Institute on Aging. “The aim of the Pepper Center is to explore modifiable pathways to functional decline,” said co-principal investigator Miriam Morey, Ph.D. Duke researchers are exploring ways to intervene in what can seem like an inevitable break-down of physical function.

One method may be as simple as taking a brisk walk. For 20 years, Morey has been investigating how regular physical activity can keep older adults out of nursing homes and independent. Her most recent study, called Project Life, partnered with primary care physicians at the Durham VA to look at how counseling older patients during doctor visits can help motivate them to exercise.

The Pepper Center houses a number of other aging studies by junior and senior faculty. These include looking at how the body ages on a cellular level, looking at stem cells to understand regenerative capacities, and examining genetic predispositions for conditions such as osteoporosis, diabetes, cardiovascular disease, and others, as well as the genetics of successful aging.

Cognitive declines can be just as, if not more devastating as functional ones. Diseases like Alzheimer’s and dementia can rob an older person of their memories and personalities. At Duke’s John and Kathleen Bryan Alzheimer’s Research Center, founded in 1985, Kathleen Welsh-Bohmer, Ph.D., along with P. Murali Doraiswamy, Ph.D. of the Center for Aging, and other physicians are looking for clues into the causes and management of Alzheimer’s disease (AD) and other dementias.

“One of the biggest obstacles facing physicians with regard to Alzheimer’s is the lack of a reliable method for diagnosis,” said Doraiswamy. Alzheimer’s is usually diagnosed after the patient has died and the brain is examined for the telltale protein plaques and tangles characteristic of the disease. At the recent meeting of the International Association of Alzheimer’s Disease, Doraiswamy presented a study of imaging techniques he collaborated on with Edward Coleman, M.D., of Radiology that may make it easier to detect the presence of plaques and tangles in a living person.

“The Bryan Center is an interdisciplinary effort using different approaches to study Alzheimer’s. We’re looking at how environmental and lifestyle effects, like dietary habits and pharmaceuticals affect the onset of AD, as well as how genetics influences the onset of dementia. It now appears that good cardiovascular health is important for maintaining cognitive function,” said Welsh-Bohmer.

As the American population ages, geriatrics research and care will become increasingly pressing. Indeed, this year, the Centers for Medicare & Medicaid Services (CMS), which administers Medicaid, the nation’s largest health insurance program, for the first time released a list of research priorities for diseases and conditions affecting the elderly. Duke researchers in the Division of Geriatrics and the Center for Aging are leading the way in investigating many of these.

To learn more about geriatrics research and resources available to Duke employees and patients, visit http://www.dukehealth.org/Services/Geriatrics/.