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Editorial  |   April 2013
A Rising Tide of Older Patients: Preparing Future DOs
Author Notes
  •    Dr Shannon is a member of the Editorial Advisory Board of The Journal of the American Osteopathic Association (JAOA). He has served as the guest editor for the JAOA's annual theme issue on osteopathic medical education since 2006.
     
  • Address correspondence to Stephen C. Shannon, DO, MPH, President, American Association of Colleges of Osteopathic Medicine, 5550 Friendship Blvd, Chevy Chase, MD 20815-7213. E-mail: sshannon@aacom.org  
Article Information
Geriatric Medicine
Editorial   |   April 2013
A Rising Tide of Older Patients: Preparing Future DOs
The Journal of the American Osteopathic Association, April 2013, Vol. 113, 262-264. doi:10.7556/jaoa.2013.113.4.262
The Journal of the American Osteopathic Association, April 2013, Vol. 113, 262-264. doi:10.7556/jaoa.2013.113.4.262
The baby-boomers (ie, those born between 1946 and 1964) are entering their senior years, and as a result our health care system is experiencing a rising tide of older patients. The number of US citizens aged 65 years or older is increasing dramatically. In 2010, older adults accounted for approximately 13% of the US population, with numbers estimated at 40.2 million.1 By 2050, these individuals are projected to account for nearly 20% of the US population, with their numbers estimated to be 88.5 million.1 In addition, the number of citizens aged 85 years or older (ie, the “old old”) is also projected to increase, from 5.8 million in 2010 to 8.7 million in 2030 to 19 million in 2050 (when the last of the baby boomers will reach age 85 years).1 
Although older adults comprise only approximately 13% of the US population, they account for a substantial portion of the disease burden among our citizens. Eighty-two percent of US adults aged 65 years or older have at least 1 chronic disease, and 43% have 3 or more.2 According to the 2008 Institute of Medicine Report Retooling for an Aging America: Building the Health Care Workforce,2 this segment of our population has accounted for approximately 26% of all physician office visits, 47% of all hospital outpatient visits with nurse practitioners, 35% of all hospital stays, 34% of all prescriptions, 38% of all emergency medical service responses, and 90% of all nursing home use. On the basis of demographic trends alone, a higher proportion of our health care resources will be devoted to older adults as their presence grows within our health care system. 
Longevity, of course, is associated with a host of chronic illnesses related to aging, including diabetes mellitus, hypertension, and heart disease, among others. These very same chronic diseases, however, are also related to the lifestyle choices and behavioral characteristics that have negatively impacted the health of the US population in recent decades, including poor nutrition, smoking, lack of physical activity, and obesity. When you combine the resulting epidemic of chronic diseases with the aging of the US population, it is easy to appreciate the challenges that our health care system will be facing in coming decades. 
So what does this mean for osteopathic medical education? What can be done to ameliorate the effect of these predictions? What should our educational system be doing to prepare for these circumstances? 
The rising tide of older patients truly is a new and potentially profession-altering challenge for osteopathic medicine. However, it is not something that has been ignored. The curricula of osteopathic medical schools have been changing to address these developments.3-5 It has never been the expectation that provision of health care to older patients will be relegated to geriatric specialists, who have either pursued residency, fellowship training, or both to achieve these skills, or who have focused their practices along these lines. Today, although the value of geriatric training is recognized, the reality is that all physicians—and other health professionals—need to be trained in providing team-based health care to older patients. 
In 2011, I drew the following conclusions from the aforementioned trends in health care for the US older adult population, and I believe that they still hold true6:
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    Prevention of disease and maintenance of optimal health must be a priority for physicians, the health care system, and local, state, and national policymakers.
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    The diversity of the health care workforce must improve to better reflect the changing population, and the cultural competency of physicians and all health care workers should be a priority in training.
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    Practice patterns will change, and it is time to proactively plan for such changes by providing physicians and other health care professionals with the interprofessional education necessary to build a team-based practice that can help meet the needs of our changing population.
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    All physicians and other health care professionals need more extensive training and experience with the geriatric population, as well as with active, complex management of chronic disease. Given current trends, training focused on diseases associated with obesity (such as training in diabetes prevention and management) should be a priority.
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    Unless we institute the health care system and medical education changes needed to deal with a burgeoning older population, we will be unable to provide necessary health care for the patients who are most in need of care.
In recent years, several allopathic physician colleagues, who are well-known and eminent medical education leaders or scholars from major academic medical centers, have pointed out to me that they thought that osteopathic medicine could offer some important advances to the care of our nation's older adults. Of course, the roots of osteopathic medicine and medical education in community-based, preventive, patient-centered, primary care training and health care delivery are particularly aligned with the needs of this growing segment of the population. My allopathic physician colleagues, however, were referring to the contribution of osteopathic manipulative medicine (OMM) to the diagnosis and treatment of the older adult population. They wondered about the potential of OMM to provide effective drug-free interventions to manage musculoskeletal and other conditions, improve function, and alleviate pain. They also encouraged the osteopathic medical education community to develop access to efficacious interventions that hold great promise in improving the health of older adults and reducing the adverse effects of medication and other interventional methods in geriatric care. Also, although research to evaluate efficacy is under way, the education of osteopathic physicians in osteopathic principles and practice must increasingly include developing competencies in geriatric care as well. 
Therefore, it is particularly important to acknowledge the publication of the article “Developing Osteopathic Competencies in Geriatrics for Medical Students,” by Donald R. Noll, DO, and colleagues, which appears in this osteopathic medical education theme issue of The Journal of the American Osteopathic Association (JAOA).7 The article describes a consensus-building process involving educators from departments of OMM at all osteopathic medical schools in the United States (operating through the Educational Council on Osteopathic Principles of the American Association of Colleges of Osteopathic Medicine). From this consensus process, guidelines were developed that will be useful for all our osteopathic medical schools in addressing the training of our graduates to use OMM in the care of older patients. Dr Noll and colleagues7 identified the following proposed competencies for a new geriatrics OMM domain in the education of osteopathic physicians:
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    Identify posture and gait abnormalities that contribute to gait and balance disorders.
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    List and explain the relative contraindications and adverse effects of specific osteopathic manipulative treatment techniques in the elderly.
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    Apply osteopathic manipulative treatment as a nonpharmaceutical treatment of somatic manifestations of physical, cognitive, and behavioral disorders, including pain relief and comfort and common end-of-life symptoms (eg, nausea, constipation, anxiety).
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    Describe and demonstrate the positional modifications of the physical examination and osteopathic manipulative treatment techniques for use in elderly patients with limited or minimal mobility (eg, hospitalized, nursing home, or disabled patients).
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    Justify osteopathic techniques chosen for elderly patients based on individual needs and physical/psychological limitations.
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    Evaluate and treat somatic dysfunctions that limit patient range of motion and the ability to perform activities of daily living.
These competencies are elements critical to ensuring the well-being of the older adult population in the United States, and I believe that further work needs to be done to help osteopathic medical students master them. Although osteopathic research, especially in the area of efficacy, needs to be expanded, the article by Dr Noll and colleagues offers a great step forward as our educational system prepares the osteopathic physicians of the future. 
There are many examples of the good geriatrics-related work being done by osteopathic medical schools across the country. However, much more research, curricular advancement, and clinical opportunity will need to be generated to ensure that future physicians are well prepared to provide high-quality health care to a burgeoning elderly population. With our traditional training and clinical practice focus on prevention and optimization of health in community-based primary care settings, I believe that osteopathic medical education will rise to this challenge and thereby further increase its importance in the health care system of tomorrow. 
The annual osteopathic medical education theme issue of the JAOA is also filled with reports on important developments in osteopathic medical education, as well as the data that are so important to benchmarking the changing profile of the profession and its position in medicine and medical education. We are in the midst of substantial changes that will call on all of us to be diligent in the evaluation of our profession, engage in the policy discussions that are under way, and use the information generated by the work of the professionals publishing here in the JAOA to inform the directions that we choose to pursue in the future. 
   Financial Disclosures: None reported.
 
References
Vincent GK, Velkoff VA. The Next Four Decades. The Older Population in the United States: 2010 to 2050. Washington, DC: US Census Bureau; 2010. P25-1138. http://www.census.gov/prod/2010pubs/p25-1138.pdf. Accessed March 4, 2013.
Committee on the Future Health Care Workforce for Older Americans, Board on Health Care Services, Institute of Medicine of The National Academies. Retooling for an Aging America: Building the Health Care Workforce. Washington, DC: The National Academies Press; 2008:3-4. http://www.nap.edu/openbook.php?record_id=12089. Accessed February 16, 2013.
Gugliucci MR, Giovanis A. Geriatrics curricula for undergraduate medical education in osteopathic medicine. In: Standards and Guidelines for Gerontology and Geriatrics Programs. Washington, DC: Association for Gerontology in Higher Education; 2008. http://www.aacom.org/InfoFor/educators/mec/curriculum/Documents/GeriatricsCurricula.pdf. Accessed February 16, 2013.
American Association of Colleges of Osteopathic Medicine. AACOM 2011-12 Academic Year Survey of Graduating Seniors: Summary Report. Chevy Chase, MD: American Association of Colleges of Osteopathic Medicine; 2012. http://www.aacom.org/data/classsurveys/Documents/2011-12_Graduating_Summary.pdf. Accessed February 16, 2013.
Leipzig RM, Granville L, Simpson D, Anderson MB, Sauvigné K, Soriano RP. Keeping granny safe on July 1: a consensus on minimum geriatrics competencies for graduating medical students. Acad Med. 2009;84(5):604-610. [CrossRef] [PubMed]
Shannon SC. Confronting the challenge of a graying America. Inside OME [serial online]. Chevy Chase, MD: Association of American Colleges of Osteopathic Medicine; September, 2011;5(9). http://www.aacom.org/resources/e-news/ome/archives/2011/2011-09/Pages/president.aspx. Accessed March 4, 2013.
Noll DR, Channell MK, Basehore PMet al. Developing osteopathic competencies in geriatrics for medical students. J Am Osteopath Assoc. 2013;113(4):276-289. [PubMed]