LAUSR

Geriatric research over the past several decades has robustly described the clinical complexity of older adults. Disability, frailty, multimorbidity, dementia, polypharmacy— all of these conditions increase in prevalence with age and have been associated with nursing home placement, hospitalizations, and mortality. New results from Patel et al now add an additional layer of complexity to the picture by underscoring the significant burden of symptoms in older adults and their association with poor outcomes. Nearly half of older adults had two or more symptoms, and almost 1 in 6 had four or more symptoms in a nationally representative sample from the United States. Higher symptom count was independently associated with decreased physical capacity, disability, hospitalizations, nursing home admissions, and mortality in longitudinal analyses. These findings provide a clarion call for confronting head-on the problem of symptom burden in older adults. Unfortunately, our ability to address symptoms effectively in clinically complex older adults is hampered for two primary reasons: (1) a dearth of pharmacologic and nonpharmacologic interventions, and (2) an inadequate workforce supply and lack of training of existing providers. Managing symptoms is hard enough in younger adults, but the clinical complexity of older adults often limits the available treatment options and makes symptom management more challenging. Many of the pharmacologic therapies for symptoms are on the Beers Criteria list of medications to potentially avoid in older adults (eg, nonsteroidal anti-inflammatories, opioids, selective serotonin uptake inhibitors, tricyclic antidepressants, benzodiazepines, hypnotics, etc). Initiating new medications for symptoms risks polypharmacy and its attendant risks: drug-drug interactions, side effects, and high out-of-pocket costs. Cognitive and sensory impairments make communication and education efforts for managing medications challenging. Older adults frequently rely on caregivers for support, adding an additional person or people in the milieu of factors that need to be considered in managing symptoms in older adults. Government and industry investment in interventions for treating symptoms appropriate for older adults pales in comparison with the impact and challenge of the problem. The National Institute of Health’s (NIH) National Institute of Nursing Research (NINR), whose domain encompasses the science of symptom measurement, mechanisms, models, and management is the second lowest ranked nationally focused NIH institute in terms of funding (Figure 1). The pipeline for new pharmaceutical treatments for symptoms is woefully inadequate. For example, there are only 220 clinical-stage drug programs for pain, in comparison with 2617 for oncology pharmaceuticals. Venture funding has disproportionately flowed toward cancer treatments, whereas pain and other conditions receive much smaller amounts relative to their impact on US healthcare costs (Figure 2). Investment in nonpharmacologic treatments is even lower than pharmacologic treatments, where at least the pharmaceutical industry is incentivized by potential profits. However, the National Institute of Complementary and Integrative Health (NCCIH) that investigates nonpharmacologic interventions receives the lowest amount of funding of the NIH institutes, below even the NINR (Figure 1). Even if adequate interventions for managing symptoms in older adults existed, the healthcare workforce is distressingly unprepared and understaffed to address the symptom burden of older adults. It is a well-cited statistic that currently almost 50 million adults older than age 65 live in the United States, and this number is expected to reach 95 million by 2060. However, there are only 7200 geriatricians, 6400 palliative care physicians, and fewer than 1% of registered nurses specialize in geriatrics or palliative care. The average pay of geriatricians and palliative care physicians is lower than a hospitalist, even though both specialties require an additional year of training. Lower pay for additional training and more work mean the incentives are not aligned to encourage providers to pursue these specialties. Quite simply, there is no possible no way for geriatric and palliative care specialists to provide care for all of the older adults who need it. Healthcare workers outside of geriatrics and palliative care could help address the symptom burden in older adults, but they currently receive inadequate training in geriatric and palliative care principles. This is especially true for providers who care for patients on the frontlines, such as nursing assistants. These are the providers who are very often the first ones to assess symptoms and provide education to patients and families in symptom management strategies. Nurses’ aides, however, are only required to receive 75 hours of training total per federal regulations. In comparison, hair stylists are required to undergo 1500 hours of training. How can it be that we ask so much of this group of healthcare workers in terms of their responsibilities but provide them with so few tools and resources to be successful? DOI: 10.1111/jgs.15674