What Is a Geriatrician, and When Should You See One?

Aging does not necessarily mean that you have to feel older or worse than you used to feel. Geriatricians are primary care doctors who are experts in caring for older adults and helping them stay as healthy as possible while they age.

“I see lots of 70-year-olds who look and act like they’re 90, and I see 90-year-olds who are very healthy and active, running around acting like they’re a 70-year-old,” says  Fiorella Myrella Perez, M.D., a board-certified geriatrician with the University of Miami Health System.

Seeking geriatric care early has advantages.

“It’s best to start seeing a geriatrician around age 65, so he or she can guide you through healthy aging in ways that align with your goals. Patients may think, ‘I’m not old or frail.’ But it’s better to come early, to identify any health risks early and before problems develop,” she says.

Seeking geriatric care early gives the doctor a baseline sense of your condition and functioning to help you remain independent, a major goal for many older people.    

A unique, age-friendly approach called the “4Ms model.” 

As people age, their care needs often grow more complex. They may see many doctors and take many different medications.

Most health systems are not designed to deal well with such complexity.

In 2017, a group of health-focused nonprofits joined forces to address these problems.

What is the 4Ms Model of age-friendly care?

The model relies on evidence-based practices.

The 4Ms are: What Matters, Medication, Mentation and Mobility.

Dr. Perez uses the model in a gradual fashion. She does an overview-type screening using the 4Ms during the first visit in order to develop a care plan. Then, over time, she and the patient work on  each one of the Ms, in order to make improvements.

“You don’t want to overwhelm a patient with too many issues at once. At one visit I’ll say, ‘Today we will focus on medications,’” she says. Gradually, they address each of the “M”s.

1. What Matters Most

Geriatricians tend to spend more time with their patients than other sorts of primary care doctors, asking many questions about each person’s main health goals.

Dr. Perez frequently meets patients who are older but say that they don’t feel their age. “They often say what matters to them is to remain independent, not to depend on others, on their children. Some of them may have been so independent for so long, but they are starting to decline in their memory or functioning, which can really lead to dependence,” says Dr. Perez.  Such patients may benefit from interventions designed to help them maintain good balance and strength, and to improve their vision and hearing.  

Other patients report that religion matters most, or their children. Others mention staying mobile, being pain-free and comfortable, being able to walk their dog daily. Their first M may be to breathe better.  “What matters most to each patient serves to guide my care plan for them. It provides a foundation,” she says. 

2. Medication

“With any new patient, I review the medications they are taking. But I go beyond just asking them for a list,” says Dr. Perez. Instead, she has each patient bring all of their actual medication bottles.

“I can see when a drug was prescribed and when someone actually picked it up. Sometimes, patients with memory issues will bring in bottles of one drug with some bottles dated years back, and others bearing the current year,” she said. She asks what, if any, system they use to keep track of their medicines, things such as trays to fill each week or month. If they lack such a system, she helps them implement one.

She checks to see if her patients are taking medications known to be risky for older adults. The Beers Criteria serves to identify such drugs.

If medication is truly necessary, Dr. Perez prescribes age-friendly medications that do not interfere with what matters to the older adult or to their mobility and mental well-being.

3. Mentation

In assessing mentation, geriatricians look at diverse measures of brain health. “I screen for memory issues a person might be having and also their mood. Sometimes a problem may look like memory issues but actually the person is so depressed they can’t focus. It’s the mood that is affecting their mentation,” she says. Geriatricians are trained to perform formal memory tests.

One tool she uses for measuring depression is the Patient Health Questionnaire-9 (PHQ-9), a series of short questions. Another short survey called the Generalized Anxiety Disorder-7 (GAD-7) serves as a screening tool for anxiety.

 Geriatricians also check to see if memory changes, anxiety or depression might have an underlying cause. For instance, symptoms such as palpitations or confusion could be related to a person’s thyroid hormones not falling within a healthy range. Thyroid imbalances can also lead to symptoms that feel like anxiety.

What looks like depression may be normal bereavement. “Older people experience many losses, and, of course, need to grieve. But has it been months? Are they losing weight, not sleeping?” Dr. Perez says. Therapy may be warranted, or medication.  

4. Mobility

Staying active daily and avoiding falls allows older adults to achieve the fitness to do what matters. Geriatricians take a comprehensive approach to preserving mobility. “We do balance tests and fall risk screenings.  Then we make a plan to address problems such as pain and weakness, to improve mobility,” Dr. Perez says.  

Geriatricians also advise patients on how to lower fall risk at home and avoid prescribing medications that can impair balance.

Geriatric care means comprehensive care, with family included

As useful as the 4Ms Model is, for Dr. Perez, an initial geriatric visit often goes even further than those areas.  “I ask the patient who they want to be their healthcare surrogate. I want to know who the people are in my patient’s life. Who should I call if they’re sick and can’t make decisions?” says Dr. Perez. Other primary care doctors often do not ask about those important matters.

“I see myself as the gatekeeper in handling my patients’ care.  As primary care doctors, geriatricians align with our patients and advocate for them. We help navigate their care if they are seeing different specialists,” she says.

She also asks about the patient’s end-of-life wishes and if they want to sign a DNR [do not resuscitate order]. “I lay it out. I want people to be used to having this kind of discussion, so I know and the family knows,” she says.

“I love geriatrics because it involves working with my patients on all the important variables, helping them in ways that support their goals. As a geriatrician, I’m taking the time to see the patient as a whole.”

Written by Milly Dawson. Reviewed by Fiorella Myrella Perez, M.D.

Tags: active aging, aging process, Dr. Fiorella Perez, geriatric medicine, seniors