Treating Older People in the Emergency Department

In my 16 years in Emergency Medicine in England it has become increasingly common to see people over 85 years of age. This is an experience shared with ED colleagues from several other countries. Even the proud near-centurion awaiting a “letter from the Queen” is a not infrequent visitor to my department.

EDs are increasingly thronged with older people. Our ED has seen a 40% increase in the over-85’s in one year! They are increasingly coming by ambulances and are taking up more and more of our time and hospital beds. Is this a problem or is it a symptom? Continue reading…


Unreasonable Health Choices

Long before reaching 65, most people know all too well the costs of decades of going against their own best interests by engaging in practices they knew carried risks for their health – as with smoking or overeating. In at least some respects, they resonate to Oscar Wilde’s “I can resist everything except temptation.” Even if they have finally succeeded in bringing about change, as many seniors have with respect to smoking, they may ask, looking back, “Why did I not decide to try to stop much sooner?” Continue reading…


Balancing adequacy and sustainability: lessons from the Global Aging Preparedness Index

The world stands on the threshold of a stunning demographic transformation brought about by falling fertility and rising life expectancy. It is called global aging, and it will challenge the ability of many countries to provide a decent standard of living for the old without imposing too big a burden on the young.

The GAP Index

Which countries are most prepared and which are least prepared to meet the challenge? The Global Aging Preparedness (GAP) Index, developed by the Center for Strategic and International Studies (CSIS), provides a unique new analytical tool for assessing the progress countries are making in preparing for global aging—especially in balancing the twin goals of income adequacy and fiscal sustainability (see sidebar on page 10 for GAP Index Country Rankings in these areas). Continue reading…

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Japan – and then there was one

Population: 127.4m

65 years and over: 23.9%

Life expectancy at birth: 83.9 years

Population in 2050: 99.7m

Everybody knows that Japan is ground zero for global ageing. The youngest of the developed countries as recently as the mid-1970s, it is now the oldest – and its age wave will continue to roll in for decades to come. 

By 2050, the proportion of Japanese who are 65 or older is on track to reach 39 per cent, up from 23 per cent in 2010 and only 9 per cent in 1980, when Japan Inc seemed poised to conquer the global economy. Japan’s total population, which is already contracting, will enter a precipitous decline, shrinking by over a half by the end of the century. Extending this dismal forecast even further into the future, the Japanese Government projects, half seriously, the date when there will be only one Japanese citizen left living.   Continue reading…

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Reimagining Geriatrics

A little over a year ago, I found myself burning out and realized that my work life was unsustainable.

 I’d been working at a Federally Qualified Health Center, and had become the site’s medical director a few months before. I was practicing as a primary care doc, trying to improve our clinical workflows, problem-solving around the new e-prescribing system, helping plan the agency’s transition from paper charts to electronic charts, and working on our house calls and geriatrics programs. 

 All of this was supposed to be a 50% position — plus 5% paid time for follow-up. Needless to say, this job was taking far more than 55% of my time, and seemed to be consuming 110% of my psyche. I very much liked my boss and colleagues, was learning a lot, and felt I was improving care for older adults.

 But I was also irritable, stressed out, and had developed chronic insomnia. And clinic sessions were leaving me drained and feeling miserable: try as I might, I couldn’t find a way to provide care to my (and my patients’) satisfaction with the time and resources I had available. Continue reading…


Preparing for the Final Exam of Life

Recently, I was taken aback by being asked to deliver the memorial eulogy for our departed classmates at our upcoming 50th year High School Reunion. Why me, I asked? Isn’t there a Priest or Rabbi in our class who is used to doing something like this? That question not only did not seem to matter to the classmate planning the event, but she replied that my professional background would be the most appropriate of all. No stigma about psychiatry here. At least I had done a couple of memorial eulogies for staff who had died, one even from suicide. And I had learned much about eulogies from my Rabbi son. So, with a feeling of both personal and professional honor, I agreed.

Here is what I prepared to say: Continue reading…


Public pensions need to evolve

The Ontario Teachers Pension Plan recently released a new documentary on the sustainability of pension plans titled “Pension Plan (ev e looSHen).”  It presents interviews with practitioners and experts from Canada, the United States, and The Netherlands.  The tone and conclusions of the film really resonated with me.

The theme of the documentary is that the world changes and public pension plans, like other institutions, need to adapt and evolve – hence, the subtitle “ev e looSHen.” Continue reading…

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The Medicare Showdown

A distinct advantage of writing for my Over 65 colleagues and readers is that I can safely refer to bits of popular culture now long gone. In this case, I want to invoke the “perils of Pauline,” the troubles of a famous heroine in the silent film era. She went from one likely disaster to another (e.g., tied to the train tracks with the night express bearing down on her) but always managed to pull through.

Medicare is like that. Continue reading…

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Two Common Sources of Overtreatment

Experts, most recently former CMS administrator Don Berwick, tell us that no less than 20% – 30% of medical care is “waste.” At the very least, “waste” is harmful to all those who pay for Medicare. But often it’s directly harmful to the patient as well.

I recently saw a friend at a party. Since we’d last seen each other my friend’s spouse had died. (I’m deliberately avoiding gendered pronouns and omitting other identifying details.) My friend contrasted the excellent hospice care the spouse received with problem-ridden hospital care. Here are two examples of “waste” that were thwarted only by my friend’s vigilance. Continue reading…

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How Hospital Care Should Work

This is a corny essay by a man who, having recently undergone surgery, was reminded of those people who, in tending to our health, urge us to focus on what issues properly define life.

 First it was the emergency room where I observed the palpable concern on the face of a woman whose only job was to admit me. And then the folks in the emergency room itself. There isn’t much privacy in those spaces; you see and hear too much. And along with feeling ill there’s plenty to be humiliated about. But every one of those workers was sensitive to these matters. Continue reading…