We recently sat down with Dr. David Nace, chief of the Division of Geriatric Medicine, to discuss how the division is addressing a nationwide shortage of geriatricians and what they are doing to care for Pittsburgh’s aging.

If we look at the United States, I think one of the single greatest issues in health today is aging. The population is growing older, with roughly 17% of the US population, about 58 million people, being 65 years of age or older. In Allegheny County, it’s over 20%. As a result of that, the need for folks who are trained in geriatrics – those who understand what aging looks like and how it can affect health and certain specialties – becomes critically important.

Aging has a major impact beyond healthcare, as well. It impacts housing, as the average home may not be set up properly to accommodate the growing number of those who choose to age in place. It impacts how our communities are structured and how livable they are. It impacts the labor workforce, as the need for caregivers who provide support increases. It’s critical that we take a wide look at these factors when making health policy and designing our systems, so we can adapt, plan, and direct resources according to the changes we know are ahead.

If you look at medicine from a complexity science perspective, over the last 30 to 40 years, we’ve been really trying to develop best practices and guidelines to start to standardize our approach – and that works well in somebody who’s 40. If somebody’s 40 and they present with high blood pressure, we know the things to investigate and the decisions that are often made in those circumstances.

What’s interesting in geriatric medicine is that approach doesn’t work because we’re dealing with multi-complexity. The patients we see are far more complex, on average, than most other patients because in many cases they are dealing with multimorbidity or multi-complexity. They might be dealing with multiple different disease processes. Couple that with social determinants of health, such as where the patient is living, how they get access to care, what support they have at home. Then add in the potential cognitive factors. Some individuals have great cognitive reserve, while others may be suffering from early symptoms of depression, dementia, or delirium. In addition to age, frailty is also a big component that can affect how patients respond to medications and treatment.

For many folks, this can be a really wonderful challenge. It’s not the same thing all the time. You’re really being stimulated intellectually to put the pieces together, and you have to be flexible enough to realize what you might do in one person is going to be different than another. So, for the challenge aspect of it, the science aspect of it, it really makes you think out-of-the-box. It makes you think innovatively.

We’re also seeing a lot of growth into expanding what our capabilities are. Geriatric Medicine physicians probably see vastly more individuals with cognitive impairment and dementia than many other physicians. We have a new series of medications coming out, monoclonal antibodies, the ability to diagnose Alzheimer’s and other forms of dementia through, not just the clinical exams, but now through biomarkers and rapid development of science in that area. New imaging and diagnostic capabilities can now be coupled with interventions that are high-tech, and I think this exciting area will really propel geriatrics forward. We will be able to learn from that and apply it to other common problems that are aging-related, so I think that’s an area that really is an exciting growth opportunity.

There are also changes in how we deliver long-term care. Traditionally, we thought of nursing homes, but a lot of care is now being moved into the home and community setting. How do you do it efficiently and have the capabilities for rapid diagnostics and rapid response in that area? A number of different areas are rapidly expanding as we understand what aging is a little better, and how people respond as they age, whether it’s to treatments or interventions. There are new developments for a whole host of different conditions, such as new ways of identifying infections early.

The work we do at the Aging Institute at Pitt is focused on looking at drug discovery, not to treat aging as a disease, but to enable people as they age to respond to treatments better and to hopefully improve quality of life and reduce some of the morbidity that can happen at the extremes of life.

What are some hot topics in geriatrics here at Pitt?

There is a Center for Cognitive Health, which is our center for leveling the playing field for dementia care. It’s taking a population health approach to providing dementia-based care. A couple years ago, we were awarded a Hillman Healthy Aging Challenge grant from the Hillman Foundation to develop caregiver training. In the last 15 months, we have trained over 564 people as a caregiver for people living with dementia. That includes family caregivers, professional caregivers, intergenerational champions, those thinking about a career in healthcare, and others that have been trained and touched by this program.

We utilized that caregiver training as a guide for the CMS GUIDE Model program, which is a Center for Medicare and Medicaid innovation program that’s going to be here for eight years, through 2032, and takes a population health approach. This program moves dementia care from being episodic – only connecting with the doctor at visits – to allowing patients to have ongoing iterative care between those visits. It’s a wrapping of resources around the person, and we’ll take the caregiver training that we have and utilize it for part of this program. It has allowed us to expand our services. We are going to cover central and western Pennsylvania (20 counties), bringing care into not just the urban areas, but the inner-city areas that are underserved, and rural communities which don’t have access to this type of care. So, we’re excited because it will level the playing field for access to dementia care.

A number of fellows have wanted to do geriatrics and cardiology. Dr. Dan Foreman has really been focused on heart disease in older adults, especially on how to effectively treat it, what are the guidelines, what can be done in terms of physical fitness and wellness to address that and mitigate some of the impact or prevent some of the outcomes from occurring.

The Center for Bone Health is being run by Dr. Nami Safai Haeri, one of our former fellows who trained in both geriatrics and endocrinology. Dr. Susan Greenspan has also been doing osteoporosis and bone health in older adults. We’d like to build a stronger connection between geriatrics and endocrinology going forward.

I’ve recently had conversations with Dr. Melanie Königshoff regarding the Center of Lung Aging and Regeneration (CLAR) to brainstorm new opportunities, as well.

We take a two-pronged approach to addressing bench-to-bedside research at Pitt. Not only do we have the Aging Institute, we also have a lot of other research pockets, like the Lung Aging center, which focus on aging, its mechanisms, its impact, which focuses on bench research. Then, we have geriatric medicine, which is the clinical delivery, addressing the diseases and syndromes that occur commonly as you age. We have clinical care centers where we’re caring for individuals. We’re looking at how we deliver the care, and our research is focused around – from a clinical trial perspective – which drug works better, which population better. Then we have this opportunity with bench science, what we’re understanding and how we can start in preclinical and clinical trials, moving from bench to bedside. Having this two-pronged approach allows us to then collaborate back-and-forth.

One of our division’s greatest strengths is in the area of dissemination and implementation. We’ve had a number of projects where we were taking what we’ve already learned and should be doing and finding ways to actually have people do that in the real world. So, I think we have a nice spectrum from the bench all the way into implementation.

We see this population aging in the United States, and we see the excitement about what can be done in geriatric medicine. But the number of people actually entering geriatrics is going down. In 2023, we had 174 fellows match to geriatrics in the United States. If you do the math, that’s only a few per state. That doesn’t replace the number of people retiring, especially when you factor in that a significant number of those individuals don’t plan on staying in geriatrics. Only 42% of spots were filled nationally last year. If you look at the fill rate for programs, combining geriatrics internal medicine and geriatrics family medicine together, only 25% of programs filled. So, 75% of programs in the country were unfilled, and that’s concerning because the need is certainly growing.

We’re in the process of developing fellow-to-faculty pathways to address the shortage of geriatric faculty nationally, but one of the major things we’ve done here at Pitt is to rethink how we do our Geriatric Medicine fellowship, where we have four slots per year that we have set aside for the standard one-year geriatric training.

A big challenge for recruitment to a one-year geriatrics program is, if you become interested in geriatrics as a resident, it’s likely because you were in contact with someone at your residency program who was really good at geriatrics. And, chances are, that means there’s a strong geriatric program there. So, a resident can apply to fellowship programs and choose to go to another institution, possibly move across the country, and meet a group of people they’ve never met before, spending one year there. Or, that resident can choose to stay where they had that exposure to a good geriatric group. A lot of people are going to stay where they are, especially for a one-year slot.

This made us relook at our whole recruitment process, and as a result of those efforts, we had multiple individuals that matched. We also created a non-standardized training program for one of our trainees that wanted to stay on, so now there is an optional second year for geriatric medicine research to drive academic geriatrics that is offered to all new fellows in our program. We’re really excited that this coming year we have three residents from our internal medicine training program here at Pitt who have applied to our fellowship. It’s the first time we’ve had [Pitt/UPMC] residents apply to our fellowship in probably over a decade, and to have, not only one, but three apply!

We also received approval for a new Med-Geri program, which is three years of residency and one year of fellowship, allowing geriatrics to infuse the first three years. This provides a pathway where a resident will automatically know that their fellowship is in geriatrics. The program has two available slots, and our first candidate was accepted. So, in four years, we’ll have a geriatric medicine fellow confirmed already.

The interest level is there, and it’s an exciting thing for us.