Obstetrician/Gynecologist Care Considerations: Practice Changes in Disease Management with an Aging Patient Population

Abstract

Demographic changes across the country are leading to an increased proportion of older Americans. This shift will likely lead to changes in the patient population seen by obstetrician/gynecologists, and practices may need to adapt to the needs of older women. This article looks at mental health, sexual health, bone loss, cardiovascular disease and cancer as areas in which obstetrician/gynecologists may experience changes with the increasing age of patients. While this is by no means a comprehensive list of changing areas of practice, it offers a guide for reflecting on the future of obstetrician/gynecologists training, and the importance of considering the needs of older patients in practice.

Keywords

aging continuity of care geriatric obstetrician/gynecologist

As baby boomers approach older age and a growing proportion of the population lives to a greater age than previously seen, the medical implications of an aging population become increasingly important. In 2030, approximately 19% of the US population will be above the age of 65 years, as opposed to 2010 when that proportion was just 13% (Figure 1) [1,2]. The field of geriatric gynecology may grow in the face of this change, and other obstetrician/gynecologists (ob/gyns) may also begin to see older patients in their practices. Ob/gyns play an important role in screening for general health complaints, domestic violence, alcohol or drug use and mental health concerns [3], and recognizing that the unique health and social concerns of older women may become an increasingly necessary practice quality. Given the probabilty of a demographic shift in patients toward older age, it is important that the field of obstetrics and gynecology looks ahead at how best to meet the general health needs of these women.

Figure 1.

US population aged 65 years and older, 1950-2050.

There are other providers who could provide this care. However, given the regularity with which women see their ob/gyns, these physicians often provide the first line of medical care for women [3]. In addition, a desire among women for continuity of care throughout their lifetimes may lead patients to wish to see their ob/gyn provider into older age. It is with this context in mind that we look more closely at the responsibilities of ob/gyns in the face of shifts in patient demographics. In this article, we address several areas of women's health that may require increased attention from ob/gyn practitioners as the population of older women grows. While this list is by no means exhaustive, we discuss key areas of women's health in which ob/gyns might play an important role in recognizing, diagnosing or managing symptoms in older women.

Mood symptoms

Literature is emerging to suggest that an increasing number of older adults suffer from depression symptoms, and that over 10% have clinically significant depressive symptoms [4]. In addition, prevalence rates of depression are higher among older women than older men [5]. Individuals with other illnesses are more likely to experience depression than healthy individuals [6,7], and those who have depression have been found to have higher mortality rates [4]. Older individuals may be more likely to experience depressive symptoms related to social changes and physical disabilities, in addition to other life changes related to aging [4]. Treatment for older adults with depression is similar to that of younger adults; however, treatment can take longer to be effective [4]. While increased emphasis has been given in practice bulletins regarding the identification and treatment of depression in postpartum women, less has been done in the way of clarifying indications for older women experiencing depression symptoms. In particular, differential diagnoses of depression symptoms and other neurobiological processes, such as dementia, are important for physicians caring for elderly adults. Ob/gyns may be well poised to provide the necessary treatment to older women who experience depressive symptoms using recommended screenings and interventions [8].

Sexual health

Sexual dysfunction becomes more common in aging individuals and can be associated with adverse consequences for a person's quality of life [9]. In the face of an aging patient population, ob/gyns may encounter increased questions regarding sexual health and functioning from their patients. Research indicates that many individuals may respond to psychotherapy or pharmaceutical interventions, and continue on to have satisfying intimate lives well into old age [10]. In spite of this, many health practitioners report that they do not regularly screen for sexual dysfunction, or that they are affected by stereotypes that elderly individuals do not have active sex lives. Elderly people are also unlikely to discuss issues of sexual dysfunction without prompting [9]. Having a trusted ob/gyn who can refer one to those services is a resource that may become increasingly important for patients who feel that they cannot access resources through other sources of information [11]. In addition, ob/gyns should be on alert for sexual dysfunction as a possible symptom of other disease processes, such as cardiovascular disease, diabetes or depression [12]. HIV and other sexually transmitted infections occur with increasing frequency among older adults, and the risk of infection increases with partner changes following divorce or the death of a partner [13]. Ob/gyns should continue to inquire into the sexual practices of patients in later life, and elderly patients should be encouraged to practice ‘safer sex‘, for instance by using condoms.

Cardiovascular disease

Cardiovascular disease is a leading cause of death in women [14]. Various trends in wellbeing suggest that women may have increased risk factors for cardiovascular disease compared with men, such as hypertension, excess weight and diabetes [15]. Underlying cardiovascular conditions can contribute to cancer, chronic illness and other disease processes. In regular health checks, ob/gyns can provide an essential access point for women to receive screening for cardiovascular risk factors, including high cholesterol, blood pressure or diabetes. In addition, ob/gyns may be able to counsel patients about lifestyle factors, such as exercise, diet and reducing smoking, that would contribute to better cardiovascular health overall [14]. While ob/gyns are well acquainted with the cardiovascular risk factors associated with pregnancy, they may be less focused on making these same assessments among nonpregnant or older women. Assessment for cardiovascular risk factors; however, has been found to be less than optimal among ob/gyns, raising the concern that at-risk women may not be identified by their physicians [15,16]. By asking important questions of their patients during well-woman exams and by running regular screening tests with their patients, ob/gyns can potentially provide patients with early-warning information regarding cardiovascular disease risk, which may allow them to access healthcare or make lifestyle changes that could dramatically increase their lifespan [14,17]. While it is not within the scope of this article to discuss all possible interventions for cardiovascular disease prevention, resources are available to physicians looking for information on risk factors such as smoking [18], hypertension [19] and obesity [20], among others.

Bone loss

Bone loss increases in women as they age resulting in widespread health problems, including chronic pain and fractures [21]. In addition, these risks contribute to shortened lifespan and reduced quality of life [22]. Increased cognizance regarding the health impacts of bone loss in later life, as well as the increasing frequency of such cases in ob/gyn practices, may mean that ob/gyns should pay closer attention to possible signs of bone loss in their patients. Recognition of bone loss should begin early in a woman's life and continue onward, but becomes particularly important as she ages. Screening for bone loss using techniques, such as dual-energy x-ray absorptiometry, may be important for assessing a woman's likelihood of developing osteoporosis and other bone loss conditions; however, uncertainty remains over the interval at which changes in bone density can be detected between testing [23]. Important factors, such as late-stage menopause, family history, alcohol intake, sedentary lifestyle and lower BMI, may also contribute to accelerated bone loss, and ob/gyns should be alert for these risk factors [24]. If ob/gyns begin to provide more regular care to a greater proportion of older patients, they may be uniquely positioned to offer advice for self-care to women as they age, and to encourage the use of appropriate supplements and therapy.

Previous research has found that ob/gyns are knowledgeable about the importance of nutrition in maintaining the overall health of their patients, but their specific knowledge regarding calcium is varied [25]. This indicates an area for which further training and awareness may be helpful within the ob/gyn community. The Institute of Medicine (DC, USA) recommends 1200 mg/day of calcium and 600 mg/day of vitamin D for women aged over 51 years [26]. While controversies remain regarding the potential cardiovascular risks associated with over-consumption of these supplements, recommendations still endorse the overall health benefits of maintaining optimal levels of calcium and vitamin D [26,27].

Cancer

Certain cancers that predominantly affect women (e.g., cervical and breast cancers), as well those such as colorectal cancer, increase in frequency as women age; however, the utility of screening for some types of cancer decreases with advanced age [28]. The importance of cancer screening and referral services for oncological treatment are, therefore, relative to a woman's age and the likelihood of competing diseases, in addition to other risk factors. It is important that ob/gyns familiarize themselves with new guidelines in order to avoid unnecessary screenings, particularly for women in the 65–70-year age group [29]. Routine cancer screening for breast and colorectal cancer is recommended for women at and above this age group, and ob/gyns often hold an important role in both the detection and treatment of cancer in women, and may be the first medical professionals that a woman visits with symptoms. As increasing numbers of older women see their ob/gyns, there will likely be an increased need for alertness to risk factors and symptoms that may suggest cancer. Ob/gyns are often familiar with the guidelines regarding cancer screening (e.g., breast cancer screening), but given the growing body of evidence and information, as well as conflicting recommendations, the field may benefit from more specific guidelines and education [29]. Further information on recommendations on screening for breast, cervical and colorectal cancers are available through the US Preventive Services Task Force [30].

In addition, ob/gyns play a vital role in helping the increasing number of cancer survivors to cope with the transition after cancer [31]. This becomes particularly true for women who have complicated survivorship and struggle with psychological or other health concerns following remission. Ob/gyns can add value to the care that they provide by paying attention to post-cancer healing [31], as well as by collaborating with other healthcare providers, such as mental health practitioners, when providing care for cancer [3]. The Institute of Medicine recommends that cancer survivors be given details regarding continuing care and risks, as well as supportive information about healthy behaviors. The Institute of Medicine also recommends that appropriate information be given to patients regarding relevant follow-up care providers [32].

Dementia

As the mean population age rises, so does the prevalence of Alzheimer's disease and other dementia syndromes [33]. Women are more likely to develop Alzheimer's and other dementia-related diseases than men due to a longer life expectancy and other clinical factors [34]. Screening for these conditions has not historically been seen as a primary role for ob/gyns; however, understanding basic dementia assessment will be of vital importance as more patients fall into age groups that are vulnerable to dementia syndromes. Early specialized care for dementia patients can have significant impacts on the course of the disease and can substantially improve the quality of patients' lives. Early care; however, relies on early detection. As consistent care providers, ob/gyns may be well-positioned to observe and assess important behavioral and cognitive changes that accompany dementia conditions.

Although evidence is mixed [35], there is some suggestion that HRT may be beneficial in preventing the onset of Alzheimer's or reducing the severity of symptoms in some individuals [36 –38]. As further research in this area emerges, it is possible that ob/gyns will be part of the first-line treatment in the care of patients with dementia. Practitioners should be aware of best practices with regard to assessing for and managing dementia in older patients [39].

Elder abuse

An increasing elderly population also means that there has been a significant increase in reports of elder abuse over recent years, and that the occurrence of elder abuse continues to grow [40,41]. In a recent study, 10% of older participants reported some form of abuse in the past year [40]; however, it is likely that instances of abuse are even more common. Elder abuse may include psychological, physical, sexual or financial abuse of an elderly person. Abuse has been linked to significant psychological impairments in abused individuals, and also appears to contribute to significant health problems and increased mortality among the elderly [42]. As with younger patients, ob/gyns need to be alert to the signs of abuse in their older patients and to be aware of the necessary steps in the case of suspected abuse. Learning how to both recognize the signs of abuse, and treat an individual who has suffered abuse, may become critical for ob/gyns in coping with the changing demographic of their patients [43]. Elder abuse is an emerging area of research and, as such, little is known about ob/gyns' knowledge and practices regarding abuse of elders. Attention to relevant risk factors; however, such as a patient's living situation, may be an increasingly important aspect of medical history taking [43].

Grief

Grief and loss can occur at any stage in a person's life, but as a person ages the likelihood that they will experience a significant loss, such as the death of a spouse or parent, significantly increases [44]. Indeed, in 2010, 40% of all women over the age of 65 years were widows [45]. Widowhood and loss has been shown to have a negative psychological impact on the elderly [46]. While ob/gyns may not be the primary care providers for individuals who are suffering with extended grief, they may be well-positioned to identify patients who are struggling to cope with both the mental health and social implications of the loss of a loved one [44]. Training aimed at encouraging ob/gyns to ask about recent losses and to assess for subsequent mood problems may help to provide a first-line response in order to help grieving patients access available care, such as support groups or individual counseling.

Executive summary

An aging patient population

In 2030, 19% of the US population will be over 65 years of age.

This shift will likely lead to an increased presence of older women as patients in obstetrician/gynecologist (ob/gyn) practices.

Ob/gyns may be particularly well positioned to provide continuous care to women as they age.

Perimenopausal mood symptoms

Symptoms of depression can emerge during perimenopause; however, differences in presentation and treatment may make it harder for practitioners to recognize or manage.

Sexual health

Sexual health may decline in older age, but is often not addressed in regular health screenings.

Cardiovascular disease

Cardiovascular disease is the leading cause of death in women.

Ob/gyns provide an important point for risk-factor screening.

Bone loss

Bone loss in older age can contribute to a variety of health consequences and reduced lifespan.

Cancer

Practitioners must consider the utility of cancer screening among older women, while being alert for risk factors.

Caring for cancer survivors is an important aspect of practice, particularly among older patients.

Dementia

As the aging population grows, so too will the prevalence of Alzheimer's disease and other dementia diseases.

Practitioners must be informed on early recognition of such conditions in order to ensure early intervention when possible.

Elder abuse

At least 10% of elderly adults may have experienced abuse in some form.

Elder abuse may include psychological, physical, sexual or financial abuse of an elderly person.

Grief

Grief may be a common-presenting concern among older patients and can lead to long-term health consequences.

Future perspective

Training should be adapted in anticipation of the demographic shift in patient populations so that ob/gyns are aware of the changing health concerns of older women.

Conclusion & future perspective

The changing demographics of the USA mean that ob/gyns may experience a change in the make-up of their patient population and that a greater proportion of those patients will be older women. It is likely that ob/gyns will face some shifts in the emphasis of their caseload, which may, along with technological and innovative changes in the field, create new challenges for physicians. In particular, ob/gyns may see increasing presentation of certain age-related mental health concerns that are less common in a younger population. In addition, many health concerns, such as cardiovascular disease and cancer, which are becoming increasingly common in women in general, may be seen with even more frequency as the mean age of patients rises. This shift in demographics will likely lead to increased importance of collaborative care with other providers, both within and outside the field of women's healthcare [3]. In addition to these disease-specific challenges, ob/gyns will likely face increased need for disease prevention and health promotion in their practices, such as counseling on diet, weight loss and smoking cessation. Medical training programs and individual practices preparing for the possibility of seeing older women more frequently, and increased education about adjusted screening and interventions, may help the field to transition to a new age in women's care.

Financial & competing interests disclosure

This paper was supported by grant number UA6MC19010 from the Maternal and Child Health Bureau (Title V, Social Security Act, Health Resources and Services Administration, and Department of Health and Human Services). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

References

Papers of special note have been highlighted as:

of interest

of considerable interest

Vincent

Velkoff

. The Next Four Decades: the Older Population in the United States: 2010 to 2050 (No. 1138). US Department of Commerce, Economics and Statistics Administration, US Census Bureau, Washington, DC, USA (2010).

Provides a comprehensive look at future projections of population aging in the USA, as well as additional demographic information on the aging population.

Jacobsen

Kent

Lee

Mather

. America's aging population. Population Reference Bureau 66(1), 1–20 (2011).

Farrow

Lawrence

Schulkin

. Women's healthcare providers' range of services and collaborative care. J. Healthc. Qual. doi: 10.1111/j.1945-1474.2012.00216.x (2012) (Epub ahead of print).

Thomas

O'Brien

. Mood disorders in the elderly. Psychiatry 8(2), 56–60 (2005).

Chang-Quan

Xue-Mei

Bi-Rong

Zhen-Chan

Ji-Rong

Quing-Xiu

. Health status and risk for depression among the elderly: a meta-analysis of published literature. Age Ageing 39, 23–30 (2010).

10.

Moser

Draccup

Evangelista

Comparison of prevalence of symptoms of depression, anxiety and hostility in elderly heart failure, myocardial infarction and coronary artery bypass graft patients. Heart Lung 39(5), 378–385 (2011).

11.

Provides an analysis of factors contributing to perimenopausal depression, including both hormonal and psychosocial factors.

12.

Barry

Allore

Guo

Bruce

Gill

. Higher burden of depression among older women: the effect of onset, persistence and mortality over time. Arch. Gen. Psychiatry 65(2), 172–178 (2008).

13.

Flood

Buckwalter

. Recommendations for mental health care of older adults: part 1 – an overview of depression and anxiety. J. Gerontol. Nurs. 35(2), 26–34 (2009).

14.

Lindau

Schumm

Laumann

Levinson

O'Muircheartaigh

Waite

. A study of sexuality and health among older adults in the United States. N. Engl. J. Med. 357(8), 762–774 (2007).

15.

Yang

Toy

Baker

. Sexual dysfunction in the elderly patient. Prim. Care Update Ob. Gyns 7(6), 269–274 (2000).

16.

Langer-Most

Langer

. Aging and sexuality: how much do gynecologists know and care? J. Women Aging 22(4), 283–289 (2010).

17.

Provides a specific look at the role of gynecologists in assessing and caring for sexuality concerns among older women.

18.

Camacho

Reyes-Ortiz

. Sexual dysfunction in the elderly: age or disease? Int. J. Impot. Res. 17, S52–S56 (2005).

19.

Minicheiello

Hawkes

Pitts

. HIV, sexually transmitted infections, and sexuality in later life. Curr. Infect. Dis. Rep. 13, 182–187 (2011).

20.

Mosca

Benjamin

Berra

Effectiveness-based guidelines for the prevention of cardiovascular disease in women – 2011 update: a guideline from the American Heart Association. J. Am. Coll. Cardiol. 57(12), 1404–1423 (2011).

21.

Schmittdiel

Selby

Swain

Missed opportunities in CVD prevention? Low rates of hypertension recognition for women at medicine and obgyn clinics. Hypertension 57(4), 717–722 (2011).

22.

Looks specifically at assessment for cardiovascular disease risk factors in women in obstetrics/gynecology practices.

23.

Barnhart

Lewis

Houghton

Charney

. Physician knowledge levels and barriers to coronary risk prevention in women: survey results from the Women and Heart Disease Physician Education Initiative. Womens Health Issues 17(2), 93–100 (2007).

24.

Hirsch

Allison

Gomes

Corriere

Duval

Ershow

. A call to action: women and peripheral artery disease: a scientific statement from the American Heart Association. Circulation 125, 1449–1472 (2012).

25.

Fiore

Jaen

Baker

Treating Tobacco Use and Dependence: 2008 Update. US Department of Health and Human Services Public Health Service, Rockville, MD, USA (2008).

26.

Aronow

Fleg

Pepine

ACCF/AHA 2011 expert consensus document on hypertension in the elderly. J. Am. Coll. Cardiol. 57(20), 2037–2114 (2011).

27.

Han

Tajar

Lean

. Obesity and weight management in the elderly. Br. Med. Bull. 97, 169–196 (2011).

28.

Vasikaran

Eastell

Bruyère

; IOF–IFCC Bone Marker Standards Working Group. Markers of bone turnover for the prediction of fracture risk and monitoring of osteoporosis treatment: a need for international reference standards. Osteoporosis Int. 22(2), 391–420 (2011).

29.

Matityahu

Elson

Morshed

Marmor

. Survivorship and severe complications are worse for octogenarians and elderly patients with pelvis fractures as compared with adults: data from the National Trauma Data Bank. J. Osteoporosis 2012, 475739 (2012).

30.

Gourlay

Fine

Preisser

Bone-density testing interval and transition to osteoporosis in older women. N. Engl. J. Med. 366(3), 225–233 (2012).

31.

Sowers

Zheng

Jannausch

Amount of bone loss in relation to time around the final menstrual period and follicle-stimulating hormone staging of transmenopause. J. Clin. Endocr. Metab. 95(5), 2155–2162 (2010).

32.

Identifies, with greater specificity, the staging of bone-loss acceleration in older women.

33.

Power

Holzman

Schulkin

. Knowledge and clinical practice regarding calcium nutrition among obstetrician–gynecologists. Obstet. Gynecol. 94(3), 421–426 (1999).

34.

Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. The National Academies Press, Washington, DC, USA (2011).

35.

Miller

Baraldi

. Geriatric gynecology: promoting health and avoiding harm. Am. J. Obstet. Gynecol. 207(5), 355–367 (2012).

36.

Heaney

Kopecky

Maki

Hathcock

MacKay

Wallace

. A review of calcium supplements and cardiovascular disease risk. Adv. Nutr. 3, 763–771 (2012).

37.

Anderson

Pearlman

Griffin

Schulkin

. Conflicting and changing breast cancer screening recommendations: survey study of a national sample of ob-gyns after the release of the 2009 USPSTF guidelines. J. Healthc. Qual. 35(4), 25–35 (2013).

38.

US Preventive Services Task Force. Guide to clinical preventive services. Office of Disease Prevention and Health Promotion, Washington, DC, USA (2010). www.uspreventiveservicestaskforce.org/recommendations.htm

39.

Salani

Andersen

. Gynecologic care for breast cancer survivors: assisting in the transition to wellness. Am. J. Obstet. Gynecol. 206(5), 390–397 (2012).

40.

Institute of Medicine. From Cancer Patient to Cancer Survivor: Lost in Transition. Hewitt

Greenfield

Stovall

(Eds.). The National Academies Press, Washington, DC, USA (2006).

41.

Thies

Bleiler

; Alzheimer's Association. 2013 Alzheimer's disease facts and figures. Alzheimers Dement. 9(2), 208–245 (2013).

42.

Wilson

Weir

Leurgans

Sources of variability in estimates of the prevalence of Alzheimer's disease in the United States. Alzheimers Dement. 7(10), 74–79 (2011).

43.

Schulkin

. Medical Decisions, Estrogen, and Aging. Springer, NY, USA (2010).

44.

Pinkerton

Henderson

. Estrogen and cognition, with a focus on Alzheimer's disease. Semin. Reprod. Med. 23(2), 172–179 (2005).

45.

Wharton

Baker

Gleason

Short-term hormone therapy with transdermal estradiol improves cognition for postmenopausal women with Alzheimer's disease: results of a randomized controlled trial. J. Alzheimers Dis. 26(3), 495–505 (2011).

46.

Pike

Carroll

Rosario

Baron

. Protective actions of sex steroid hormones in Alzheimer's disease. Front. Neuroendocrin. 30(2), 239–258 (2009).

47.

Flood

Buckwalter

. Recommendations for mental health care of older adults: part 2 – an overview of dementia, delirium, and substance abuse. J. Gerontol. Nurs. 35(2), 35–47 (2009).

48.

Acierno

Hernandez

Amstadter

Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment study. Am. J. Public Health 100(2), 292–297 (2010).

49.

Dong

Simon

. Enhancing national policy and programs to address elder abuse. J. Am. Med. Assoc. 305(23), 2460–2461 (2011).

50.

Addresses possible policy changes aimed at reducing the impact of elder abuse.

51.

Dong

Simon

Beck

Elder abuse and mortality: the role of psychological and social wellbeing. Gerontology 57, 549–558 (2010).

52.

Baker

Sugar

Eckert

. Sexual assault of older women: risk and vulnerability by living arrangement. Sex Res. Soc. Policy 6(4), 79–87 (2009).

53.

Todd

Baker

III . Grief, mourning, and bereavement: a guide for the ob/gyn. Prim. Care Update Ob. Gyns 5(6), 311–314 (1998).

54.

Fowles

Greenberg

. A Profile of Older Americans: 2011. Administration on Aging, US Department of Health and Human Services, Washington, DC, USA (2011).

55.

Momataz

Ibrahim

Hamid

Yahaya

. Mediating effects of social and personal religiosity on the psychological well being of widowed elderly people. Omega (Westport) 61(2), 145–162 (2010).