Introduction

 

As the US population increases in average age, the demand for healthcare, and thus laboratory testing, increases dramatically.  In addition to a greater demand for services, the following concerns affect the laboratory:

·         Specimen collection issues unique to a geriatric population

·         Interpersonal skills required for dealing with the geriatric patient

·         Reference ranges evaluation for a changing demographic cohort

·         Need for clinical laboratory professionals to interpret laboratory data in view of a patient’s age and concomitant physiology/pathology

·         Access and affordability of health care services

·         Need for laboratory professionals to conduct research to expand the knowledge and practice of geriatric laboratory medicine

 

In accordance with the ASCLS mission and vision of “excellent, accessible and cost effective laboratory services”, the way services are provided for the geriatric population needs to be examined and adapted to meet the needs of this growing demographic group.

 

Projections

 

a. The geriatric population

 

As of the 2000 census, 16.3% of the population is over 60 years of age, a 12% increase in this demographic group since 1990. Based on Bureau of the Census population projections released in 1996, a moderate increase in the geriatric population is projected until 2010 bringing this group to 39 million, an increase of 17%. A rapid increase from 2010-2030 to 69 million will follow, an increase of 75%. From 2030-2050, the growth rate is projected to increase another 14%, bringing the geriatric population to 79 million.¹ 

 

b. Health care needs

 

The demand on the healthcare system by geriatric patients is different from the rest of the population. Projections indicate that healthcare, which has  historically focused on acute care, will be challenged with an increasing need to shift its emphasis to meet the needs of the chronically ill. As the population ages, increases in the occurrences and effects of many chronic diseases - cancer, arthritis, hypertension, diabetes and chronic pulmonary disease - are expected.

 

Steady increases in physician office visits and the use of hospitals and skilled nursing facilities by this population are expected. With time, projections indicate the impact on home care services will be more pronounced. A corresponding increased demand for laboratory services is also occurring.  The Bureau of Labor Statistics estimates that between 1998-2008, the volume of laboratory testing will increase by 17%.²  This is due to a combination of forces, including an aging population that places more demand on the system. These changes further stress a healthcare system experiencing significant personnel shortages.  For the same 10-year period, it is anticipated that 9,300 new laboratory positions will be created annually due to increased demand and retirement of current professionals.  At present, the clinical laboratory profession educates fewer than 5,000 laboratory professionals per year.  The increasing shortage of competent laboratory professionals will create a significant access issue for our industry that may affect provision and quality of health care services to the geriatric population.

 

c. Projected healthcare and laboratory needs

 

The total healthcare expenditures in the United States have increased from $214.6 billion in 1980, to $1130 billion in 2000 and are predicted to rise to a projected $2267 billion in 2010. From 1980 to 2000, out-of-pocket expenses for health care consumers rose from $58 to $189.5 billion. However, out-of-pocket expenses have decreased as a percentage of the total expenditures (27.1% in 1980 to a projected 16.4% in 2010) while the percentage of funding from the government has risen (40.3% in 1980 to a projected 44.0% in 2010). As the population ages, the amount expended by the government for healthcare is expected to rise substantially.³

 

At a time when demand is increasing, the supply of qualified laboratory professionals and other allied health professionals is shrinking. Shortages of healthcare professionals are expected to create health care quality and access issues. Rural areas are expected to experience the greatest shortages and therefore access to quality healthcare will be affected if small hospitals and ambulatory care providers are forced to close or consolidate. It is documented that over the last 10 years 2 to 4% of people aged 65 and older had difficulty obtaining the care they needed, while 6% actually delayed care due to the rising costs and out-of-pocket expenses. These findings are expected to continue and worsen as the geriatric population increases.³

 

d. Impact on test volumes and menus, laboratory staff needs, and access to services

 

Utilization of health care services by geriatric patients has been increasing steadily. In 1990, there were 300 hospital stays per 1000 elderly people. This rose to 380 in 1998. Skilled nursing stays increased from 10 per 1000 in 1990 to 75 per 1000 in 1998.

 

Laboratory test volumes are expected to increase during the 1998-2008 period. This is due to primarily two reasons – the aging of the population and the explosive development of new tests related to the completion of the human genome project and other scientific developments. In addition, as people live longer, they utilize more services.

 

Medicare currently accounts for 17% of the healthcare dollars. This percentage is projected to rise over the next twenty years and the widely publicized deficits in the Medicare program become reality. However, only about 3% of the total Medicare expenditures are related to laboratory services. Since 1984, the laboratory is the only sector of healthcare for which reimbursement has declined. During the same period, salary and supply costs rose. These factors in turn exacerbate the laboratory personnel shortage. Reduced reimbursements, increased costs, and the personnel shortage result in threats to quality of laboratory services and reduced access to testing.  A recent movement to perform a demonstration project for competitive bidding further threatens the laboratory’s ability to maintain quality and service.³

 

Geriatric Issues Impacting Clinical Laboratory Practice

 

a) Patient interaction and specimen collection

Geriatric patients may be subject to loss of hearing, eyesight, mental acuity, mobility, and loss of control/independence, all of which affect their emotional states. Many have minimal experience with illness or the healthcare environment, resulting in a fear of the unknown. These factors demand that, during interaction with the geriatric patient, the clinical laboratory professional must explain the process clearly, with patience and understanding, and treat geriatric patients with dignity and respect. To the extent possible, the geriatric patient must also be included as an active and informed participant in the process.

 

Another area of concern is specimen collection from the geriatric patient. Certain geriatric specimen collection requirements are unique.^{4, 5} Urine specimen collection may require thorough explanation as well as physically assisting the patient. Blood collection is more difficult than with younger patients due to the thinning and increased fragility of epithelium and subcutaneous tissue resulting from the aging process. Muscle mass is decreased resulting in an increased need to anchor the vein when phlebotomy is attempted. The skin must be held taut to increase vein stability, the arm should not be excessively touched or handled, and maximum pressure must be placed on the venipuncture site for several minutes to avoid hematomas and purpura.  Increased hypersensitivity and allergic reactions need to be considered to prevent adverse reactions to the phlebotomy or other specimen collection procedures. Specimen collection procedures must be developed to best serve the needs of geriatric patients by taking these age-related physiologic changes into consideration.

 

ASCLS supports and participates in educating laboratory practitioners to develop and practice effective and compassionate interactions with the geriatric patient and encourages the development of appropriate procedures, techniques and equipment for geriatric specimen collection.

 

b) Increased demands for point-of-care testing

 

Geriatric patients with chronic illnesses are frequently referred either to extended care facilities or to at-home care. The patient’s distance from the laboratory provider requires a critical assessment of specimen collection and transportation issues that might affect quality test results. It also increases the likelihood of more decentralized, point-of-care testing. Point-of-care educators, including laboratory practitioners, must verify that a geriatric patient has the mental capacity and motor skills to engage in self-care testing tasks.

 

ASCLS supports the active participation of clinical laboratory professionals in the development of testing modalities, the education of non-laboratory personnel responsible for testing, as well as the supervision and evaluation of all processes associated with the generation of test results.

 

c) Analysis of geriatric patient specimens

The following factors and complex interactions may alter or compromise the specimen and/or the subsequent test results in ways not commonly encountered in younger patients:

• Chronic disease,
• Muted symptoms,
• Responses to acute diseases (frequently observed in this population),
• Increased frequency of immunopathologies such as autoimmune diseases,
• Age-related changes in hormone production, metabolism, action, diet, and reduced physical activity.

Specimen analyses and the interpretation of results should be performed with these factors in mind to provide accurate and meaningful data. An example is asymptomatic bacteriuria, frequently encountered with geriatric patients, during which decreased, but significant, colony counts and growth of diagnostic organisms occur in patients with muted (or no) symptoms.⁶   This example demonstrates that geriatric values obtained from analyses must be evaluated and interpreted in relation to the specimen and the patient.

 

ASCLS supports and participates in educating laboratory practitioners to anticipate and appropriately respond to geriatric-specific situations affecting specimen quality and/or the interpretation of test results.  ASCLS encourages clinical laboratory professionals to establish criteria for the analysis of geriatric patient specimens to maximize accurate and useful interpretation of test results.

 

d) Interpretation of geriatric patient data

Clinical laboratory test values from geriatric patients must be interpreted differently when compared to those of younger patients. Lack of awareness by the laboratory practitioner of pertinent and unique aspects of geriatric clinical testing may result in inaccurate interpretation of test results and subsequent dissemination of these results to the primary care provider.⁶ Providers may utilize the information for diagnosis and treatment through comparison to reference ranges established on younger adults that may not be applicable to the geriatric patient.

  

ASCLS supports and participates in educating laboratory practitioners and other healthcare professionals about differences that may be seen with geriatric laboratory specimens as compared to those of younger adults.

 

The uniqueness of geriatric clinical laboratory results may have been missed in the past due to shorter life spans resulting in fewer geriatric specimens for testing. Longer life expectancies have resulted from medical advances, improved access to care under Medicare, and increased emphasis on maintaining healthy lifestyles.⁷ In addition, recent increases in the number of medical studies on geriatric patients and the presence of more informed healthcare consumers among this population have contributed to an urgent call for the establishment of age-appropriate criteria for the analysis and interpretation of geriatric laboratory tests.

 

ASCLS encourages the development of reliable criteria to be used with geriatric laboratory test interpretation.

 

e) Reference values for the geriatric population

Some laboratory values change with age and others do not, and in some cases studies performed by using a random well-defined population to establish relevant reference ranges have not been performed.⁸ Limited geriatric reference values are currently available. What is a “healthy” geriatric individual? The presence of multiple chronic and possibly acute diseases and the variety of medications taken by the geriatric patient create challenges when one attempts to evaluate test results in the geriatric population. Reference ranges in the past have been established for healthy middle-aged adults. In the geriatric population, variation around the patient’s homeostatic “set-point” provides the most valuable “reference range” to determine within-patient variations that are significant for diagnosis and treatment of each specific geriatric individual.⁹

  

ASCLS supports and participates in educating laboratory practitioners and other healthcare professionals concerning the relevance of  “reference ranges” and encourages activities that support and implement research to establish laboratory test reference ranges that are appropriate for interpretation of geriatric test results.

 

f) Common illnesses/lab tests particularly relevant to geriatric patients

There is some variation in recommendations for preventive (or wellness) geriatric laboratory testing. The standard preventive medicine list includes: non-fasting total cholesterol every 5 years over 65 years of age; glucose testing after age 45 to detect type II diabetes; tuberculosis (TB) testing; thyroid function tests (especially in females) and reagent strip urinalysis to detect hematuria, bacteruria and proteinuria over age 65.  Early cancer screening tests currently recommended include the prostate specific antigen (PSA) in males up to age 75, PAP smear in females up to age 69, and fecal occult blood test for all after age 50.^{9,10, 11, 12} 

 

Some screening tests depend on normal antibody production in response to illness, and the results of these analyses may be inaccurate for the geriatric patient. For example, the decreased immune response observed in the geriatric population will result in tests such as the erythrocyte sedimentation rate (ESR) appearing within the normal reference range despite the presence of inflammation and other immune response stimulants.

 

ASCLS supports the expansion of the Body of Knowledge to include expertise in analysis and interpretation of both routine preventive geriatric tests as well as cancer screening tests.

 

g) Education of patients and healthcare professionals concerning geriatric tests/results

 

The caretakers of geriatric patients should be encouraged to participate in and understand the testing process and the test significance in health management. The ability of primary care physicians to order laboratory tests efficiently and effectively and interpret results is important to promote:

• More accurate diagnosis and monitoring of disease.
• Improvement in quality of care through appropriate therapy and shorter hospital stays.
• Decreased cost to the patient.⁸

The role of the clinical laboratory professional is to participate in the design of any order requisition process, including electronic entry, as well as the decision making process that leads to ordering and interpretation of clinical laboratory results by the primary care provider.

 

ASCLS supports the educational preparation of clinical laboratory practitioners to participate as active members of the healthcare team and encourages primary care providers to fully utilize clinical laboratory professionals’ expertise through consultation.

 

h. Determination of Medical Relevance/Outcomes

 

As the number of persons over 65 increases and as the healthcare system improves geriatric care, the need for laboratory services will increase. Studies are necessary to identify test menus that provide laboratory results shown to be medically relevant, routinely available, and necessary to improved outcomes for the geriatric patient. As these issues increase the complexity of healthcare decision making, clinical laboratory professionals will require increasingly sophisticated competencies, such as those required to conduct outcomes research.

 

ASCLS supports the development of outcomes research that provides medically relevant data useful for medical decision-making. ASCLS supports and participates in educating laboratory practitioners for this future need.

 

i. Response to the personnel shortage

 

The current personnel shortage is projected as both acute and long-term, thereby requiring significant creative and strategic initiatives. The shortage is exacerbated by the requirements of the growing geriatric population.

 

ASCLS participates in efforts to address the current laboratory personnel shortage through a focused legislative agenda, continued support of accreditation of educational programs and certification of graduates, and development and implementation of innovative public education and recruitment goals.

 

Summary

 

ASCLS strives to promote “excellent, accessible, and cost effective laboratory services”. ASCLS provides leadership in examining and enhancing laboratory services to meet the healthcare needs of the growing geriatric population. ASCLS:

• Supports and promotes compassionate interactions with geriatric patients.
• Encourages the development of improved specimen collection procedures for the geriatric patient.
• Supports participation, evaluation, and supervision by laboratory practitioners in point-of-care testing of specimens from geriatric patients.
• Promotes through provision of educational opportunities the appropriate responses by laboratory practitioners to geriatric-specific situations regarding specimen collection and/or test interpretation.
• Encourages the establishment of criteria for accurate and useful interpretation of geriatric test results.
• Encourages new research to establish laboratory reference ranges that are appropriate and useful for the interpretation of geriatric test results.
• Promotes the education of healthcare practitioners concerning the uses of “reference ranges” appropriate to geriatric patients.
• Promotes expansion of the Body of Knowledge to include expertise in analysis and interpretation of geriatric test results
• Supports and promotes the educational preparation of laboratory practitioners to participate as consultative members of healthcare teams providing services to geriatric patients.
• Encourages primary care providers to utilize through consultation the expertise of laboratory practitioners when making medical decisions regarding geriatric patients.
• Supports and promotes the development of outcomes research that provides medically relevant data for medical decision-making regarding geriatric patients.
• Promotes efforts to alleviate the laboratory personnel shortage such that geriatric patients may readily access quality healthcare services.

 

Cited References

 

1.        Aging into the 21^st century. (May 31, 1996) Administration on Aging. National Aging Information Center. (This special report was prepared by Jacob Siegel under contract number HHS-100-95-0017 with the Administration on Aging, U.S. Department of Health and Human Services.) Accessed at: www.aoa.dhhs.gov/aoa/STATS/aging21/demography.html on July 9, 2002.

2.        2000 Bureau of Labor Statistics Report.

3.        http://www/hcfa.gov/stats/nhe-proj/proj2001/methodology/

4.        Garza D. Tailoring phlebotomy to the patient. ADVANCE for Medical Laboratory Professionals. 11(4):7-10. 1999.

5.        Garza D and Becan-McBride K. Phlebotomy Handbook: Blood Collection Essentials, 6^th Edition. Prentice Hall, New Jersey. 2002.

6.        Mellilo DD. Interpretation of laboratory values in older adults. Nurse Practitioner. 18(7):59-67.

7.        Cassel, C.K.  How increased life expectancy and medical advances are changing geriatric care.  Geriatrics, 56(1): 35 – 40, 2001.

8.        Duthie WH and Abbasi AA. Laboratory testing: Current recommendations for older adults. Geriatrics. 46(10):41-50. 1991.

9.        Noble D. Geriatric ranges needs in TDM. Clinical Chemistry News. 17(9):1,8-9. 1991.

10.     Bloom, H.G. Preventive Medicine: When to screen for disease in older patients.  Geriatrics, 56(4): 41 – 45, 2001.

11. AARP. http://aarp.ort/confacts/healthy/tests.html. Accessed 7/15/02. No update date given. Copyright 1995-2002.
12. Gambert S.R. Prostate Cancer: When to offer screening in the primary care setting.  Geriatrics, 56(1): 22 – 31, 2001.