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In response to the changing demographics and the demand for self-health promotion by well-but-worried older adults, Dr. Mathew Maurer, Irving Assistant Professor of Medicine at CUMC, along with several colleagues formed the Columbia University Cooperative Aging Program (CCAP) two years ago. CCAP is a training ground for doctors that focuses on a "new" geriatric population – those who are still in relatively good health but are at risk for functional decline. Here, Dr. Maurer talks about the importance of exposing doctors-in-training to elderly adults who are aging in a way that doesn't fit the stereotype.

The growing population of elderly individuals in the United States will undoubtedly have a major impact on the practice of medicine and health care costs. Because of this new reality, there is an urgent need to develop geriatrics programs of a size and scope comparable to those of other academic disciplines. Based on the basic tenets of geriatric medicine (see sidebar), faculty at Columbia developed the Columbia University Cooperative Aging Program (CCAP) as a way to create a new model of care for older individuals aimed at forestalling functional decline.

Based at the Allen Pavilion of New York-Presbyterian Hospital and Columbia University Medical Center in northern Manhattan, the CCAP team, which includes medical residents, geriatricians, internists, cardiologists, geriatric nurse practitioners and occupational therapists, has for the past two years delivered an extensive clinical evaluation and geriatric management plan to healthy older adults. The service and follow-up assessments are free for participants.

The program, which is affiliated with 11 community-based senior centers in Manhattan and the Bronx, has recruited more than 130 functional older individuals in its first two years of operation. CCAP participants receive extensive information about health and well-being and are strongly motivated to obtain recommendations about any proactive steps they can take to stay healthy. In addition to comprehensive assessments and evaluations, CCAP also provides participants with a monthly preventive-health newsletter and educational events at the Allen Pavilion, which are designed to help ease isolation among the elderly by fostering a sense of community and to promote a sense of commitment to the program. At the same time, these events also serve to educate physicians-in-training about the resources available to their patients at community centers.

Tenets of Geriatric Medicine

The onset of a new disease in an elderly person generally affects an organ system made vulnerable by prior physiologic and pathologic changes.

Because of this impaired physiologic reserve, older patients often present at an earlier stage. Since many homeostatic mechanisms may be compromised concurrently, multiple abnormalities are usually amenable to treatment, and small improvements in each may yield dramatic benefits overall.

Because the older patient is more likely to suffer the adverse consequences of disease, treatment – and even prevention – may be equally or more effective than in the younger patient.

According to pilot studies conducted by CCAP, a majority of adults 75-80 years old who attend senior centers report their own health as being "good to excellent" when compared with others their age, but almost two-thirds are worried about being able to keep up activities such as shopping, going to senior centers, using public transportation, and spending time with grandchildren. CCAP faculty cite this as the major motivator for participation. Many of the patients want to attend the CCAP program, despite being functional and leading active lives, because they have a sense that they are vulnerable to functional decline.

By focusing on an older population that is aging "successfully," CCAP provides a novel face of geriatrics for young physician trainees, allowing them the opportunity to interact with healthy older adults and to develop unique approaches to geriatric care. In addition, by giving trainees an opportunity to conduct an expanded medical interview with those in other disciplines, and the time to reflect upon this interaction, CCAP aims to improve the breadth and depth of communication skills among physicians-in-training, elderly health care recipients and the entire health care team.

As part of their geriatric rotation experiences, first-year medical residents at CCAP conduct a comprehensive, structured interview and evaluation with one or two CCAP participants. They explore a patient's function by using the modified ClinCARE tool developed by the Stroud Center for the Quality of Life at Columbia University, which evaluates multiple domains of function particularly relevant to the field of geriatrics in order to evaluate an individual's quality of life, with special attention to detection of the risks and early signs of declines, identification of the elder's strengths, understanding the elder as a whole person, and following the course of the elder's quality of life over time.

The interviews also explore socioeconomic backgrounds, psychological profiles, physical function and health care beliefs, providing a rich trove of information for the health care team to integrate and assist in developing an effective health care plan. Each year the program seeks to add new participants to the existing cohort of 130 members, who are offered follow-up interviews approximately every 18 months. A major research focus is to assess the ability of such a comprehensive approach to improve diagnosis and management of chronic illnesses that afflict many elderly people. By focusing on early and subtle manifestations of clinical disorders – what have been termed "minimal clinical syndromes" – we may be able to intervene earlier and alter the trajectory of many older individuals.

The CCAP approach is client-centered. By providing education and guidance, subjects can better direct their own care, engaging in certain activities or therapies that can prevent decline and promote health. We are interested in having our clients utilize their positive qualities and coping mechanisms in managing their chronic issues. We want participants to leave the interview inoculated with the strength of their own life experiences and suggestions about how they might live longer and feel better.

To learn more about the Columbia Cooperative Aging Program or to refer a client, call 212-932-4384 or 212-932-4909.


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