I'm Dr. Glimcher, dean of Weill Cornell Medical College. Today, I'm speaking with Dr. Mark Lachs, who is the co-chief of the Division of Geriatric Medicine. Dr. Lachs is particularly interested in extinguishing elder abuse and promoting healthy aging.
LAURIE H. GLIMCHER: Mark, thanks for taking the time to meet with me and talk about an issue that you and I both think is very important. Several weeks ago you spoke on the panel of the seventh annual World Elder Abuse Awareness Day at the White House where you called elder abuse an epidemic. That's a word that none of us takes lightly. Why did you use such a strong word?
MARK LACHS: Well, Laurie, I'm an epidemiologist. I don't take it lightly, either. In the last year, we completed one of the largest studies of elder abuse prevalence, interviewing 4,000 older adults. Over 7 percent endorsed having experienced elder abuse just within the past year. Over half of those cases — over 4 percent — were cases of financial exploitation. Any disease that afflicted 7 percent of the population, by any epidemiologic definition, would be considered an epidemic.
GLIMCHER: It sounds like an epidemic; 7 percent is a horrifying number. Did you do this in collaboration with Cornell University?
LACHS: I did. Cornell University is home to one of the eminent aging programs generally, and around elder abuse specifically, and is led by a colleague of mine, Karl Pillemer. We've collaborated for 20 years in this field. I also made use of the Cornell Survey Research Institute, which is a magnificent shop that is responsible for the many important surveys around many topics of public health. This was, to our knowledge, the largest study of its kind, and really sampled very scientifically from every corner of the state — rural, urban. There was a Spanish language version of the questionnaire. So it's a really good comprehensive view of elder abuse in New York state. What was also compelling was we simultaneously looked at reports that officially came to the awareness of the state through formal reporting mechanisms and found that for every case that was self reported, about 25 go unreported. So the underreporting rates are remarkable. We call the study under the radar for that reason. We know that for all forms of family violence, for every case you find, you miss many others. And we know that, in the case of child abuse, we miss many. The problem is worse in elder abuse because older adults are frequently isolated. A child comes to school with a black eye or doesn't come to school, there's a modern day equivalent of a truant officer who investigates. But often in elder abuse, it's only the victim and the person doing the abusing or neglecting who is in the orbit of that individual. That's why I tell the residents who I train around these issues is that annual physical may be the only opportunity to intervene.
GLIMCHER: Do you think that the high incidence of financial abuse has anything to do with the economy tanking in 2008?
LACHS: That's a very sophisticated question and the answer is yes. Interviews were conducted in about 2008 - 2009. We were simply stunned about not only minor financial exploitation, but people getting deeds to houses, credit cards, bank statements. And it's a huge public health issue. People don't think of elder abuse as a public health problem. Dr. Pillemer and I, in the late '90s, published a study that showed elder abuse victims, after adjusting for their comorbidity, their chronic medical conditions and other factors that predict death, have a three-fold risk of death. So these victims, Laurie, behave like people with chronic medical illness. When they're financially exploited and there are no resources left for their care, they effectively become wards of the state. We all pay. They become Medicaid recipients. And this is something the administration has taken notice of and to be speaking at the White House was truly an honor.
GLIMCHER: What was it like?
LACHS: It's been a lonely field for 20 or 25 years. Domestic violence among younger folks and child abuse really, very reasonably, had the front stage and we have sort of been banging this drum quietly. To be sitting there with Secretary Sebelius and the other dignitaries was simply remarkable. We all had to kind of stop and pinch ourselves that our efforts really had gained momentum.
GLIMCHER: Do you think that public awareness has been raised recently by the Brooke Astor case?
LACHS: Well, the Astor case really lit a fire under the news media and under the public. Here was a woman with a magnificent history of giving, was socially connected, and still managed to be financially exploited. The other point that I would make about financial exploitation and the ways it affects society — many of the cases we become involved with involving financial exploitation where an unscrupulous financial agent or someone from outside of the family gets those resources, often those monies were destined for the Boys Club, your synagogue, your church, the Central Park Conservancy. Even if you don't have an older person in your life, effectively elder abuse affects you. It's so pervasive and so important. As an internist, I care for a lot of patients. I'm really good at adjusting insulin and futzing with blood pressure medication, and it goes up and it goes down. You extricate someone from an abusive environment, it's life changing. You want to see quality of life change. It's simply remarkable.
GLIMCHER: Do most elders who are abused get rescued or is this a minority?
LACHS: Most don't. Often the adult child who is abusing may be drug addicted or have a mental illness, which is the basis for their abusive behavior. They may not recognize that it's abusive. There's a great deal of shame on the part of the person being abused or neglected, unwilling to come forward or press charges, and that's completely understandable. Or that patient may be cognitively impaired. Their true wishes are not known or they're hidden from a social network that can effectively extricate them. In response to that, Weill Cornell has created, along with partners in New York City, the New York City Elder Abuse Center, which is this remarkable multi-disciplinary group of people from social work, law enforcement, housing, spearheaded by my division here at the Medical College. Modeled after child abuse, the Center brings together all the relevant people who can come together to help with these cases. The reasons people get into problems with domestic violence, it's not just one thing. It's not just mental health or poverty. It's multifactorial, and to think a single pediatrician could solve child abuse problems or a single geriatrician on his own can solve elder abuse problems is really quite naive. It's been three or four years now. It's got remarkable momentum. It's one of the great stories about the way Weill Cornell is interacting with senior centers and agencies throughout the city. We tend to think of translational research and the basic sciences but there are translational opportunities in the social sciences, as well.
GLIMCHER: Absolutely. How is that funded?
LACHS: With sticks and gum. [Glimcher laughs]
LACHS: The initial funding came from the Samuels Fan Fox Foundation, a wonderful local philanthropy. Some of the research within the program is supported by my grants. I have an RO1 in this area and a K24 mentoring award in patient interview research. I'm constantly trying to get medical students and residents and trainees in mental health and internal medicine interested in this. There are people who have made their careers in child abuse. There are child abuse fellowships in pediatrics and I think there will be those kinds of opportunities in elder abuse for geriatricians who are interested in making their career mark. The epidemiologic challenges are so interesting. There are certain injuries in child abuse that we know have to be child abuse, certain long bone injuries and certain kinds of fractures. We just don't know yet for elder abuse because our patients have higher burden of comorbidity. It's hard to know if a hip fracture came from osteoporosis or from a malevolent push. I can give a dozen examples of the way in which comorbidity cause false positives and false negatives.
GLIMCHER: How interested are our medical students in geriatrics?
LACHS: Increasingly so. Admittedly, it's been a tough sell over the last couple of decades. There are lots of reasons for that. Some of them are economic, quite candidly. Our students often graduate with enormous debt and it's not the most remunerative field. Some people cite the social comorbidity and having to deal with those kinds of problems on top of multiple illnesses. It's inspiring to see a small and growing cohort of medical students who want to make this their thing. We run a magnificent summer program called the MSTAR program, the Medical Students Summer Research Program, in which we take often 10 percent of the first year class and put them in laboratories, pair them with investigators over a 10-week session. And these could be from the basic sciences, epidemiology, ethics, and then we also combine that with a shadowing experience in the House Call program or at the Wright Center where we see patients. We now have our first crop of those folks coming into geriatric fellowships, selecting that instead of cardiology or gastroenterology. Some of the most interesting challenges in research and biomolecular research and epidemiologic research these days are in the field of aging. You look at the longevity gene, the sirtuin story. Aging will affect everything. It'll affect our health care system delivery and how our industries operate. Unless you are going to be a pediatrician, dermatologist, psychiatrist or cardiologist, you're mostly going to be seeing older adults given the demographic shift in our population. I know this is something you feel pretty dearly about.
GLIMCHER: Well, I'm glad to hear that enthusiasm is increasing for our medical students thinking about a career in geriatric medicine because, given the demographics and the aging of our population, this is going to be an enormous problem.
LACHS: What I tell the students is,'Look, I don't know what the health care system is going to look like 25 years from now, but I do know there will be jobs for geriatricians.' [Glimcher and Lachs laugh]
GLIMCHER: You wrote a book, 'Treat Me and Not My Age,' a how-to guide to make sure you're being seen by the right person, getting the best treatment. What inspired you to write this book?
LACHS: My grandparents. I often tell the medical students, 'Your grandmother could have figured a lot of this out.' The technology is wonderful, but sometimes it's a distraction. I like to tell the story of a patient of mine who was falling repeatedly at home. And she had the proverbial $1 million workup with the MRIs. I got to her home one evening to make a house call and I noticed the color of her seat cushion was the exact same color as her carpeting, and she couldn't figure out where the seat began and the carpeting ended. And a $20 cushion from Target of a different color fixed that problem. That story is demonstrative of how geriatric medicine is both high tech and high touch. You want to get a geriatrician angry at you, Laurie, tell him or her you won't do an angioplasty on his or her 90-year-old because they're old. That's a great way to get a geriatrician angry at you. I am thoroughly for rationing technology, not on the basis of age, but on the basis of function and the potential for functional loss. It's this great combination of sort of the art of medicine and clinical judgment, alongside data. It's not for everybody. But I come home every day just feeling blessed I can do what I do at one of the greatest places in the country.
GLIMCHER: I'm always curious to hear how people decided to make medicine their career. Specifically, why did you choose to go into geriatric medicine?
LACHS: Being raised by grandparents, I think, had a large influence. Through a series of unfortunate circumstances, my grandfather was my father. So interesting now to think back, him bringing me to kindergarten and my friends saying, 'Your dad's so old.' I did the math; he was probably 55. I'm 52. [Glimcher laughs]
GLIMCHER: Doesn't seem that old, does it?
LACHS: This was a guy who shattered every stereotype of what was then old. He was an amateur boxer, he was a Scrabble champion.
GLIMCHER: The concept of what's old — 60 is the new 40.
LACHS: 60 could be the new 40, or 60 could be the new 90, depending on what you do when you're 30, 40 or 50.
GLIMCHER: Well, that's true. How did you come to Weill Cornell?
LACHS: After residency at the University of Pennsylvania in internal medicine, I did a fellowship called the Robert Wood Johnson Clinical Scholars Program at Yale, which is a program to interest physicians in societal health problems. That's when I became interested in geriatrics. They saw some ember of promise in me and brought me on as an assistant professor. In year two or three of my assistant professor-dom, Ralph Nachman and the late David Skinner told me they were interested in building a geriatric program at Weill Cornell, one of the last great bastions of academe not to have a full fledged aging program. It was probably a little too soon; I couldn't resist it. I'm a New Yorker at heart and the pizza is better in New York than in New Haven. Seventeen years later, thanks to my co-chief Ron Adelman, we have a program that's consistently nationally ranked among the top with a superb balance — and I think this is emblematic of the institution — of scientists and master clinicians. I just love that about the institution, where both are equally honored. I spend my day trying to get students and residents to see that and want to become that.
GLIMCHER: Mark, I'm very proud of the program you and Ron have developed in geriatric medicine, and I think it really is our responsibility as physicians to stamp out elder abuse. And you're doing a great job.
Lachs: Thank you.