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Geriatrics is a subspecialty of medicine that focuses on health care of the elderly. It aims to promote health and to prevent and treat diseases and disabilities in older adults.

Geriatrics was separated from internal medicine as a distinct entity in the same way that neonatology is separated from pediatrics.[1]

Elderly female in residential care home

There is no set age at which patients may be under the care of a geriatrician. Rather, this is determined by a profile of the typical problems that geriatrics focuses on.

The term geriatrics differs from gerontology which is the study of the aging process itself. The term comes from the Greek geron meaning "old man" and iatros meaning "healer". However "Geriatrics" is considered by some as "Medical Gerontology".

Contents

Scope

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Differences between adult and geriatric medicine

Geriatrics differs from adult medicine in many respects. The body of an elderly person is substantially different physiologically from that of an adult. Old age is the period of manifestation of decline of the various organ systems in the body. This varies according to various reserves in the organs, as smokers, for example, consume their respiratory system reserve early and rapidly.

Many people cannot differentiate between Disease and Aging effects, e.g. renal impairment may be a part of aging but renal failure is not. Also urinary incontinence is not part of normal aging, but it is a disease that may occur at any age and is frequently treatable. Geriatricians aim to treat the disease and to decrease the effects of aging on the body. Years of training and experience, above and beyond basic medical training, go into recognizing the difference between what is normal aging and what is in fact pathological.

The decline in physiological reserve in organs makes the elderly develop diseases (such as dehydration from a mild gastroenteritis) and be liable to complications from mild problems. Fever in elderly persons may cause confusion leading to a fall and to a fracture of the neck of the femur ("breaking her/his hip").

Functional ability, independence and quality of life issues are of greater concern to geriatricians, perhaps, than to adult physicians.

Treating an elderly person is not like treating an adult. A major difference between geriatrics and adult medicine is that elderly persons sometimes cannot make decisions for themselves. The issues of power of attorney, privacy, legal responsibility, advance directives and informed consent must always be considered in geriatric procedure. Elder abuse is also a major concern in this age group. In a sense, geriatricians often have to "treat" the caregivers and sometimes, the family, rather than just the elder.

Elderly people have specific issues as regard medications. Elderly people particularly are subjected to polypharmacy due to many causes. Some elderly people have multiple medical disorders; some use many herbs & OTCs; some adult physicians just prescribe medications to their specialty without reviewing other medications used by the elder patient. This polypharmacy may result in many drug interactions and may cause some drug adverse reactions. Drugs are excreted mostly by the kidneys or the liver, either of which maybe impaired in the elderly, and as a result the medication might need adjustment, either renal (kidneys) or hepatic (liver).

The presentation of disease in elderly persons may be vague and non-specific, or it may include delirium or falls. (Pneumonia, for example, may present with fever, low-grade fever, dehydration, confusion or falls.) Some elderly people may find it hard to describe their symptoms in words, especially if the disease is active and causing confusion, or if they have cognitive impairment. Delirium in the elderly may be caused by a minor problem such as constipation or by something as serious and life-threatening as a heart attack (myocardial infarction).

All of the baby boomers will be 65 years and older by 2030. At the same time there is a deficiency of geriatric trained physicians, nurses, and other health professionals. This will create a challenge for the health care workforce. It will be necessary to have models of care that meet the needs of the aging population. Geriatricians will need to have training in public health and to lead programs as they may not be able to physically consult on all the vulnerable frail elderly.

Geriatrics giants and elderly diseases

The so-called 'Geriatric giants' are immobility, instability, incontinence and impaired intellect/memory. Health issues in older adults may also include elderly care, delirium, use of multiple medications, impaired vision and hearing.

Geriatrics subspecialties and related specialties

Some diseases commonly seen in elderly are rare in adults, e.g. dementia, delirium, falls, etc. As societies aged, many specialized geriatric- and geriatrics-related services emerged[2][3] including:

Medical

  • Geriatric psychiatry or psychogeriatrics (focus on dementia, delirium, depression and other psychiatric disorders).
  • Cardiogeriatrics (focus on cardiac diseases of elderly)
  • Geriatric nephrology (focus on kidney diseases of elderly)
  • Geriatric dentistry (focus on dental disorders of elderly)
  • Geriatric Rehabilitation (focus on physical therapy in elderly)
  • Geriatric oncology (focus on tumors in elderly)
  • Geriatric rheumatology (focus on joints and soft tissue disorders in elderly)
  • Geriatric neurology (focus on neurologic disorders in elderly)
  • Geriatric diagnostic imaging
  • Geriatrics dermatology (focus on skin disorders in elderly)
  • Geriatric subspeciality medical clinics (As Geriatric Anticoagulation Clinic Geriatric Assessment Clinic, Falls and Balance Clinic, Continence Clinic, Palliative Care Clinic, Elderly Pain Clinic, Cognition and Memory Disorders Clinic
  • Geriatric emergency medicine
  • Geriatric Physical Examination of intrest especially to Physicians & Physician Assistants.
  • Geriatric public health or Preventive Geriatrics (focuses on geriatrics public health issues including disease prevention and health promotion in elderly)
  • Geriatric pharmacotherapy

Surgical

  • Orthogeriatrics (close cooperation with orthopedic surgery and a focus on osteoporosis and rehabilitation).
  • Geriatric Cardiothoracic Surgery
  • Geriatric Urology
  • Geriatric Otolaryngology
  • Geriatric General Surgery
  • Geriatrics trauma
  • Geriatric Gynecology
  • Geriatric ophthalmology

Other geriatrics subspecialties

  • Geriatric Anesthesia (focuses on anesthesia & perioperative care of elderly)
  • Geriatric Intensive Care Unit: (a special type of intensive care unit dedicated to citically-ill elderly)
  • Geriatric nursing (focuses on nursing of elderly patients and the aged).
  • Geriatric Nutrition
  • Geriatric Occupational Therapy(part of Geriatric Rehabilitation)
  • Geriatric Pain Management
  • Geriatric Physical Therapy
  • Geriatric Podiatry
  • Geriatric Psychology

History

The Canon of Medicine, written by Abu Ali Ibn Sina (Avicenna) in 1025, was the first book to offer instruction in the care of the aged, foreshadowing modern gerontology and geriatrics. In a chapter entitled "Regimen of Old Age", Avicenna was concerned with how "old folk need plenty of sleep", how their bodies should be anointed with oil, and recommended exercises such as walking or horse-riding. Thesis III of the Canon discussed the diet suitable for old people, and dedicated several sections to elderly patients who become constipated.[4][5][6]

The famous Arabic physician, Ibn Al-Jazzar Al-Qayrawani (Algizar, circa 898-980), also wrote a special book on the medicine and health of the elderly, entitled Kitab Tibb al-Machayikh[7] or Teb al-Mashaikh wa hefz sehatahom.[8] He also wrote a book on sleep disorders and another one on forgetfulness and how to strengthen memory, entitled Kitab al-Nissian wa Toroq Taqwiati Adhakira,[9][10][11] and a treatise on causes of mortality entitled Rissala Fi Asbab al-Wafah.[7] Another Arabic physician in the 9th century, Ishaq ibn Hunayn (died 910), the son of Hunayn Ibn Ishaq, wrote a Treatise on Drugs for Forgetfulness (Risalah al-Shafiyah fi adwiyat al-nisyan).[12]

The first modern geriatric hospital was founded in Belgrade, Serbia in 1881 by doctor Laza Lazarević.[13]

The term geriatrics was proposed in 1909 by Dr. Ignatz Leo Nascher, former Chief of Clinic in the Mount Sinai Hospital Outpatient Department (New York City) and a "Father" of geriatrics in the United States.

Modern geriatrics in the United Kingdom really began with the "Mother" of Geriatrics, Dr. Marjorie Warren. Warren emphasized that rehabilitation was essential to the care of older people. Using her experiences as a physician in a London Workhouse infirmary, she believed that merely keeping older people fed until they died was not enough; they needed diagnosis, treatment, care and support. She found that patients, some of whom had previously been bedridden, were able to gain some degree of independence with the correct assessment and treatment.

The practice of geriatrics in the UK is also one with a rich multi-disciplinary history. It values all the professions, not just medicine, for their contributions in optimizing the well-being and independence of older people.

Another "hero" of British Geriatrics is Bernard Isaacs, who described the "giants" of geriatrics mentioned above: immobility and instability, incontinence and impaired intellect.[14] Isaacs asserted that if you look closely enough, all common problems with older people relate back to one or more of these giants.

The care of older people in the UK has been advanced by the implementation of the National Service Frameworks for Older People, which outlines key areas for attention.[15]

Geriatricians' training

In the United States, geriatricians are primary care physicians who are board-certified in either family medicine or internal medicine and who have also acquired the additional training necessary to obtain the Certificate of Added Qualifications (CAQ) in geriatric medicine.

In the United Kingdom, most geriatricians are hospital physicians, while some focus on community geriatrics. While originally a distinct clinical specialty, it has been integrated as a specialisation of general medicine since the late 1970s.[16] Most geriatricians are therefore accredited for both. In contrast to the United States, geriatric medicine is a major specialty in the United Kingdom; geriatricians are the single most numerous internal medicine specialists.

Minimum Geriatric Competencies

In July 2007 the Association of American Medical Colleges (AAMC) and the John A. Hartford Foundation hosted a National Consensus Conference on Competencies in Geriatric Education where a consensus was reached on minimum competencies (learning outcomes) that graduating medical student needed to assure competent care by new interns to older patients. Twenty-six (26) Minimum Geriatric Competencies in eight content domains were endorsed by the American Geriatrics Society (AGS), the American Medical Association (AMA), and the Association of Directors of Geriatric Academic Programs (ADGAP). The domains are: cognitive and behavioral disorders; medication management; self-care capacity; falls, balance, gait disorders; atypical presentation of disease; palliative care; hospital care for elders, and health care planning and promotion. Each content domain specifies three or more observable, measurable competencies. The competencies list is available on the Portal of Geriatric Online Education (POGOe) at: http://www.pogoe.org/Minimum_Geriatric_Competencies.

Geriatrics organizations

  • American geriatrics society
  • British geriatrics society
  • Canadian geriatrics society

Research

Hospital Elder Life Program

Perhaps the most pressing issue facing geriatrics is the treatment and prevention of delirium. This is a condition in which hospitalized elderly patients become confused and disoriented when confronted with the uncertainty and confusion of a hospital stay. The health of the patient will decline as a result of delirium and can increase the length of hospitalization and lead to other health complications. The treatment of delirium involves keeping the patient mentally stimulated and oriented to reality, as well as providing specialized care in order to ensure that her/his needs are being met.

The Hospital Elder Life Program [1]HELP)is an innovative model of hospital care created by Sharon Inouye, MD, MPH and her colleagues at the Yale University School of Medicine. It is designed to prevent delirium and functional decline among elderly individuals in the hospital inpatient setting. HELP uses a core team of interdisciplinary staff and targeted intervention protocols to improve patients' outcomes and to provide cost-effective care. Unique to the program is the use of specially trained volunteers who carry out the majority of the non-clinical interventions.

In up to 40% of the cases, incident delirium can be prevented. To that end, HELP promotes interventions designed to maintain cognitive and physical functioning of older adults throughout the hospitalization, maximize patients' independence at discharge, assist with the transition from hospital to home and prevent unplanned hospital readmissions. Customized interventions include daily visitors; therapeutic activities to provide mental stimulation; daily exercise and walking assistance; sleep enhancement; nutritional support and hearing and vision protocols.

HELP has been replicated in over 63 hospitals across the world. Although the majority of the sites are based in the United States located in 25 different states, there is a growing international presence. International sites include: Australia, Canada, the Netherlands, Taiwan and the United Kingdom. HELP is protected by copyright held by Sharon Inouye MD, MPH. The Dissemination Team including Dr. Inouye are located at Hebrew SeniorLife at the Institute for Aging Research in Boston, MA.

Pharmacology

Pharmacological constitution and regimen for older people is an important topic, one which is related to changing and differing physiology and psychology.

Changes in physiology with aging may alter the absorption, the effectiveness and the side effect profile of many drugs. These changes may occur in oral protective reflexes (dryness of the mouth caused by diminished salivary glands), in the gastrointestinal system (such as with delayed emptying of solids and liquids possibly restricting speed of absorption), and in the distribution of drugs with changes in body fat and muscle and drug elimination.

Psychological considerations include the fact that elderly persons (particularly those experiencing substantial memory loss or other types of cognitive impairment) are unlikely to be able to adequately monitor and adhere to their own scheduled pharmacological administration. One study (Hutchinson et al., 2006) found that 25% of participants studied admitted to skipping doses or cutting them in half. Self-reported noncompliance with adherence to a medication schedule was reported by a striking one-third of the participants. Further development of methods which might possibly help monitor and regulate dosage administration and scheduling is an area that deserves attention.

Another important area is the potential for improper administration and use of potentially inappropriate medications, and the possibility of errors which could result in dangerous drug interactions. Polypharmacy is often a predictive factor (Cannon et al., 2006). Research done on home/community health care found that "nearly 1 of 3 medical regimens contain a potential medication error" (Choi et al., 2006).

Ethical and medico-legal issues

See also

References

  1. ^ Geriatrics separation from internal medicine
  2. ^ GERIATRICSFOR-SPECIALISTS INITIATIVE (GSI)
  3. ^ Increasing Geriatrics Expertise in Surgical and Medical Specialties
  4. ^ Howell, Trevor H. (January 1987), "Avicenna and His Regimen of Old Age", Age and Ageing 16: 58–9, doi:10.1093/ageing/16.1.58, PMID 3551552, http://ageing.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=3551552 
  5. ^ Howell TH (1972). "Avicenna and the care of the aged". Gerontologist 12 (4): 424–6. PMID 4569393. 
  6. ^ Pitskhelauri GZ, Dzhorbenadze DA (1970). "[Gerontology and geriatrics in the works of Abu Ali Ibn Sina (Avicenna) (on the 950th anniversary of the manuscript, Canon of Medical Science)]" (in Russian). Sov Zdravookhr 29 (10): 68–71. PMID 4931547. 
  7. ^ a b Al Jazzar
  8. ^ Vesalius Official journal of the International Society for the History of Medicine
  9. ^ Algizar a web page in french
  10. ^ Ibn Jazzar
  11. ^ [Geritt Bos, Ibn al-Jazzar, Risala fi l-isyan (Treatise on forgetfulness), London, 1995]
  12. ^ Islamic culture and medical arts
  13. ^ New bibliography of scientific papers by Dr. Laza K. Lazarević
  14. ^ Isaacs 1965
  15. ^ Department of Health Older People's information
  16. ^ Barton A, Mulley G (April 2003). "History of the development of geriatric medicine in the UK". Postgrad Med J 79 (930): 229–34; quiz 233–4. doi:10.1136/pmj.79.930.229. PMID 12743345. PMC 1742667. http://pmj.bmjjournals.com/cgi/content/full/79/930/229. 

Further reading

  • Cannon KT, Choi MM, Zuniga MA (June 2006). "Potentially inappropriate medication use in elderly patients receiving home health care: a retrospective data analysis". Am J Geriatr Pharmacother 4 (2): 134–43. doi:10.1016/j.amjopharm.2006.06.010. PMID 16860260. 
  • Gidal BE (January 2006). "Drug absorption in the elderly: biopharmaceutical considerations for the antiepileptic drugs". Epilepsy Res. 68 (Suppl 1): S65–9. doi:10.1016/j.eplepsyres.2005.07.018. PMID 16413756. 
  • Hutchison LC, Jones SK, West DS, Wei JY (June 2006). "Assessment of medication management by community-living elderly persons with two standardized assessment tools: a cross-sectional study". Am J Geriatr Pharmacother 4 (2): 144–53. doi:10.1016/j.amjopharm.2006.06.009. PMID 16860261. 
  • Isaacs B (1965). An introduction to geriatrics. London: Balliere, Tindall and Cassell. 

External links


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