From Wikipedia, the free encyclopedia
Geriatrics, or geriatric medicine, is a medical specialty focused on providing care for the unique health needs of older adults. The term geriatrics originates from the Greek γέρων geron meaning "old man", and ιατρός iatros meaning "healer". It aims to promote health by preventing, diagnosing and treating disease in older adults. There is no defined age at which patients may be under the care of a geriatrician, or geriatric physician,
a physician who specializes in the care of elderly people. Rather, this
decision is guided by individual patient need and the caregiving
structures available to them. This care may benefit those who are
managing multiple chronic conditions or experiencing significant
age-related complications that threaten quality of daily life. Geriatric
care may be indicated if caregiving responsibilities become
increasingly stressful or medically complex for family and caregivers to
manage independently.
There is a distinction between geriatrics and gerontology. Gerontology is the multidisciplinary study of the aging
process, defined as the decline in organ function over time in the
absence of injury, illness, environmental risks or behavioral risk
factors. However, geriatrics is sometimes called medical gerontology.
Scope
Differences between adult and geriatric medicine
Geriatric
providers receive specialized training in caring for elderly patients
and promoting healthy aging. The care provided is one largely based on
shared-decision making and is driven by patient goals and preferences,
which can vary from preserving function, improving quality of life, or
prolonging years of life. A guiding mnemonic
commonly used by geriatricians in the United States and Canada is the 5
M's of Geriatrics which describes mind, mobility, multicomplexity, medications and matters most to elicit patient values.
It is common for elderly
adults to be managing multiple medical conditions, or, multi-morbidity.
Age-associated changes in physiology drive a compounded increase in
susceptibility to illness, disease-associated morbidity, and death.
Furthermore, common diseases may present atypically in elderly patients,
adding further diagnostic and therapeutical complexity in patient care.
Geriatrics is highly interdisciplinary consisting of specialty
providers from the fields of medicine, nursing, pharmacy, social work,
physical and occupational therapy. Elderly patients can receive care
related to medication management, pain management, psychiatric and
memory care, rehabilitation, long-term nursing care, nutrition and
different forms of therapy including physical, occupational and speech.
Non-medical considerations include social services, transitional care,
advanced directives, power of attorney and other legal considerations.
Increased complexity
The
decline in physiological reserve in organs makes the elderly develop
some kinds of diseases and have more complications from mild problems
(such as dehydration from a mild gastroenteritis). Multiple problems may compound: A mild fever in elderly persons may cause confusion, which may lead to a fall and to a fracture of the neck of the femur ("broken hip").
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 low-grade fever
and confusion, rather than the high fever and cough seen in younger
people.) Some elderly people may find it hard to describe their symptoms in words, especially if the disease is 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. Many of these problems are treatable, if the root cause can be discovered.
Geriatric pharmacology
Elderly people require specific attention to medications. Elderly people particularly are subjected to polypharmacy
(taking multiple medications) given their accumulation of multiple
chronic diseases. Many of these individuals have also self-prescribed
many herbal medications and over-the-counter drugs. This polypharmacy, in combination with geriatric status, may increase the risk of drug interactions or adverse drug reactions. Pharmacokinetic and pharmacodynamic
changes arise with older age, impairing their ability to metabolize and
respond to drugs. Each of the four pharmacokinetic mechanisms
(absorption, distribution, metabolism, excretion) are disrupted by
age-related physiologic changes. For example, overall decreased hepatic
function can interfere with clearance or metabolism of drugs and
reductions in kidney function can affect renal elimination. Pharmacodynamic changes lead altered sensitivity to drugs in geriatric patients, such as increased pain relief with morphine use. Therefore, geriatric individuals require specialized pharmacological care that is informed by these age-related changes.
Geriatric syndromes
Geriatric syndromes
is a term used to describe a group of clinical conditions that are
highly prevalent in elderly people. These syndromes are not caused by
specific pathology or disease, rather, are a manifestation of
multifactorial conditions affecting several organ systems. Common
conditions include frailty, functional decline, falls, loss in
continence and malnutrition, amongst others.
Frailty
Frailty
is marked by a decline in physiological reserve, increased
vulnerability to physiological and emotional stressors, and loss of
function. This may present as progressive and unintentional weight loss,
fatigue, muscular weakness and decreased mobility. It is associated with increased injuries, hospitalization and adverse clinical outcomes.
Functional decline
Functional
disability can arise from a decline in physical function and/or
cognitive function. It is associated with an acquired difficulty in
performing basic everyday tasks resulting in an increased dependence of
other individuals and/or medical devices.
These tasks are sub-divided into basic activities of daily living (ADL)
and instrumental activities of daily living (IADL) and are commonly
used as an indicator of a person's functional status.
Activities of daily living (ADL)
are fundamental skills needed to care for oneself, including feeding,
personal hygiene, toileting, transferring and ambulating. Instrumental
activities of daily living (IADL) describe more complex skills needed to
allow oneself to live independently in a community, including cooking,
housekeeping, managing one's finances and medications. Routine
monitoring of ADL and IADL is an important functional assessment used by
clinicians to determine the extent of support and care to provide to
elderly adults and their caregivers. It serves as a qualitative
measurement of function over time and predicts the need for alternative
living arrangements or models of care, including senior housing
apartments, skilled nursing facilities, palliative, hospice or
home-based care.
Falls
Falls are
the leading cause of emergency department admissions and
hospitalizations in adults age 65 and older, many of which result in
significant injury and permanent disability.
As certain risk factors can be modifiable for the purpose of reducing
falls, this highlights an opportunity for intervention and risk
reduction. Modifiable factors include:
- Improving balance and muscle strength.
- Removing environmental hazards.
- Encouraging use of assistive devices.
- Treating chronic conditions.
- Adjusting medication.
Urinary incontinence
Urinary
incontinence or overactive bladder symptoms is defined as
unintentionally urinating oneself. These symptoms can be caused by
medications that increase urine output and frequency (e.g.
anti-hypertensives and diuretics), urinary tract infections, pelvic
organ prolapse, pelvic floor dysfunction, and diseases that damage the
nerves that regulate bladder emptying. Other musculoskeletal conditions affecting mobility should be considered, as these can make accessing bathrooms difficult.
Malnutrition
Malnutrition
and poor nutritional status is an area of concern, affecting 12% to 50%
of hospitalized elderly patients and 23% to 50% of institutionalized
elderly patients living in long-term care facilities such as assisted
living communities and skilled nursing facilities.
As malnutrition can occur due to a combination of physiologic,
pathologic, psychologic and socioeconomic factors, it can be difficult
to identify effective interventions.
Physiologic factors include reduced smell and taste, and a decreased
metabolic rate affecting nutritional food intake. Unintentional weight
loss can result from pathologic factors, including a wide range of
chronic diseases that affect cognitive function, directly impact
digestion (e.g. poor dentition, gastrointestinal cancers, gastroesophageal reflux disease) or may be managed with dietary restrictions (e.g. congestive heart failure, diabetes mellitus, hypertension). Psychologic factors include conditions including depression, anorexia, and grief.
Practical concerns
Functional abilities, independence and quality of life
issues are of great concern to geriatricians and their patients.
Elderly people generally want to live independently as long as possible,
which requires them to be able to engage in self-care and other activities of daily living. A geriatrician may be able to provide information about elder care options, and refers people to home care services, skilled nursing facilities, assisted living facilities, and hospice as appropriate.
Frail elderly
people may choose to decline some kinds of medical care, because the
risk-benefit ratio is different. For example, frail elderly women
routinely stop screening mammograms, because breast cancer
is typically a slowly growing disease that would cause them no pain,
impairment, or loss of life before they would die of other causes. Frail
people are also at significant risk of post-surgical complications and
the need for extended care, and an accurate prediction—based on
validated measures, rather than how old the patient's face looks—can
help older patients make fully informed choices about their options.
Assessment of older patients before elective surgeries can accurately
predict the patients' recovery trajectories. One frailty scale uses five items: unintentional weight loss, muscle weakness,
exhaustion, low physical activity, and slowed walking speed. A healthy
person scores 0; a very frail person scores 5. Compared to non-frail
elderly people, people with intermediate frailty scores (2 or 3) are
twice as likely to have post-surgical complications, spend 50% more time
in the hospital, and are three times as likely to be discharged to a
skilled nursing facility instead of to their own homes.
Frail elderly patients (score of 4 or 5) who were living at home before
the surgery have even worse outcomes, with the risk of being discharged
to a nursing home rising to twenty times the rate for non-frail elderly
people.
Subspecialties and related services
Some
diseases commonly seen in elderly are rare in adults, e.g., dementia,
delirium, falls. As societies aged, many specialized geriatric- and
geriatrics-related services emerged including:
Medical
Surgical
- Geriatric orthopaedics or orthogeriatrics (close cooperation with orthopedic surgery and a focus on osteoporosis and rehabilitation).
- Geriatric cardiothoracic surgery.
- Geriatric urology.
- Geriatric otolaryngology.
- Geriatric general surgery.
- Geriatric trauma.
- Geriatric gynecology.
- Geriatric ophthalmology.
Other geriatrics subspecialties
History
One of the eight branches of the traditional Indian system of medicine, Ayurveda, is jara or rasayana, similar to geriatrics. Charaka described the fatigue and physical exhaustion caused by premature aging as the result of a poor diet. The Charaka Samhita recommends that elderly patients avoid excessive physical or mental strain and consume a light but nutritious diet.
A number of physicians in the Byzantine Empire studied geriatrics, with doctors like Aëtius of Amida evidently specializing in the field. Alexander of Tralles viewed the process of aging as a natural and inevitable form of marasmus, caused by the loss of moisture in body tissue. The works of Aëtius describe the mental and physical symptoms of aging. Theophilus Protospatharius and Joannes Actuarius also discussed the topic in their medical works. Byzantine physicians typically drew on the works of Oribasius
and recommended that elderly patients consume a diet rich in foods that
provide "heat and moisture". They also recommended frequent bathing,
massaging, rest, and low-intensity exercise regimens.
In The Canon of Medicine, written by Avicenna in 1025, the author was concerned with how "old folk need plenty of sleep" and 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.
The Arab physician Algizar (c. 898–980) wrote a book on the medicine and health of the elderly. He also wrote a book on sleep disorders and another one on forgetfulness and how to strengthen memory, and a treatise on causes of mortality. Another Arab physician in the 9th century, Ishaq ibn Hunayn (died 910), the son of Nestorian Christian scholar Hunayn Ibn Ishaq, wrote a Treatise on Drugs for Forgetfulness.
George Day published the Diseases of Advanced Life in 1849, one of the first publications on the subject of geriatric medicine. The first modern geriatric hospital was founded in Belgrade, Serbia, in 1881 by doctor Laza Lazarević.
The term geriatrics was proposed in 1908 by Ilya Ilyich Mechnikov, Laurate of the Nobel Prize for Medicine and later by 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 began with the "mother" of geriatrics, Dr. Marjory 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
multidisciplinary history. It values all the professions, not just
medicine, for their contributions in optimizing the well-being and
independence of older people.
Another innovator of British geriatrics is Bernard Isaacs, who
described the "giants" of geriatrics mentioned above: immobility and
instability, incontinence, and impaired intellect. Isaacs asserted that, if examined closely enough, all common problems with older people relate 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.
Geriatrician training
United States
In the United States, geriatricians are primary-care physicians (D.O. or M.D.) 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.
Geriatricians have developed an expanded expertise in the aging process,
the impact of aging on illness patterns, drug therapy in seniors,
health maintenance, and rehabilitation.
They serve in a variety of roles including hospital care, long-term
care, home care, and terminal care. They are frequently involved in
ethics consultations to represent the unique health and diseases
patterns seen in seniors. The model of care practiced by geriatricians
is heavily focused on working closely with other disciplines such as
nurses, pharmacists, therapists, and social workers.
United Kingdom
In
the United Kingdom, most geriatricians are hospital physicians, whereas
others focus on community geriatrics in particular. Although originally
a distinct clinical specialty, it has been integrated as a
specialization of general medicine since the late 1970s.
Most geriatricians are, therefore, accredited for both. Unlike in the
United States, geriatric medicine is a major specialty in the United
Kingdom and are the single most numerous internal medicine specialists.
Canada
In Canada, there are two pathways that can be followed in order to work as a physician in a geriatric setting.
- Doctors of Medicine (M.D.) can complete a three-year core
internal medicine residency program, followed by two years of
specialized geriatrics residency training. This pathway leads to
certification, and possibly fellowship after several years of
supplementary academic training, by the Royal College of Physicians and Surgeons of Canada.
- Doctors of Medicine (M.D.) can opt for a two-year residency program
in family medicine and complete a one-year enhanced skills program in care of the elderly. This post-doctoral pathway is accredited by the College of Family Physicians of Canada.
Many universities across Canada also offer gerontology training programs for the general public, such that nurses
and other health care professionals can pursue further education in the
discipline in order to better understand the process of aging and their
role in the presence of older patients and residents.
India
In India,
Geriatrics is a relatively new speciality offering. A three-year post
graduate residency (M.D) training can be joined for after completing the
5.5-year undergraduate training of MBBS
(Bachelor of Medicine and Bachelor of Surgery). Unfortunately, only
eight major institutes provide M.D in Geriatric Medicine and subsequent
training. Training in some institutes are exclusive in the Department of
Geriatric Medicine, with rotations in Internal medicine, medical
subspecialties etc. but in certain institutions, are limited to 2-year
training in Internal medicine and subspecialities followed by one year
of exclusive training in Geriatric Medicine.
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 students 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.
Research
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 (in particular, 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 that 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 that 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
Elderly persons sometimes cannot make decisions for themselves. They may have previously prepared a power of attorney and advance directives
to provide guidance if they are unable to understand what is happening
to them, whether this is due to long-term dementia or to a short-term,
correctable problem, such as delirium from a fever.
Geriatricians
must respect the patients' privacy while seeing that they receive
appropriate and necessary services. More than most specialties, they
must consider whether the patient has the legal responsibility and competence to understand the facts and make decisions. They must support informed consent and resist the temptation to manipulate the patient by withholding information, such as the dismal prognosis for a condition or the likelihood of recovering from surgery at home.
Elder abuse
is the physical, financial, emotional, sexual, or other type of abuse
of an older dependent. Adequate training, services, and support can
reduce the likelihood of elder abuse, and proper attention can often
identify it. For elderly people who are unable to care for themselves,
geriatricians may recommend legal guardianship or conservatorship to care for the person or the estate.
Elder abuse occurs increasingly when caregivers of elderly
relatives have a mental illness. These instances of abuse can be
prevented by engaging these individuals with mental illness in mental
health treatment. Additionally, interventions aimed at decreasing elder
reliance on relatives may help decrease conflict and abuse. Family
education and support programs conducted by mental health professionals
may also be beneficial for elderly patients to learn how to set limits
with relatives with psychiatric disorders without causing conflict that
leads to abuse.
