Geriatric medicine

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ΕΤΥΜΟΛΟΓΙΑ

Greek. geron - old man, iatrokos - treatment :atrib. Ignatz Leo Nascher[1]

Geriatric Medicine is the practice of medicine involving older patients. It differs from general internal medicine only in the fact that age adds an extra dimension to the issues involved. The ability of illness to impair a person's ability to function in the activites of daily life becomes important. The interrelationship between the patient, family, carers and society becomes the added dimension.

Older patients are also more complex as they have more diseases, have complicated dependency needs and often take a variety of medications. Decision making is inherently more complex.

The presentation of disease in the elderly is also different. This led to Professor Bernard Issacs to talk about the Geriatric Giants of Incontinence, Instability and Falls, and Intellectual Impairment.

In the very old physical and cognitive impairment is more likely to be present but still 40% over 89 years in age function with no significant restriction in activities of daily living[2]

Contents

Historical Aspects

Geriatric Medicine in the UK became a specialty in its own right following the pioneering work done by Marjorie Warren at the West Middlesex Hospital in London[3]and her Lancet paper of 1946.[4] She showed the importance of comprehensive medical assessment with goal setting with a multiprofessional team in identifying and aiding the successful community discharge of a group of patients others would have considered incurable. Lord Amulree with his maxim "Adding Life to Years" was also extremely influential and contributed to the key medical journal interest in 1946.[5][6] Other important figures included the surgeon Lionel Cosin at Orsett in Essex who effectively started the subspeciality of orthogeriatrics with operation and early mobilization of the elderly with fractured neck of femur, coining the phrase "bed is bad" and Dr Eric Brooke at St Helier Hospital, Carshalton who introduced the domicillary visit for the elderly to manage an impossible waiting list for inpatient assessment. The creation of the National Health Service in the U.K. in 1948 can be seen to have been the essential enabling event for an area of speciality interest that is unattractive to many in item or service-orientated health systems. This model of care has been successfully exported to other socially-orientated health systems and other specialities have also adapted and learnt from the speciality. It was not until the 1990's that another belief of many who practice geriatric medicine, namely that the hospital management of the complex elderly had best outcomes when the patients were managed under their care rather than advice being offered to other physicians, was shown to be true in randomised controlled trials in the U.S.A.

  • Social Aspects of Geriatric Medicine in the UK
  • Social Aspects of Geriatric Medicine in other Countries

Gerontology

The fundamental biology of aging also known as (biogerontology) is not the same as age-associated pathology (geriatric medicine) but often confused although of course the two are relevant to each other.

Conditions Relevant to Geriatricians

Interventions

The basic proven interventions are:

  1. Multidimensional geriatric assessment as basis for problem identification[7]
  2. Geriatric medicine team that formulates recommendations and controls implementation of the recommendations[8]
  3. Inpatient geriatric medicine care combined with outpatient geriatric medicine follow-up[8]

Complex interventions in the elderly

The evidence base was reviewed in 2008[9]. Comprehensive geriatric assessment and falls assessment seem particularly good at preventing morbidity and geriatric assessment of the frail elderly and community-based care after hospital discharge prevent hospital admission. Inpatient geriatric rehabilitation was reviewed in 2010 and needs to treat between 9 and 28 to avoid one admission to a nursing home at hospital discharge, and needs to treat 38 patients to prevent on death at one year follow-up. Orthogeriatric inpatient rehabilitation has particularly strong evidence for both short and long term clinical and economic benefit[10]. In more detail:

Maintaining the elderly at home

  • Group education and counselling -RR 0.62(0.43-0.88) is beneficial
  • General or orthopaedic geriatric rehabilitation programmes -RR 0.64 (0.51 to 0.81) is beneficial[10]
  • Community-based care after hospital discharge -RR 0.90 (0.82-0.99) is beneficial
  • Geriatric assessment general elderly people -RR 0.95(0.93-0.98) is beneficial
  • Fall prevention -RR 0.86(0.63-1.19) is likely to be ineffective or harmful
  • Geriatric assessment frail elderly people -RR 1.0 (0.87-1.15) is likely to be ineffective or harmful

Preventing falls

  • Geriatric assessment general elderly people -RR 0.76(0.67-0.86) is beneficial
  • Fall prevention -RR 0.92(0.87-0.97) is beneficial
  • Community-based care after hospital discharge -RR 0.82 (0.61-1.08) is likely to be ineffective or harmful
  • Geriatric assessment frail elderly people -RR 0.99 (0.89-1.10) is likely to be ineffective or harmful

Improving physical function

  • General or orthopaedic geriatric rehabilitation programmes -odds ratio 1.75 (1.31 to 2.35) is beneficial[10]
  • Fall prevention -RR -0.25(-0.36- -0.13) is beneficial
  • Geriatric assessment general elderly people -RR -0.12(-0.16- -0.08) is beneficial
  • Community-based care after hospital discharge -RR -0.05 (0.15-0.0.04) is likely to be ineffective or harmful
  • Geriatric assessment frail elderly people -RR -0.01 (-0.06-0.04) is likely to be ineffective or harmful
  • Group education and counselling -RR 0.05(-0.20-0.30) is likely to be ineffective or harmful

Preventing death

  • General or orthopaedic geriatric rehabilitation programmes -RR 0.72 (0.55 to 0.95) is beneficial[10]
  • Fall prevention -RR 0.79(0.66-0.96) is beneficial
  • Group education and counselling -RR 0.80(0.42-1.55) is likely to be ineffective or harmful
  • Community-based care after hospital discharge -RR 0.97 (0.89-1.05) is likely to be ineffective or harmful
  • Geriatric assessment general elderly people -RR 1.00(0.98-1.03) is likely to be ineffective or harmful
  • Geriatric assessment frail elderly people -RR 1.03 (0.89-1.19) is likely to be ineffective or harmful

Preventing hospital admission

  • Geriatric assessment frail elderly people -RR 0.90 (0.84-0.98) is beneficial
  • Community-based care after hospital discharge -RR 0.95 (0.90-0.99) is beneficial
  • Group education and counselling -RR 0.75(0.51-1.09) is likely to be ineffective or harmful
  • Fall prevention -RR 0.84(0.66-1.16) is likely to be ineffective or harmful
  • Geriatric assessment general elderly people -RR 0.98(0.92-1.03) is likely to be ineffective or harmful

References

  1. Nascher IL. Geriatrics:The Diseases of Old Age and Their Treatment 1914
  2. Newman AB, Arnold AM, Sachs MC, Ives DG, Cushman M, Strotmeyer ES, Ding J, Kritchevsky SB, Chaves PH, Fried LP, Robbins J. Long-term function in an older cohort--the cardiovascular health study all stars study. Journal of the American Geriatrics Society. 2009 Mar; 57(3):432-40.(Link to article – subscription may be required.)
  3. Warren MW. Care of chronic sick. A case for treating chronic sick in blocks in a general hospital. BMJ 1943;ii:822–3.
  4. Warren MW. Care of the chronic aged sick. Lancet 1946;i:841–3.
  5. Amulree L, Sturdee EL. Care of the chronic sick and of the aged. BMJ 1946; 1: 617–8.
  6. Amulree L. Care of the elderly. Lancet 1946; 2: 801–2.
  7. Huss A, Stuck AE, Rubenstein LZ, Egger M, Clough-Gorr KM. Multidimensional preventive home visit programs for community-dwelling older adults: a systematic review and meta-analysis of randomized controlled trials. The journals of gerontology. Series A, Biological sciences and medical sciences. 2008 Mar; 63(3):298-307.
  8. a b Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet. 1993 Oct 23; 342(8878):1032-6.
  9. Beswick AD, Rees K, Dieppe P, Ayis S, Gooberman-Hill R, Horwood J, Ebrahim S. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet 2008;371:725-35 or DOI:10.1016/S0140-6736(08)60342-6
  10. a b c d Bachmann S, Finger C, Huss A, Egger M, Stuck AE, Clough-Gorr KM. Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. BMJ (Clinical research ed.). 2010; 340:c1718.(Epub)
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