Geriatrics
high blood pressure | |
Specialist | Geriatrician |
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Occupation | |
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Names |
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Occupation type | Specialty |
Activity sectors | Medicine |
Description | |
Education required |
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Fields of employment | Hospitals, Clinics |
Geriatrics, or geriatric medicine,
There is a distinction between geriatrics and
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.[6]
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
The presentation of disease in elderly persons may be vague and non-specific, or it may include
Geriatric pharmacology
Elderly people require specific attention to
Geriatric syndromes
Geriatric syndromes[10] 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.[11]
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.[12] 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.[13][14] 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.[13]
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.[15] 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
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.[17] As malnutrition can occur due to a combination of physiologic, pathologic, psychologic and socioeconomic factors, it can be difficult to identify effective interventions.[18] 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.[17]
Practical concerns
Functional abilities, independence and
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[20][21] including:
Medical
- Geriatric cardiology or cardiogeriatrics.
- Geriatric dentistry.
- Geriatric dermatology.
- Geriatric diagnostic imaging.
- Geriatric emergency medicine.
- Geriatric nephrology.
- Geriatric neurology.
- Geriatric oncology.
- Geriatric physical examination of interest especially to physicians & physician assistants.
- depressionand other psychiatric disorders).
- Geriatric public health or preventive geriatrics
- Geriatric rehabilitation.
- Geriatric rheumatology (focus on joints and soft tissue disorders in elderly).
- Geriatric sexology(focus on sexuality in aged people).
- Geriatric subspeciality medical clinics (such as geriatric anticoagulation clinic, geriatric assessment clinic, falls and balance clinic, continence clinic, palliative care clinic, elderly pain clinic, cognition and memory disorders clinic).
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.
- Perioperative medicine for Older People having Surgery (POPS)
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 critically ill elderly).
- Geriatric nursing(focuses on nursing of elderly patients and the aged).
- Geriatric nutrition.
- Geriatric occupational therapy.
- Geriatric pain management.
- Geriatric pharmacy.
- Geriatric optometry.
- Geriatric physical therapy.
- Geriatric podiatry.
- Geriatric psychology.
- Geriatric speech-language pathology (focuses on neurological disorders such as dysphagia, stroke, aphasia, and traumatic brain injury).
- Geriatric mental health counselor/specialist (focuses on treatment more so than assessment).
- Geriatric audiology.
History
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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.[citation needed][22] 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.[23]
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.[24][25][26]
The
George Day published the Diseases of Advanced Life in 1849, one of the first publications on the subject of geriatric medicine.[33] The first modern geriatric hospital was founded in Belgrade, Serbia, in 1881 by doctor Laza Lazarević.[34]
The term geriatrics was proposed in
Modern geriatrics in the United Kingdom began with the "mother"[37] of geriatrics, Marjory Warren.[33] 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.[38]
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.[39][40] 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.[41]
Geriatrician training
United States
In the
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.[42] 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
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
Minimum geriatric competencies
In July 2007, the Association of American Medical Colleges (AAMC) and the John A. Hartford Foundation[43] 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
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
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
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.[45]
See also
- Aging in Place
- Aging-associated diseases
- Alliance for Aging Research
- Commission for Certification in Geriatric Pharmacy
- Elderly care
- Gero-Informatics
- GERRI
- Nosokinetics
- Life extension
- Geriatric medicine in Egypt
- Transgenerational design
- Physical & Occupational Therapy in Geriatrics (journal)
- Gerontological nursing
References
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- ^ "Geriatrics separation from internal medicine". University of Minnesota. Archived from the original on 14 January 2009.
- ^ "Geriatric Medicine Specialty Description". American Medical Association. Retrieved 5 September 2020.
- ^ "About Geriatrics | American Geriatrics Society". www.americangeriatrics.org. Retrieved 29 August 2022.
- ^ "What is Gerontology?". www.geron.org. Retrieved 12 September 2022.
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- ^ "Pharmacokinetics in Older Adults - Geriatrics". Merck Manuals Professional Edition. Retrieved 12 September 2022.
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- ^ "Geriatric Syndrome - an overview | ScienceDirect Topics". www.sciencedirect.com. Retrieved 1 March 2023.
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- ^ CDC (16 December 2020). "Keep on Your Feet". Centers for Disease Control and Prevention. Retrieved 12 September 2022.
- ^ "Urinary Incontinence in Older Adults". National Institute on Aging. Retrieved 12 September 2022.
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- ^ Burton JR (2008). "Geriatrics-for-Specialists Initiative (GSI)" (PDF). The American Geriatrics Society (AGS). Archived from the original (PDF) on 25 March 2009. Retrieved 9 February 2016.
Increasing Geriatrics Expertise in Surgical and Related Medical Specialties
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- ^ "Algizar". medarus.org (in French). Archived from the original on 7 April 2016.
- ^ "Islamic Medical Manuscripts: Bio-Bibliographies - I". www.nlm.nih.gov.
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- ^ Kanjuh V, Pavlović B (2002). "New bibliography of scientific papers by Dr. Laza K. Lazarević". Glas SANU–Medicinske Nauke. 46: 37–51. Archived from the original on 25 March 2012.
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- ^ "Vignette: Marjory Warren (1897-1960)". MDDUS. Retrieved 16 August 2022.
- ^ "A giant of geriatric medicine - Professor Bernard Isaacs (1924-1995)". British Geriatrics Society. Retrieved 23 October 2018.
- ^ Isaacs B (1965). An introduction to geriatrics. London: Balliere, Tindall and Cassell.
- ^ "Older People's information". Department of Health. Archived from the original on 3 January 2007.
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- ^ "The John A. Hartford Foundation". www.jhartfound.org.
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Further reading
- Atchley RC, Baxter SL, Blanchard J, Brady K, Comfort WE, Egbert AB (2009). Working with seniors: Health, financial and social issues. Denver, CO: Society of Certified Senior Advisors.
- Cannon KT, Choi MM, Zuniga MA (June 2006). "Potentially inappropriate medication use in elderly patients receiving home health care: a retrospective data analysis". The American Journal of Geriatric Pharmacotherapy. 4 (2): 134–143. PMID 16860260.
- Gidal BE (January 2006). "Drug absorption in the elderly: biopharmaceutical considerations for the antiepileptic drugs". Epilepsy Research. 68 (Suppl 1): S65–S69. S2CID 39671722.
- 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". The American Journal of Geriatric Pharmacotherapy. 4 (2): 144–153. PMID 16860261.
External links
- Merck Manual of Geriatrics
- Health-EU Portal – Care for the elderly in the EU
- American Geriatrics Society