Geriatrics

Geriatrics is the branch 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 separate entity as pediatrics separation from adult internal medicine and the same as neonatology separation from pediatrics.^[1]

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. This 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 1 Scope 1.1 Differences between adult and geriatric medicine 1.2 Geriatrics giants and elderly diseases 1.3 Geriatrics subspecialties and related specialties 1.4 Medical 1.5 Surgical 1.6 Other geriatrics subspecialities. 2 History 3 Geriatricians training 4 Geriatrics organizations 5 Research 5.1 Hospital Elder Life Program 5.2 Pharmacology 6 Ethical and medicolegal issues 7 See also 8 Notes 9 References 10 Further reading 11 External links

Scope

Differences between adult and geriatric medicine

Geriatrics differs from adult medicine in many respects. The body of an elderly 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 reserve in the organs (e.g. Smokers 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). Geriatricians aim at treating the disease and decreasing the effect of aging on the elderly life. Years of training and experience (above and beyond basic medical training) goes into recognizing the difference between normal aging and what is actually pathological.

The decline in physiological reserve in organs make elderly very vulnerable to have diseases (as dehydration from a mild gastroenteritis) and liable to have complications from mild problems (Fever in elderly may cause confusion leading to a fall and fracture of neck of femur).

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

Treating an elderly is not like treating an adult. A major difference between geriatrics and adult medicine is that elderly sometimes cannot make decisions for themselves. The issues of power of attorney, privacy, legal responsibility, advance directives and informed consent must always be considered 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 have specific issues as regard medications. Elderly particularly are subjected to polypharmacy due to many causes. Some of the causes is that some elderly have multiple medical disorders, some elderly use many herb & OTCs, some adult physicians just prescribe medications to their specific specialty not reviewing other medications used by the elder. The polypharmacy may result in many drug interactions and may be some drug adverse reactions. also drugs are excreted mostly by kidneys or liver which maybe impaired in elderly and medication might need adjustment (Renal or Hepatic).

Also presentations of diseases in elderly may be vague and non-specific or present with delirium of falls (Pneumonia may present with fever, low grade fever, dehydration, confusion or falls) . Also some elderly like children may find difficulty expressing their symptoms especially if the disease is active and causing confusion or if they have cognitive impairment. Delirium in elderly may be caused from a minor problem as constipation to a serious life threatening problem as myocardial infarction.

Geriatrics giants and elderly diseases

'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 (as Dementia, delirium, falls....etc). With the surfacing of the aging phenomenon of societies many specialized geriatrics 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^{[4] [5] [6]}
• Geriatrics dermatology (focus on skin disorders in elderly)
• Geriatric subspeciality medical clinics (As Geriatric Anticoagulation Clinic^[7], Geriatric Assessment Clinic, Falls and Balance Clinic, Continence Clinic, Palliative Care Clinic, Elderly Pain Clinic, Cognition and Memory Disorders Clinic^[8])
• Geriatric emergency medicine^{[9] [10]}
• Geriatric public health (focus on geriatrics punblic health issues including prevention and health promotion in elderly)
• Geriatric pharmacotherapy^{[11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29]}

Surgical

• Orthogeriatrics (close cooperation with orthopedic surgery and a focus on osteoporosis and rehabilitation).^{[30] [31]}
• Geriatric Cardiothoracic Surgery ^{[32] [33]}
• Geriatric Urology ^[34]
• Geriatric Otolaryngology ^[35]
• Geriatric General Surgery ^[36]
• Geriatrics trauma
• Geriatric Gynecology ^[37]
• Geriatric ophthalmology^[38] and Geriatrics optometrists

Other geriatrics subspecialities.

• Geriatric nursing (focus on nursing of elderly patients and the aged).
• Geriatric Intensive care unit (a special type of intensive care unit dedicated to citically ill elderly)
• Geriatric anesthesia (focus on anesthesia & perioperative care of elderly)
• Geriatric pain management
• Geriatric psychology^{[39] [40] [41] [42] [43] [44] [45] [46] [47] [48] [49]}
• Geriatric occupational therapy(part of geriatric rehabilitation)
• Geriatric Podiatry
• Geriatric nutrition^{[50] [51] [52]}

History

The Canon of Medicine,^[53] written by Abu Ali Ibn Sina (Avicenna) in 1025, was the first book to offer instruction for 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.^[54][55][56]

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^[57] or Teb al-Mashaikh wa hefz sehatahom.^[58] 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,^[59][60][61] and a treatise on causes of mortality entitled Rissala Fi Asbab al-Wafah.^[62] 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).^[63]

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. She took her experiences as a physician in a London Workhouse infirmary and developed the concept 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 history of multidisciplinary working, valuing 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: immobility and instability, incontinence and impaired intellect.^[64] Isaacs asserted that if you look closely enough, all common problems with older people relate back to one of these giants.

The care of older people in the UK has been forwarded by the implementation of the National Service Frameworks for Older People, which outlines key areas for attention.^[65]

Geriatricians training

In the United States, geriatricians are primary care physicians who are board-certified in either family medicine or internal medicine and 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 specialism of general medicine since the late 1970s.^[66] 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.

Geriatrics organizations

• American geriatrics society
• British 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 their needs are being met.

The Hospital Elder Life Program, HELP, is a system that was created at Yale New Haven Hospital and has been introduced to several hospitals. The goal of the program is to prevent delirium and thus improve the quality of care provided to the elderly. Yale New Haven Hospital has since developed HELP into the more comprehensive Elder Horizons Program, whose goals in addition to preventing delirium include maintenance of mobility and of functional and cognitive states.

In July 2007 the American Association of Medical Colleges (AAMC) and the 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 to older patients by new interns. There are 26 competencies in eight content domains, 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 entire list is available on the Portal of Geriatric Online Education.

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 consideration is that of elderly persons (particularly those experiencing substantial problems of memory loss or other types of cognitive impairment) being 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 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 further attention.

Another area of importance is the potential for improper administration and usage of potentially inappropriate medications, and possibility of errors which 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 medicolegal issues

• Elder abuse.
• Informed consent in elderly.
• Power of attorney (endurable & durable).
• Advance directives.
• End of life issues & Do Not Resuscitate (DNR) orders.
• Euthanasia.

See also

• Aging in Place
• Aging-associated diseases
• Commission for Certification in Geriatric Pharmacy
• Elderly care
• Gero-Informatics
• Nosokinetics
• Life extension
• Geriatric medicine in Egypt

Notes

References

Further reading

• Barton A, Mulley G. History of the development of geriatric medicine in the UK. Postgrad Med J 2003;79:229-34. Fulltext. PMID 12743345.
• Cannon, K.T., Choi, M.M., Zuniga, M.M. (2006). Potentially inappropriate medication use in elderly patients receiving home health care: a retrospective data analysis. The American Journal of Geriatric Pharmacotherapy, 4, 134-143.
• Gidal, B.E. (2006). Drug Absorption in the Elderly: Biopharmaceutical Considerations for the Antiepileptic Drugs. Epilepsy Research, 68S, S65-S69.
• Hutchison, L.C., Jones, S.K., West, D.S., Wei, J.Y. (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, 144-153.
• Isaacs B. An introduction to geriatrics. London: Balliere, Tindall and Cassell, 1965.

External links

• British Geriatrics Society
• American Geriatrics Society
• Irish Gerontological Society
• POGOe - Portal of Geriatric Education Online
• American Board Family Medicine CAQ Geriatric Medicine
• Merck Manual of Geriatrics
• Geriatric Nursing

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