Geriatrics is a sub-specialty of medicine Medicine is the science and art of healing. It encompasses a range of health care practices evolved to maintain and restore health by the prevention and treatment of illness. Before scientific medicine, healing arts were practised in accordance with alchemical treatments and ritual practices that developed out of religious and cultural traditions that focuses on health care of the elderly. It aims to promote health At the time of the creation of the World Health Organization , in 1948, health was defined as being "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity" and to prevent Preventive medicine or preventive care refers to measures taken to prevent diseases, rather than curing them or treating their symptoms. The term contrasts in method with curative and palliative medicine, and in scope with public health methods (which work at the level of population health rather than individual health) and treat diseases A disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal disfunctions, such as autoimmune diseases and disabilities The World Health Organization defines Disability as follows: "Disabilities is an umbrella term, covering impairments, activity limitations, and participation restrictions. An impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a in older adults Old age consists of ages nearing or surpassing the average life span of human beings, and thus the end of the human life cycle. Euphemisms and terms for old people include seniors , senior citizens (British and American usage) and the elderly. As occurs with almost any definable group of humanity, some people will hold a prejudice against others .

Geriatrics was separated from internal medicine Internal medicine is the medical specialty dealing with the prevention, diagnosis, and treatment of adult diseases. Doctors of Internal Medicine, also known as internists, are sometimes referred to as the "doctor's doctor," because they are often called upon to act as consultants to other physicians to help solve puzzling diagnostic as a distinct entity in the same way that neonatology Neonatology is a subspecialty of pediatrics that consists of the medical care of newborn infants, especially the ill or premature newborn infant. It is a hospital-based specialty, and is usually practiced in neonatal intensive care units . The principal patients of neonatologists are newborn infants who are ill or requiring special medical care is separated from pediatrics Pediatrics is the branch of medicine that deals with the medical care of infants, children, and adolescents. The upper age limit of such patients ranges from age 12 to 21. A medical practitioner who specializes in this area is known as a pediatrician. The word pediatrics and its cognates mean healer of children; they derive from two Greek words: π.[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 Gerontology is the study of the social, psychological and biological aspects of aging. It is distinguished from geriatrics, which is the branch of medicine that studies the disease of the elderly which is the study of the aging Ageing or aging (American and Canadian English) is the accumulation of changes in an organism or object over time. Ageing in humans refers to a multidimensional process of physical, psychological, and social change. Some dimensions of ageing grow and expand over time, while others decline. Reaction time, for example, may slow with age, while process itself. The term comes from the Greek Greek , an independent branch of the Indo-European family of languages, is the language of the Greeks. Native to the southern Balkans, it has the longest documented history of any Indo-European language, spanning 34 centuries of written records. In its ancient form, it is the language of classical ancient Greek literature and the New Testament of geron meaning "old man" and iatros meaning "healer". However "Geriatrics" is considered by some as "Medical Gerontology".

Contents

Scope

Differences between adult and geriatric medicine

Geriatrics differs from adult medicine Medicine is the science and art of healing. It encompasses a range of health care practices evolved to maintain and restore health by the prevention and treatment of illness. Before scientific medicine, healing arts were practised in accordance with alchemical treatments and ritual practices that developed out of religious and cultural traditions 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 In biology and anatomy, an organ is a collection of tissues joined in structural unit to serve a common function, as smokers, for example, consume their respiratory system reserve early and rapidly.

Many people cannot differentiate between Disease A disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal disfunctions, such as autoimmune diseases and Ageing Ageing or aging (American and Canadian English) is the accumulation of changes in an organism or object over time. Ageing in humans refers to a multidimensional process of physical, psychological, and social change. Some dimensions of ageing grow and expand over time, while others decline. Reaction time, for example, may slow with age, while effects, e.g. renal impairment may be a part of ageing but renal failure is not. Also urinary incontinence is not part of normal ageing, 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 Dehydration is defined as an excessive loss of body fluid. It is literally the removal of water (Ancient Greek: ὕδωρ hýdōr) from an object, however in physiological terms, it entails a deficiency of fluid within an organism from a mild gastroenteritis Gastroenteritis is inflammation of the gastrointestinal tract, involving both the stomach and the small intestine and resulting in acute diarrhea. It can be transferred by contact with contaminated food and water. The inflammation is caused most often by an infection from certain viruses or less often by bacteria, their toxins, parasites, or an) and be liable to complications from mild problems. Fever Fever is a common medical sign characterized by an elevation of temperature above the normal range of 36.5–37.5 °C (98–100 °F) due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering in elderly persons may cause confusion leading to a fall Autumn is one of the four temperate seasons. Autumn marks the transition from summer into winter, usually in March (Southern Hemisphere) or September (Northern Hemisphere) when the arrival of night becomes noticeably earlier and to a fracture The word fracture is often applied to bones of living creatures, or to crystals or crystalline materials, such as gemstones or metal. Sometimes, in crystalline materials, individual crystals fracture without the body actually separating into two or more pieces. Depending on the substance which is fractured, a fracture reduces strength or inhibits of the neck of the femur The femur, or thigh bone, is the most proximal bone of the leg in vertebrates capable of walking or jumping, such as most land mammals, birds, many reptiles such as lizards, and amphibians such as frogs. In vertebrates with four legs such as dogs and horses, the femur is found only in the rear legs ("breaking her/his hip").

Functional ability, independence and quality of life The term quality of life is used to evaluate the general well-being of individuals and societies. The term is used in a wide range of contexts, including the fields of international development, healthcare, and political science. Quality of life should not be confused with the concept of standard of living, which is based primarily on income 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 A power of attorney or letter of attorney in common law systems or mandate in civil law systems is an authorization to act on someone else's behalf in a legal or business matter. The person authorizing the other to act is the principal, granter or donor (of the power), and the one authorized to act is the agent, the attorney-in-fact, or in many, privacy, legal responsibility Moral responsibility can refer to two different but related things. First, a person has moral responsibility for a situation if that person has an obligation to ensure that something happens. Assume that John promises to baby-sit for his neighbor while she goes to a job interview. However, he decides he will go to a concert instead. Arguably, John, advance directives Advance health care directives, also known as advance directives or advance decisions, are instructions given by individuals specifying what actions should be taken for their health in the event that they are no longer able to make decisions due to illness or incapacity. A living will is one form of advance directive, leaving instructions for and informed consent Informed consent is a phrase often used in the law to indicate that the consent a person gives meets certain minimum standards. As a literal matter, in the absence of fraud, it is redundant. An informed consent can be said to have been given based upon a clear appreciation and understanding of the facts, implications, and future consequences of an must always be considered in geriatric procedure. Elder abuse Elder abuse is a general term used to describe certain types of harm to older adults. Other terms commonly used include: "elder mistreatment", "senior abuse", "abuse in later life", "abuse of older adults", "abuse of older women", and "abuse of older men" is also a major concern in this age group. In a sense, geriatricians often have to "treat" the caregivers Carer and caregiver (US, Canadian usage) are words normally used to refer to unpaid relatives or friends who support people with disabilities. The words may be prefixed with "family" "spousal", "child" to distinguish between different care situations. The general term dependent/dependant care is also used for the and sometimes, the family, rather than just the elder.

Elderly people have specific issues as regard medications A pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease. Elderly people particularly are subjected to polypharmacy Polypharmacy is the use of multiple medications by a patient, especially when too many forms of medication are used by a patient, when more drugs are prescribed than is clinically warranted, or even when all prescribed medications are clinically indicated but there are too many pills to take . Furthermore, a portion of the treatments may not be due to many causes. Some elderly people have multiple medical disorders; some use many herbs In American English the initial "h" is normally silent: /ˈɜrb/.[Full citation needed] In standard British English the "h" is pronounced: /ˈhɜːb/ Also see American and British English pronunciation differences. In Canada, it is pronounced either with or without the "h" & 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 The kidneys are paired organs with several functions. They are seen in many types of animals, including vertebrates and some invertebrates. They are an essential part of the urinary system and also serve homeostatic functions such as the regulation of electrolytes, maintenance of acid-base balance, and regulation of blood pressure. They serve the or the liver The liver is a vital organ present in vertebrates and some other animals. It has a wide range of functions, including detoxification, protein synthesis, and production of biochemicals necessary for digestion. The liver is necessary for survival; there is currently no way to compensate for the absence of liver function, either of which may be 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 Delirium is a common and severe neuropsychiatric syndrome with core features of acute onset and fluctuating course, attentional deficits and generalized severe disorganization of behavior. It typically involves other cognitive deficits, changes in arousal (hyperactive, hypoactive, or mixed), perceptual deficits, altered sleep-wake cycle, and or falls. (Pneumonia Pneumonia is an inflammatory condition of the lung. It is often characterized as including inflammation of the parenchyma of the lung and abnormal alveolar filling with fluid (consolidation and exudation), for example, may present with fever Fever is a common medical sign characterized by an elevation of temperature above the normal range of 36.5–37.5 °C (98–100 °F) due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering, low-grade fever, dehydration Dehydration is defined as an excessive loss of body fluid. It is literally the removal of water (Ancient Greek: ὕδωρ hýdōr) from an object, however in physiological terms, it entails a deficiency of fluid within an organism, confusion Confusion of a pathological degree usually refers to loss of orientation (ability to place oneself correctly in the world by time, location, and/or personal identity) sometimes accompanied by disordered consciousness and often memory (ability to correctly recall previous events or learn new material). Confusion as such is not synonymous with or falls.) Some elderly people may find it hard to describe their symptoms A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality. A symptom is subjective, observed by the patient, and not measured in words, especially if the disease is active and causing confusion, or if they have cognitive impairment Cognitive dysfunction is defined as unusually poor mental function, associated with confusion, forgetfulness and difficulty concentrating. A number of medical or psychiatric conditions and treatments can cause such symptoms, including Heavy metal poisoning (in particular mercury poisoning), menopause, fibromyalgia and sleep disorders (including. Delirium in the elderly may be caused by a minor problem such as constipation Constipation also known as costiveness, dyschezia, and dyssynergic defaecation is a symptom of infrequent hard to pass bowel movements. Defecation may be painful, and in severe cases may lead to symptoms of bowel obstruction. The term obstipation describes severe constipation which prevents passage of both stool and gas. Causes of constipation can or by something as serious and life-threatening as a heart attack (myocardial infarction Myocardial infarction or acute myocardial infarction (AMI), commonly known as a heart attack, is the interruption of blood supply to part of the heart, causing heart cells to die. This is most commonly due to occlusion (blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of).

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 ageing 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 Urinary incontinence is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners. There is also a related condition for defecation known as and impaired intellect/memory Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging. It may be static, the result of a unique global brain injury, or progressive, resulting in long-term decline due to damage or disease in the body. Although dementia is far more common in the geriatric population, it. Health issues in older adults may also include elderly care Elderly care or simply eldercare is the fulfillment of the special needs and requirements that are unique to senior citizens. This broad term encompasses such services as assisted living, adult day care, long term care, nursing homes, hospice care, and In-Home care, delirium Delirium is a common and severe neuropsychiatric syndrome with core features of acute onset and fluctuating course, attentional deficits and generalized severe disorganization of behavior. It typically involves other cognitive deficits, changes in arousal (hyperactive, hypoactive, or mixed), perceptual deficits, altered sleep-wake cycle, and, use of multiple medications Polypharmacy is the use of multiple medications by a patient, especially when too many forms of medication are used by a patient, when more drugs are prescribed than is clinically warranted, or even when all prescribed medications are clinically indicated but there are too many pills to take . Furthermore, a portion of the treatments may not be, impaired vision Visual impairment is vision loss (of a person) to such a degree as to qualify as a handicap through a significant limitation of visual capability resulting from either disease, trauma, or congenital or degenerative conditions that cannot be corrected by conventional means, such as refractive correction, medication, or surgery. This functional loss and hearing Hearing impairment or deafness refers to conditions in which individuals are fully or partially unable to detect or perceive at least some frequencies of sound which can typically be heard by members of their species. Use of the term impaired implies that deafness presents an inherent disadvantage to an animal, a view that is rejected within the.

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

Surgical

Other geriatrics subspecialties

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

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 (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

Academic resources

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 (1): 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.

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