SCOPE OF GERIATRIC MEDICINE

SCOPE OF GERIATRIC MEDICINE

Elderly people form a substantial proportion of our population today. Population studies demonstrate a disproportionately large rise in the numbers of people over 75 years of age (this group has increased by 12% in the five years since the 1981 Census) and predict a greater increase up to the end of this century. Medical care must therefore adapt to the changing characteristics of the population it aims to serve. Medicine has traditionally been orientated towards the younger patient and to cure disease. Disease patterns are changing, as most of the infectious diseases have now been conquered, and the structure of the population is changing—with a reduced infant mortality rate and increased life expectancy. Few diseases at any age can be completely cured; most leave tell-tale 'scars' that can be re-opened later. There are few medical specialities which are unaffected by these changes. The dramatic growth of the elderly population serves as an important challenge to medical students, who will become the doctors of the future.
Geriatric medicine is the branch of general medicine concerned with the many aspects of illness in the elderly population. It has been argued that it is not a speciality in the sense that it does not deal with a single pathology, such as oncology, or a single organ or organ system, such as cardiology. However, the practice of geriatric medicine requires a wide experience of all branches of medicine and the ability to assess and treat patients in the context of their normal home environment. Geriatricians need to be able to distinguish between what are the inevitable effects of ageing and the effects of disease, which therefore require medical treatment. Disease, developing as a result of pathological processes, may either be completely curable or reflect degenerative changes that can be substantially helped by medical means and other rehabilitative endeavours.
The differential diagnosis of the so-called 'geriatric giants', the common presentations of illness in elderly people—confusion, incontinence, falls or instability and immobility—is deceptively wide. Disease may frequently present in an atypical manner in elderly people, who often have multiple pathologies occurring simultaneously. Prescribing for several disease processes occurring together may readily cause unwanted drug interactions. Elderly people, like children, frequently handle drugs in a different manner to younger adults. Knowledge of such factors forms the core of geriatric medicine, but although good clinical skills are essential they are not sufficient alone.
'Whole person medicine' is fundamental to the care of elderly patients. The aim of a geriatrician is to enable every elderly person to live as full and active a life as possible in their own home, or if this is not feasible, in alternative accommodation of their choice. Too often in the past, elderly patients have been seen as passive recipients of care given by others. Nothing is more likely to erode their ability and confidence to look after themselves or induce dependence. Medical and nursing care of the elderly sick does not automatically require bed rest and care for every patient, as frequently happens with younger patients. Because unnecessary bed rest is positively dangerous to elderly people, care is typically directed towards enabling them to be as independent as possible, doing as much for themselves as they can, even while they are in hospital. Therefore, unless very sick, they are not nursed in bed all the time, but encouraged to wash and dress themselves whenever possible and move about as they wish in the ward.
Remedial, social and preventative aspects of illness are often as important as purely clinical matters. Rehabilitation, the process of maximizing the patients' potential for recovery after disease (and after trauma or surgery), and the provision of simple aids and appliances in the home environment may transform a difficult existence into a bearable life for an elderly patient. The ability to determine the social and environmental factors of importance in the lives of elderly people is as important as diagnosing their physical and mental conditions. The presence of a flight of stairs to the front door, for example, may be of crucial importance in deciding if an elderly person with mobility problems can return home alone.
The current generation of elderly people have low expectations of their doctors and too often readily accept illness as a 'natural' consequence of their age. Assessment of unreported illness in the elderly community is a large and important area of community medicine, especially of relevance for general practitioners, and may form an extremely satisfying area of preventative care.
The geriatrician cannot be an expert in all these areas of concern in the everyday lives of elderly patients. More than in most other medical specialities, team work is essential, so that expertise from all the paramedical disciplines (physiotherapy, occupational therapy, ortho-tics, dietetics psychology, speech therapy and social work, to name but a few) can be brought together by the geriatrician and directed towards the welfare of each patient.