Geriatrics

Geriatrics, or geriatric medicine, is a medical specialty focused on addressing the unique health needs of older adults. The term geriatrics originates from the Greek γέρων geron meaning "old man", and ιατρός iatros meaning "healer". It aims to promote health by preventing, diagnosing and treating disease in older adults. Older adults may be healthy, but they're more likely to have chronic health concerns and require more medical care. There is no defined age at which patients may be under the care of a geriatrician, or geriatric physician, a physician who specializes in the care of older people. Rather, this decision is guided by individual patient needs and the caregiving structures available to them. This care may benefit those who are managing multiple chronic conditions or experiencing significant age-related complications that threaten quality of daily life. Geriatric care may be indicated if caregiving responsibilities become increasingly stressful or medically complex for family and caregivers to manage independently. There is a distinction between geriatrics and gerontology. Gerontology is the multidisciplinary study of the aging process, defined as the decline in organ function over time in the absence of injury, illness, environmental risks or behavioral risk factors. However, geriatrics is sometimes called medical gerontology.

Geriatrics, or geriatric medicine, is a medical specialty focused on addressing the unique health needs of older adults. The term geriatrics originates from the Greek γέρων geron meaning "old man", and ιατρός iatros meaning "healer". It aims to promote health by preventing, diagnosing and treating disease in older adults. Older adults may be healthy, but they're more likely to have chronic health concerns and require more medical care. There is no defined age at which patients may be under the care of a geriatrician, or geriatric physician, a physician who specializes in the care of older people. Rather, this decision is guided by individual patient needs and the caregiving structures available to them. This care may benefit those who are managing multiple chronic conditions or experiencing significant age-related complications that threaten quality of daily life. Geriatric care may be indicated if caregiving responsibilities become increasingly stressful or medically complex for family and caregivers to manage independently. There is a distinction between geriatrics and gerontology. Gerontology is the multidisciplinary study of the aging process, defined as the decline in organ function over time in the absence of injury, illness, environmental risks or behavioral risk factors. However, geriatrics is sometimes called medical gerontology.

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 dehydration from a mild gastroenteritis). Multiple problems may compound: A mild fever in elderly persons may cause confusion, which can advance to a fall and to a fracture of the neck of the femur ("broken hip"). The presentation of disease in older persons may be vague and non-specific, or it may include delirium or falls. (Pneumonia, for example, may present with low-grade fever and confusion, rather than the high fever and cough seen in younger people.) Some elderly people may find it hard to describe their symptoms in words, especially if the disease is causing confusion, or if they have cognitive impairment. Delirium in the elderly may be caused by a minor problem such as constipation or by something as serious and life-threatening as a heart attack. Many of these problems are treatable, if the root cause can be discovered.

Cognition

Cognitive aging is characterized by declines in fluid abilities like processing speed, working memory, and executive function, while crystallized abilities such as knowledge remain stable (Anstey & Low, 2004; Murman, 2015). Age-related changes in brain structure and function correlate with these cognitive declines (Murman, 2015). Older adults show weaker occipital activity and stronger prefrontal and parietal activity during cognitive tasks, possibly reflecting compensation (Cabeza et al., 2004). Subjective cognitive complaints are common among older adults, particularly regarding working memory (Newson & Kemps, 2006). Various factors influence cognitive aging, including genetics, lifestyle, and health (Bäckman et al., 2004). Cognitive impairments can progress to mild cognitive impairment (MCI) or dementia (Mendoza-Ruvalcaba et al., 2018). MCI is a transitional state between normal aging and dementia, affecting 10-20% of adults over 65 (Schwarz, 2015). Geriatricians encounter MCI patients in various care settings, with diagnoses relying on clinical assessment and mental status examinations (Tangalos & Petersen, 2018). MCI is highly prevalent among older adults with depression and may persist after depression remits (Lee et al., 2006). While MCI is considered a high-risk condition for developing Alzheimer's disease, there is heterogeneity in its presentation and outcomes (Petersen et al., 2001). Dementia is a prevalent condition in geriatric populations, affecting cognitive function and daily activities (Talawar, 2018; Mirzapure et al., 2022). Alzheimer's disease is the most common cause, accounting for 40-80% of cases (Mirzapure et al., 2022; Chulakadabba et al., 2020). Geriatric patients with dementia often have comorbidities and other geriatric syndromes, requiring holistic and integrated care (Chulakadabba et al., 2020; Nguyen et al., 2023). Geriatricians play a crucial role in dementia care, but many feel current training is inadequate and seek more structured experiences (Mayne et al., 2014). Improving access to geriatricians and enhancing general practitioners' diagnostic skills could improve timely and accurate dementia diagnosis (Mansfield et al., 2022). However, there are significant shortages of dementia specialists, particularly in rural areas (Liu et al., 2024; Christley et al., 2022). Geriatricians support comprehensive post-diagnosis information provision, including sensitive topics like advance care planning (Mansfield et al., 2022). Collaboration between specialists and family physicians is essential, with specialists often handling contentious issues like driving competency (Hum et al., 2014). Geriatric training may influence end-of-life care patterns for dementia patients (Gotanda et al., 2023). A geriatrics perspective emphasizes prevention, considering lifestyle factors that promote healthy cognitive aging (Steffens, 2018). There are various tests to assess cognition. These include the MMSE, the Montreal Cognitive Assessment, and GERRI (geriatric evaluation by relative's rating instrument), which is a diagnostic tool for rating cognitive function, social function and mood in geriatric patients.

History

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. 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. 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. The Arab physician Algizar ( –980) wrote a book on the medicine and health of the elderly. He also wrote a book on sleep disorders and another one on forgetfulness and how to strengthen memory, and a treatise on causes of mortality. Another Arab physician in the 9th century, Ishaq ibn Hunayn (died 910), the son of Nestorian Christian scholar Hunayn Ibn Ishaq, wrote a Treatise on Drugs for Forgetfulness. George Day published the Diseases of Advanced Life in 1849¹, one of the first publications on the subject of geriatric medicine. The first modern geriatric hospital was founded in Belgrade, Serbia, in 1881¹ by doctor Laza Lazarević. The term geriatrics was proposed in 1908 by Ilya Ilyich Mechnikov, Laurate of the Nobel Prize for Medicine and later by 1909 by 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 began with the "mother" of geriatrics, Marjory 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 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. 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.

United States

In the United States, geriatricians are primary-care physicians (D.O. or M.D.) 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. Geriatricians have developed an expanded expertise in the aging process, the impact of aging on illness patterns, drug therapy in seniors, health maintenance, and rehabilitation. They serve in a variety of roles including hospital care, long-term care, home care, and terminal care. They are frequently involved in ethics consultations to represent the unique health and diseases patterns seen in seniors. The model of care practiced by geriatricians is heavily focused on addressing working closely with other disciplines such as nurses, pharmacists, therapists, and social workers.

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. 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 nurses and other health care professionals can pursue further education in the discipline in order to better understand the process of aging and their role in the presence of older patients and residents.

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 MBBS (Bachelor of Medicine and Bachelor of Surgery). Unfortunately, only eight major institutes provide M.D in Geriatric Medicine and subsequent training. Training in some institutes are exclusive in the Department of Geriatric Medicine, with rotations in Internal medicine, medical subspecialties etc. but in certain institutions, are limited to 2-year training in Internal medicine and subspecialities followed by one year of exclusive training in Geriatric Medicine.

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 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.

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