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In a recent JRSM editorial¹, a non- geriatrician specialist internist consultant physician from Colchester, wrote that “geriatric practice in hospital appears to follow two different models...”

In Model A: the geriatrician is a passive member of the specialist team and oversees the ongoing management of those patients whose conditions prevent a speedy return to the community. Model B: the geriatrician takes control of the patient’s management on arrival at the hospital.” before going on to suggest a role reappraisal whereby geriatricians are absorbed by “the four major acute specialties – cardiology, chest medicine, gastroenterology and endocrinology”.

I think the writer’s opinion serves as an excellent guide to the perception of geriatrics in certain quarters, and the challenges geriatricians face in service provision and advocacy for older people.

One of my most rewarding experiences to date was when I diagnosed polymyalgia rheumatica in a 90 year-old man who had been caring for his frail wife of over 60 years. Watching him, over a period of days, regain the strength and confidence to go back to independent living and resume his role as his wife’s carer, had a profound effect on me. I do not know how the health economics of this transformation add up, but two places in long term care were spared and something human, and incredibly affecting, happened in the process. It had not been a readily apparent diagnosis and had been overlooked in previous weeks during the usual transfers around the modern hospital.

The development of geriatrics as a specialty pre-dated the management considerations supposed erroneously by the JRSM author, to have created and helped burgeon the specialty. One of the underpinning principles of early geriatrics was seeing the infirm elderly as having different needs to the usual medical patient and attempting to address these needs. Older people deserve equality of choice and experience within healthcare but I do not believe that 48 hours on an admissions unit with 30 other acutely ill adults, after 3 hours 59 minutes and 59 seconds spent on an A&E trolley, constitutes either “choice” or an ideal of “equality”.

The dichotomisation of geriatric practice into “passive” and “active” leads me to want to add something about leadership and team dynamics, where many more subtle “faces” of the leader may be apparent under the surface. Moreover, the JRSM editorial ignores the roles of the geriatrician in providing outpatient services, day hospitals, liaison within a hospital, systems development, and community liaison (in the form of domiciliary visits or other, perhaps proactive, outreach services) are ignored.

The author’s supposition that patients would choose to have a passive geriatrician only managing those for whom a speedy (convenient, uncomplicated health economics model) return to the community is problematic, ignores the fact that this particular “difficult” population is invariably ill, frail, comorbid and/or demented (and therefore unable, in many instances, to choose without some advocacy)³.

With regard to health economics in the care of older people, the author would do better to consider the difference between the situations he compares. It is not easy to quantify the benefits of geriatric care, unlike “hard” outcomes like myocardial infarction, door to needle time, or outpatient waiting times. A moot example would be the management of faecal or urinary incontinence – a common reason for families and carers failing to cope and often leading to admission to a care setting⁴. Managers and clinicians would do well to remember who the client is in the health equation.

As regards the question of GPs or geriatricians caring for elders, and my following statement is not intended to denigrate the care GPs provide, there is a difference between the two. The number of referrals to a geriatric service from primary care and the work done within an average department are only the tip of the iceberg in terms of need. Some of the domains within the GP Quality and Outcomes framework (QOF) that are a driver to both payment and “quality” measurement, are potentially at odds with reasonable geriatric management. An example would be the blood pressure targets for the older and oldest old where a degree of common sense is required when looking at the measured blood pressure. While the Hypertension in the Very Elderly Trial (HYVET) data, recently published, strongly support antihypertensive therapy in the 80+ age group⁵, targets are less clear. Hence, adhering to QOF targets might cause an unacceptable burden of iatrogenic disease. The risk to benefit ratio in treating elderly hypertensives is not a straightforward proposition – one would not like to withhold a potentially beneficial treatment, but would equally not like to have a fractured neck of femur defining the “maximally tolerated treatment” to create an exception in terms of the QOF.

The early results from the TIME-CHF trial⁶ presented to the European Society of Cardiology Conference in Munich in 20087 support this point of view as elderly patients treated relatively aggressively by a BNP-directed strategy were found to have similar death and hospitalisation rates to those treated in a standard, non-BNP-directed fashion, but had worse quality of life (presumably iatrogenic or drug-related?) than those on standard treatment.

Indeed, a recently published study of General Practice use of a comprehensive geriatric assessment tool8, showed that even amongst the GPs with long (>8 years) relationships with patients, 14% of patients had new problems identified by the use of a simple 32 item tool. It is also of interest to note the perceived relevance of new diagnoses to patient and/or doctor – with some perhaps unsurprising results. For example, problems with the teeth were more likely to be of perceived relevance to the patient than the GP, whereas for hypertension, the situation was the reverse. Constipation and incontinence were important problems for patients (and their geriatricians where they have one) but not so much for GPs. It is also of note that 45/220 (20.5%) of GPs originally enrolled responded to follow-up concerning the tool at 1 year.

It is a matter of pride within the geriatric departments where I have worked (but nothing to do with “the kudos of empire” which the JRSM author employs perjoratively against geriatrics and geriatricians) that those people not choosing geriatrics or medicine as careers will take away something from their experience in terms of attitude, clinical acumen, team working and management of the complex, problems of older people. Considering the age of clients admitted under the average medical and surgical acute take, any experience of geriatrics after medical school (many of which fail to offer dedicated geriatrics training at undergraduate level), has to be a sine qua non of medical training in the 21st century.

I would add another option to the argument of who cares for the majority of medical inpatients – a legion of geriatrics-trained specialist physicians who occasionally consult the “internists” for their views on the organ-specific problem troubling the complex elder. The internists could then be freed to run admissions units, while the geriatricians run outpatient and outreach services, develop strategies for inappropriate admission avoidance and facilitate advance care planning, inpatient care for geriatric problems as judged by needs, not age based criteria, and develop better policy for the multi-disciplinary management of complex, multi-faceted, problems such as delirium and falls. This argument sees the non-geriatrican specialist internist as a geriatrician-manqué rather than vice-versa.

This brings me to the technologies of the gastroenterologist (the endoscope) or the respiratory physician (the bronchoscope) being immediately obvious to anyone – perhaps because they are more easily “waved around”, as opposed to a tilt table which is a little more difficult to “wave around”. The technologies of the geriatrician are overlooked, such as, taking the time to think about the cause of a fall before (over?) expeditious discharge, or managing delirium and dementia (or, at least, advocating on behalf of the demented person and their carers). This may have something to do with both the natural humility of geriatricians and the narrow prejudices of those looking on?

It seems an unassailable fact that dependent, fragile children are managed by paediatricians and their specialist teams. What is it about geriatrics or geriatricians which makes the specialty a target in some quarters? Is it the often-repeated “ageing demographic timebomb”, so eloquently debunked at the recent conference in Birmingham; is it a reflection of the value placed on the elder; is geriatrics just “old (hat) and useless”?

If client views were canvassed on ideal place and type of care, I believe we would see Day Hospitals, domiciliary visits and specialist geriatric services described in detail, possibly with the return of the cottage hospital with tertiary sevices, one way (of a few) in which I think Lord Darzi has it right. Maybe some of us have to re-invent (or, rather, market) ourselves as “frail-ologists”, as one non-geriatrician colleague recently referred to us, or to define more clearly for non-geriatricians the “geriatroscope” that one geriatrician colleague uses in order to reach his diagnoses.

We are only beginning to understand delirium, dementia, frailty and sarcopaenia. The new generation of geriatricians, and trainees, in this challenging specialty have the dynamism and drive that their ever- increasing client group demands.

In the depth of verbiage, a clear message can be lost; I am, as in reading the recent BMJ argument regarding Geriatrics as a specialty⁹, lost, at times, as to the position that the author is arguing. I would add that most arguments can be sustained with more or less elegance. A pattern of working for elders, not despite them, has been shown to work well, and I risk hubris, – obviously not everywhere¹⁰. Yet.

Ian Thompson
SpR Darent Valley Hospital
Dartford

References

1 Aiken M. Geriatricians – a role reappraisal? J R Soc Med 2008; 101: 482-3
2 Howell T. Origins of british geriatrics. Proc R Soc Med 1976; 69(6): 445-9
3 Campbell S, Seymour D, Primrose W. A systematic literature review of factors affecting outcome in older medical patients admitted to hospital. Age Ageing 2004; 33(2):110-5
4 Cassells C, Watt E. The impact of incontinence on older spousal caregivers. J Adv Nurs 2003; 42(6): 607-16
5 Beckett N, Peters R, Fletcher A et al. Treatment of hypertension in patients 80 years of age or older (the HYVET trial) NEJM 2008; 358(18): 1887-98
6 Brunner–La Rocca H, Buser P, Schindler R et al. Management of elderly patients with congestive heart failure—Design of the Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF) Am Heart J 2006; 151(5): 949-55
7 European Society of Cardiology Press Release
8 Piccoliori G, Gerolimon E, Abholz H-H. Geriatric assessment in general practice using a screening instrument: is it worth the effort? Results of a South Tyrol study. Age Ageing 2008; 37: 647-52
9 Denaro C, Mudge A. Should geriatric medicine remain a specialty? No. BMJ 2008; 337: 79
10 Oliver D. Geriatric syndromes continue to be poorly managed and recognised. BMJ 2008; 337: a892

BGS Newsletter, March 2009
Issue 20 ISSN 1748-6343 20