Education and debate

Geriatric medicine: a brief history

^a Nuffield Department of Clinical Medicine, Division of Clinical Geratology, Radcliffe Infirmary, Oxford OX2 6HE john.grimleyevans{at}geratology.oxford.ac.uk

	Introduction

Top Introduction The mother of geriatrics Geriatricians in control The picture in America... The future References

Old age has always been with us. The ancient Egyptians and the author of the 12th chapter of Ecclesiastes were familiar with the common disabilities of later life. Survival into what we still regard as old age was not unusual in classical Greece (1). The average length of human life has increased over the centuries as living conditions have improved and childhood mortality has fallen; the maximum lifespan of our species is determined largely by our genes and will be the same as it ever was.

Doctors and philosophers of antiquity commented on age associated illness. Hippocrates noted conditions common in later life, and Aristotle offered a theory of aging based on loss of heat. Two thousand years were to pass before anything better was written on the subject. Francis Bacon proposed a scientific programme of epidemiological investigations into the longevity of people living in different places and under different conditions.¹ He also noted that the pursuit of knowledge depended on "the fresh examination of particulars," advice that underlaid the systematic observation of nature that complemented the active experimentation advocated by his contemporary William Harvey.

During the 18th and 19th centuries several physicians wrote specifically about the diseases of later life and their treatment. These included Cheyne² and Day³ in Britain and Rush⁴ in the United States. Charcot's lectures on the medicine of old age aroused scientific interest in the field and became available in English translation in 1881.⁵ The word "geriatrics" was invented by Ignatz L Nascher, a Vienna-born immigrant to the United States in 1909.⁶ (It is not clear who is to blame for the barbarous miscoining of "gerontology"—the study of old men—for "geratology"—the study of old age.) Nascher's initiative provided a stimulus for social and biological research on aging,⁷ but clinical geriatrics did not flourish in the United States. The American Geriatrics Society was founded in 1942, but as a thriving and influential medical specialty geriatric medicine was essentially a product of the British NHS.

	The mother of geriatrics

Top Introduction The mother of geriatrics Geriatricians in control The picture in America... The future References

If Nascher was the father of geriatrics, Marjory Warren was its mother. She worked at the Isleworth Infirmary, which in 1935 took over responsibility for an adjacent workhouse to form the West Middlesex County Hospital. During 1936 Dr Warren systematically reviewed the several hundred inmates of the old workhouse wards. Many of the patients were old and infirm, and Dr Warren matched care to their needs through a system of classification. She discharged many patients by providing rehabilitation and appropriate equipment. She initiated upgrading of the wards, thereby improving the morale of both patients and staff. In two seminal papers she advocated creating a medical specialty of geriatrics, providing special geriatric units in general hospitals, and teaching medical students about the care of elderly people, by senior doctors with specialist interest and experience in geriatrics.^{8 9} Many visitors from elsewhere in the United Kingdom and from overseas came to observe and learn from Dr Warren's methods, and she gave lectures in Canada, Australia, and the United States.¹

The achievements of Dr Warren, and of other pioneers such as Lionel Cosin, stimulated the Ministry of Health to appoint the first consultant geriatricians within a few months of the introduction of the NHS in l948. The Medical Society for the Care of the Elderly, later renamed the British Geriatrics Society, had already been founded with eight members in 1947. Its president was Lord Amulree, who, as medical officer at the Ministry of Health, had been among the first to appreciate the importance of Marjory Warren's work.

Despite the continued support of the Ministry of Health the specialty was shadowed at first by medical politics. At the birth of the NHS many consultants assumed that the bulk of their future earnings would come, as in the past, from private practice. They were therefore unwilling to see an expansion of the consultant grade but at the same time were unenthusiastic about assuming responsibility for patients of the workhouses and municipal hospitals that the NHS had taken over along with the teaching and district hospitals. The solution was to appoint geriatricians but to exclude them from the main hospitals and inhibit their access to private practice. This medical apartheid contributed to a general perception of geriatric medicine as a refuge for doctors who had failed to make their way in some more desirable specialty. Not surprisingly, relationships between general physicians and the early geriatricians were soured for some years by a sense of resentful emulation. This soon began to pass, but ill feeling flared up for a while in the mid-1970s, when the government proposed an active transfer of resources to geriatric medicine from other specialties. Papers were hastily published advocating the abolition of the specialty,¹⁰ and old people were accused of being cuckoos in the nest of the acute general hospital. It soon became clear that the government had no intention of fulfilling its threat, and normal relations were re-established.

	Geriatricians in control

Top Introduction The mother of geriatrics Geriatricians in control The picture in America... The future References

Ironically, subsequent years brought the widespread recognition that geriatric skills could help general hospitals run more efficiently. The first geriatricians, given responsibility only for patients in long stay hospitals, concentrated like Marjory Warren on upgrading the environment, improving the morale of patients and staff, and developing rehabilitation facilities. Working within what has come to be known as the "traditional" model of geriatrics,¹¹ geriatricians were responsible for patients chosen for them by other referring doctors. Patients were sent for "long stay care," but the geriatricians saw that some would not have needed institutional care if they had received more appropriate management earlier in their illness. Geriatricians therefore began to seek more influence over the acute as well as the rehabilitative and long term care of older people. This led in the 1970s to the emergence of two models of geriatrics—the "age defined" model,¹² pioneered in Sunderland, and the "integrated" model, from Newcastle upon Tyne. The first is based on separate parallel hospital medical services for patients above and below an arbitrary age. In the second, consultant physicians trained in both geriatric and general medicine join medical "firms" with physicians with other specialist interests, sharing wards and the same team of junior medical staff for acute work while retaining separate specialist rehabilitation facilities.

Whatever their model of service, geriatricians were agreed on the components and principles of optimal care for older people. The principles are embodied in the four stage process outlined in the box, with its emphasis on functional goals agreed with the patient and its implications for multidisciplinary working. A quest for earlier and more effective detection and management of disability in older people produced a number of community oriented initiatives. Some of these aimed to fill gaps in primary care and have been overtaken by improvements in general practice. Other initiatives have found only local applicability. The most enduring of bridges with community care has been the geriatric day hospital, first introduced in Oxford in the 1950s¹⁴ but rapidly replicated elsewhere, unfortunately without adequate evaluation.

During the growth of geriatric medicine in the 1960s and 1970s specialist services were developed throughout Britain. The academic base of the specialty also became established. The first chair in geriatric medicine had been set up by private endowment in Glasgow in 1965. During the 1970s most medical schools acquired academic departments or subdepartments in the specialty, mostly using resources provided by the NHS. These units were small and focused at first on teaching and recruitment more than research, and most had responsibilities for service development.

	The picture in America and elsewhere

Top Introduction The mother of geriatrics Geriatricians in control The picture in America... The future References

In the United States things evolved differently. Geriatrics was initially restricted to nursing home practice, and there was resistance to its establishment as a recognised specialty. There was also uncertainty over whether it should develop in primary care or become, as in Britain, a secondary care specialty. It was in the Veterans' Administration service, significantly the only socialised section of American medicine, that a need to respond to the aging of the patient population was first acknowledged. The publication of a major critique of the neglect of older people in the United States¹⁵ stimulated the public concern that led to the creation of the National Institute on Aging with a multimillion dollar research budget. Experimental hospital based units, using the type of multidisciplinary geriatric evaluation that had been developed empirically in Britain, were set up and compared in randomised controlled trials with standard care. Unfortunately, given the American way of medicine, units created with research funds had no guarantee of being continued as a service even when shown, as several were,¹⁶ to be cost effective. Comprehensive geriatric services on the British pattern are still rare in the United States, especially in teaching centres. Medical schools, however, have members of faculty with responsibility for ensuring that students learn at least the rudiments of modern geriatric care.

The contrast between the United Kingdom and the United States has its ironies. The British developed and provide services that have been adequately evaluated only in the United States, where they are rarely implemented. But the advantages of geriatric care over conventional care in the United States may reflect not so much the excellence of geriatrics as the poor service provided to older people in other settings. In the United Kingdom the aim from the early days of the specialty has been to spread geriatric skills as widely as possible. Standards of good care that were at first restricted to geriatric departments are now normal practice throughout the NHS. Now in the age of evidence based medicine and threatened resources, British geriatricians can only invoke American studies in self justification. Our defence has to be that although irrelevant in a direct sense to what British geriatric medicine does, American research and experience warn of the consequences for the United Kingdom if the specialty had not existed or were to disappear.

In most other countries geriatric medicine has yet to develop, for example in Japan, or to evolve beyond the "traditional" model now obsolescent in England and Wales. After the recent expansion of the European Union geriatrics has qualified as an official European specialty, although it is still not recognised in several Union countries. There is wide variation in teaching facilities,¹⁷ and the recently founded European Academy of Medicine of Ageing is dedicated to recruiting and training a nucleus of young geriatricians to strengthen the academic departments of the future. The role of the specialty also differs between nations in Europe. In the Netherlands, geriatrics is squeezed between other hospital based specialties and a large specialty of nursing home medicine which undertakes most of the rehabilitation work of British geriatricians. Geriatrics is not a formal specialty in Italy, but there are many accomplished academic departments committed to teaching and research in the topic. The specialty has no official status in France, but several departments of medicine have a major interest in the care of older people. French patients have a right of self referral to doctors of their choice so there is resistance to recognition of the specialty from general practitioners who fear loss of custom if elderly patients have the option of specialist geriatric services.

	The future

Top Introduction The mother of geriatrics Geriatricians in control The picture in America... The future References

In terms of comprehensiveness of services, and more nebulous considerations of status and influence, British geriatrics at the age of 50 is still ahead of the rest of the world, but its research base remains poorly developed. On the clinical side, given the continued aging of the population and increasing technical demands on physicians in organ based specialties, doctors trained in geriatric and general medicine may come to staff much of the front line of acute medical services in hospitals of the future. Research may remain a problem. There is a tension between the generalist nature of clinical practice among older people and the need for clinical and basic research to be intensely focused if it is to be of the highest standard. There is also now a geratological agenda in molecular biology and genetics. How to ensure both clinical and research excellence without threatening the essential link between them is now perhaps the single most important issue for geriatrics.

View larger version (116K): [in this window] [in a new window]   Self portraits by Rembrandt at the ages of 23, 34, and 63. THE BRIDGEMAN ART LIBRARY, THE NATIONAL GALLERY, THE BRIDGEMAN ART LIBRARY

	References

Top Introduction The mother of geriatrics Geriatricians in control The picture in America... The future References

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2. Cheyne G. An essay on health and long life. London: George Strahan, J Leaker, 1724.
3. Day GE. A practical treatise on the domestic management and most important diseases of advanced life. With an appendix containing a series of cases illustrative of a new and successful mode of treating lumbago and other forms of rheumatism, sciatica and other neuralgic afflictions, and certain forms of paralysis. London: T and W Boone, 1849.
4. Rush B. Medical inquiries and observations. Philadelphia: Johnson and Warner, 1815.
5. Charcot J-M, Hunt LH, Loomis AL. Clinical lectures on the diseases of old age. New York: William Wood, 1881.
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11. Royal College of Physicians. Ensuring equity and quality of care for elderly people. The interface between geriatric medicine and general (internal) medicine. London: Royal College of Physicians, 1994.
12. O'Brien TD, Joshi DM, Warren EW. No apology for geriatrics. BMJ 1973;i: 277-80.
13. Grimley Evans J. Integration of geriatric with general medical services in Newcastle. Lancet 1983;i:1430-3.
14. Cosin L. The place of the day hospital in the geriatric unit. The Practitioner 1954;172:552-9.
15. Butler RN. Why survive? Being old in America. New York: Harper and Row, 1975.
16. Rubenstein LZ. The efficacy of geriatric assessment programmes. In: Kane RL, Grimley Evans J, Macfadyen D, eds. Improving the health of older people. A world view. Oxford: Oxford University Press, 1990: 417-30.
17. Group of European Professors of Medical Gerontology (GEPMG). Teaching medical gerontology in Europe. Age Aging 1994;23:179-81.