Head to Head

Should geriatric medicine remain a specialty? No

C P Denaro, director, associate professor1,2, A Mudge, staff physician1

1 Internal Medicine and Aged Care, Royal Brisbane and Women’s Hospital, Brisbane 4029, Australia, 2 University of Queensland, Brisbane

Correspondence to: C P Denaro c.denaro{at}uq.edu.au

The development of geriatricshas greatly improved care for older people. Leon Flicker (doi: 10.1136/bmj.39538.481273.AD) believesspecialist care remains important for this vulnerable group,butC P Denaro and A Mudge argue that age divisions are no longer relevant

Our patients have changed. The inverted pyramid is imminent. Every developed country is facing an increase in older patients.1 2 The fastest growth in emergency admission rates is in the oldest age group.2 These changes translate into major changes in the profile of our hospital patients, as older patients with multiple chronic diseases and disabilities occupy more beds. In addition, improved survival is also leading to larger numbers of younger people with chronic disease and disabilities living in our communities.3 Thus it is not just geriatricians who have to be able to manage acute and accumulated chronic diseases and to assess and manage the functional, cognitive, and psychological impairments that can influence longevity, quality of life, use of health care, and treatment decisions.

The concepts of comprehensive assessment, multidisciplinary care, rehabilitation, and planned discharge have been championed by many groups, but particularly geriatric medicine. Recognition of subtle and atypical presentations of illness in elderly people, and the decreased physiological reserve commonly recognised (but poorly defined) as frailty have been important contributions to hospital care of older people.4 Clinical and academic geriatricians have provided important leadership, and the principles they have espoused have been incorporated in the training of our hospital and family doctors and the staffing of our hospitals, which include roles such as discharge facilitators and case managers. Since most of our patients in the future will have chronic diseases or disabilities or have frailty related problems, all generalists must incorporate these holistic themes and specific knowledge into their clinical practice. So there is little point in continuing to distinguish general physicians from geriatric physicians.5

Value of team approach

The landmark trial by Rubenstein and colleagues, published 24 years ago, showed that admission to a geriatrician led, team based rehabilitation unit after acute care significantly improved outcomes compared with usual hospital practice.6 This small study had a major influence in subsequent meta-analysis of geriatric interventions, but the impressive results have not been replicated.7 Acute elder care units have had mixed success, and the evaluation of geriatric consultation services shows disappointing results.7 8 9 What are the reasons? Some have argued that the wrong patient subgroup was targeted for specialist care or that the models did not provide adequate control over management decisions. However, perhaps the successful models have relied on features other than geriatric expertise such as the multidisciplinary allied health team and dedicated rehabilitation areas.

The use of multidisciplinary teams is no longer confined to geriatric medicine. Positive results have been achieved by non-geriatric physicians supervising multidisciplinary care teams, suggesting that the team model rather than "geriatric technology" may be important.10 Similarly, there is no evidence that the important benefits seen with stroke units are tied to the leadership by a specific specialty physician group.11 The successful chronic disease management programmes for heart failure, diabetes, or chronic obstructive airways disease also require multidisciplinary teams working with general practitioners and hospital doctors.12 13 14 It seems to be resources and the model of care that make the difference.

What age is old?

It is not sensible to define a specialty by chronological age. Increasing numbers of younger people with chronic disease and disabilities also require a coordinated, function focused approach to care; artificial age cut-offs into "geriatric" and "non-geriatric" services only frustrate access to such services. In addition, attitudes to and expectations of health care for older people have changed greatly in the past generation. An approach centred on gentle symptom management and functional maintenance is no longer considered acceptable. In 2005, almost half of new patients started on renal dialysis were aged over 65, and almost 10% of patients receiving coronary artery bypass grafting were over 80.15 16 The rationing of aggressive medical care is now appropriately based on individual judgments of risks and benefits, not by a number.

Health care is a continuum, and rather than breaking the patient’s journey into arbitrary steps (under 65, over 65, acute care, subacute care, etc) a patient’s continuity of care should be maximised wherever possible. There is danger if a patient with complex multiple medical conditions during their life journey sees too many doctors or has multiple handovers when admitted to hospital.

True generalists are needed

Workforce reports across the world show increasing problems attracting trainees to geriatric medicine.17 18 Faced with the rising tide of patients with comorbidities, disabilities, and frailty there has been a renewed impetus to increase the number of generalists in hospitals. The United States has created the hospitalist movement, and the Royal Australasian College of Physicians advocates for a return to generalism.19 20 All of these staff require an understanding of geriatric principles, but singular geriatric training may no longer provide a doctor with the skills needed to manage older patients who require evidence based therapy for a wide range of conditions.

Advocacy, innovation, and teaching of health care for elderly people needs enthusiastic supporters. However, specialised geriatric training may be neither necessary nor sufficient for such a role. Our challenge is to continue to incorporate the lessons of these pioneers in aged care into everyday clinical practice.

Cite this as: BMJ 2008;337:a515

Competing interests: None declared.

References

  1. Karmel R, Lloyd J, Hales C. Older Australians in hospital. Bulletin No 53. Canberra: Australian Institute of Health and Welfare, 2007.
  2. Wood R, Bain MRS. The health and well-being of older people in Scotland: insights from national data. Edinburgh: Information and Statistics Division, 2001.
  3. Australian Institute of Health and Welfare. Australia’s welfare. Canberra: AIHW, 2007.
  4. Barton A, Mulley G. The history of the development of geriatric medicine in the UK. Postgrad Med J 2003;79:229-34.[Abstract/Free Full Text]
  5. Evans JG. Integration of geriatric with general medical services in Newcastle. Lancet 1983;i:1430-3.
  6. Rubenstein LZ, Josephson KR, Weiland GD, English PA, Sayre JA, Kane RL. Effectiveness of a geriatric evaluation unit: a randomised clinical trial. N Engl J Med 1984;311:1664-70.[Abstract]
  7. Stuck AE, Siu AL, Wieland GD, Adams J, Rubinstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993;342:1032-6.[CrossRef][Web of Science][Medline]
  8. Scott I. Optimising care of the hospitalised elderly. A literature review and suggestions for future research. Aust N Z J Med 1999;29:254-63.[Web of Science][Medline]
  9. Gray L. Geriatric consultation: is there a future? Age Ageing 2007;36:1-2.[Free Full Text]
  10. Mudge A, Laracy S, Richter K, Denaro C. Controlled trial of multidisciplinary care teams for acutely ill medical inpatients: enhanced multidisciplinary care. Intern Med J 2006;36:558-63.[CrossRef][Web of Science][Medline]
  11. Stroke Unit Trialists’ Collaboration. Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. BMJ 1997;314:1151-9.[Abstract/Free Full Text]
  12. McAlister FA, Stewart S, Ferrua S, McMurray JJ. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomised trials. J Am Coll Cardiol 2004;44:810-9.[Abstract/Free Full Text]
  13. Gaede P, Vedel P, Larsen L, Jensen GVH, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes mellitus. N Engl J Med 2003;348:383-93.[Abstract/Free Full Text]
  14. Griffiths TL, Burr ML, Campbell IA, Lewis-Jenkins V, Mullins J, Shiels K, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet 2000;355:362-8.[CrossRef][Web of Science][Medline]
  15. ANZDATA 30th Annual report: 2007. www.anzdata.org.au/anzdata/AnzdataReport/download.htm.
  16. Australian Institute of Heath and Welfare. National hospital morbidity database. 2007. www.aihw.gov.au/hospitals/datacubes/datacube_proc.cfm.
  17. Australian Medical Workforce Advisory Committee. The geriatric workforce in Australia. Sydney: AMWAC, 1997.
  18. British Geriatrics Society. Report to health select committee on medical workforce issues. London: BGS, 2006. www.bgs.org.uk/Publications/Position%20Papers/psn_workforce_needs.htm.
  19. McMahon LF. The hospitalist movement: time to move on. N Engl J Med 2007;357:2627-9.[Free Full Text]
  20. Royal Australasian College of Physicians. Restoring the balance: an action plan for ensuring equitable delivery of consultant services in general medicine in Australia and New Zealand. 2005. www.racp.edu.au/index.cfm?objectId=49F486CD-2A57-5487-D5E00B105EC4FD10.

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