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Should geriatric medicine remain a specialty? Yes

¹ Western Australian Centre for Health and Ageing, School of Medicine and Pharmacology, University of Western Australia, Royal Perth Hospital, Perth, Australia 6001

The development of geriatricshas greatly improved care for older people. Leon Flicker believesspecialist care remains important for this vulnerable group,butC P Denaro and A Mudge (doi: 10.1136/bmj.39533.696076.AD) argue that age divisions are no longer relevant

How are specialties of internal medicine determined? Mostly by a focus on individual organs, which reflect the colocation of cellular systems, which have been so arranged by some chance survival advantage common to all mammals. Even within a specific "organology," individual specialists have a distinct range of expertise based on patients’ and practitioners’ interests, such as interventional versus non-interventional cardiologists. The advantage of subspecialisation, no matter how determined, is clear—it allows the practitioner to focus on specific knowledge, skills, and attitudes that can achieve better patient outcomes. However, for most subspecialties of internal medicine, the evidence for benefit on patient outcomes is lacking. Fortunately, this is not the case for geriatric medicine, and in fact if the specialty of geriatric medicine did not exist, we would be obliged to invent it.

Evidence of benefit

The origins of geriatric medicine lay in the medical neglect of older people with multiple chronic illnesses and concomitant functional disability. Doctors used to assume, without any scientific basis, that such patients would not benefit from any interventions. Their beliefs were shown to be wrong. Older patients do benefit from medical interventions, coupled with the judicious use of therapies to increase functional status and introduction of community support.

Initially, like penicillin, geriatric assessment and rehabilitation had such a dramatic effect that observational data were judged to be sufficient to justify their adoption.¹ Numerous randomised controlled trials and systematic reviews have since shown the benefits of organised multidisciplinary care and rehabilitation over routine general practice and physician care in inpatient and outpatient populations² and in specific disease states affecting predominantly older people, such as stroke³ and fractured neck of femur.⁴ Some parts of this mix of interventions, particularly the team focus and the availability of allied health staff to inpatients, have been partially adopted by general physicians and other subspecialists, with some improvements in care.⁵ This non-randomised controlled study mirrors previous studies, where general physicians and general practitioners formed the control groups to which geriatricians were shown to add value by decreasing disability and length of stay.⁶

Furthermore, it is not just individual patients who benefit from geriatricians. The training of the geriatrician focuses on a whole system approach, facilitating patients to obtain access not only to acute care but to subacute, outpatient, and domiciliary care, as well as determining the appropriateness of residential care. This focus on a whole system approach provides efficiency gains to the whole medical system and contributes to the substantial job satisfaction of geriatricians.⁷

Emerging definitions

Although the specialty has been based on utilitarian values rather than a specific organ, a scientific framework is beginning to emerge. Most experienced clinicians intuitively identify frail older people—sometimes by derisive terms such as gomers⁸ or bed blockers—but their categorisation has been difficult. Frailty characterises people at the limits of their physiological reserve in one or more of the major homoeostatic systems. Such individuals are vulnerable to relatively minor endogenous or exogenous changes, which may lead to stereotypical clinical problems such as falls and confusion.

Over the past decade two competing definitions for frailty have emerged. One definition implies that older people acquire this "phenotype" of frailty, defined by items including unintentional weight loss, weakness, and slow walking speed.⁹ Another defines frailty as "multiple phenotypes"—that is, as a multitude of vulnerabilities and instabilities¹⁰ in a process of "deficit accumulation" that can be used to produce a frailty index.¹¹ These concepts explain why any minor perturbation in a frail person may precipitate a cascade of events in multiple systems,¹⁰ leading to further illness and death. Importantly, a large observational study has now shown that older people can improve, or become less frail, and decrease their risk of disability and death,¹² highlighting the importance of targeted interventions.

These modern concepts of frailty help elucidate why the specialty of geriatric medicine works, and for whom. The accumulation of multiple insults over time and consequent reduction of homoeostatic reserve must be tackled by a comprehensive approach that includes all organ systems and focuses on functional effects. Furthermore, the loss of homoeostatic reserve, and the need to treat multiple conditions concurrently will lead to an inevitable risk of iatrogenic complications, the avoidance and early detection of which are some of the core domains of geriatric medicine. Finally, deficit accumulation is not just confined to physical insults. Life course events, extending to the fetal period,¹³ may increase susceptibility to illness and so called psychosocial factors may have important influences, requiring psychosocial interventions to which other clinicians may often see little point.

Geriatric medicine does not deserve to be abandoned. It has been shown to work and continues to work well. Excitingly, it is only now that we are beginning to understand why.

Cite this as: BMJ 2008;337:a516

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I thank Kenneth Rockwood for advice.

Competing interests: None declared.

References

1. Warren M. Care of the chronically aged sick. Lancet 1946;i:841-3.
2. Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993;342:1032-6.[CrossRef][Web of Science][Medline]
3. Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2007;(4):CD000197.
4. Cameron ID, Handoll HHG, Finnegan TP, Madhok R, Langhorne P. Co-ordinated multidisciplinary approaches for inpatient rehabilitation of older patients with proximal femoral fractures. Cochrane Database Syst Rev 2001;(3):CD000106.
5. 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]
6. Day P, Rasmussen P. What is the evidence for the effectiveness of specialist geriatric services in acute, post-acute and sub-acute settings? New Zealand Health Technology Assessment Report 2004;7(3). http://nzhta.chmeds.ac.nz/publications/geriatric_services.pdf.
7. Leigh JP, Kravitz RL, Schembri M, Samuels SJ, Mobley S. Physician career satisfaction across specialties. Arch Intern Med 2002;162:1577-84.[Abstract/Free Full Text]
8. Shem S. The house of god. New York: Richard Marek, 1978.
9. Fried LP, Young Y, Rubin G, Bandeen-Roche K, WHAS II Collaborative Research Group. Self-reported preclinical disability identifies older women with early declines in performance and early disease. J Clin Epidemiol 2001;54:889-901.[CrossRef][Web of Science][Medline]
10. Walston J, Hadley EC, Ferrucci L, Guralnik JM, Newman AB, Studenski SA, et al. Research agenda for frailty in older adults. J Am Geriatr Soc 2006;54:991-1001.[CrossRef][Web of Science][Medline]
11. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci 2007;62:722-7.[Abstract/Free Full Text]
12. Mitnitski A, Song X, Rockwood K. Improvement and decline in health status from late middle age: modeling age-related changes in deficit accumulation. Exp Gerontol 2007;42:1109-15.[Web of Science][Medline]
13. Barker DJP. The developmental origins of adult disease. Eur J Epidemiol 2003;18:733-6.[Web of Science][Medline]

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