Education And Debate

Geriatric medicine: a brief history

BMJ 1997; 315 doi: http://dx.doi.org/10.1136/bmj.315.7115.1075 (Published 25 October 1997) Cite this as: BMJ 1997;315:1075

Re: Geriatric medicine: a brief history

Introduction
It seems to be interesting and enlightening to review ancient physicians' views on geriatric topics written about more than one thousand years ago. Special considerations of elderly health were important from the past, and it can be seen in the study of ancient medical texts. Perhaps the earliest attention to this issue was found in Greek and Byzantine medicine(1), but Avicenna’s “Canon of Medicine” seems to be the first book that described geriatric medicine in detail. In this book, the terms such as aging, elderly, geriatrics, etc has been used over 200 times.
Avicenna (980 AD, Afshana near Bukhara—1037 AD, Hamedan) was one of the most outstanding and influential Persian physicians and philosophers(2). He wrote more than 450 treatises on medicine, philosophy, religion and logic. Avicenna’s Canon of Medicine is the most famous work among Avicenna’s medical books. He categorized diseases in the Canon of Medicine based on organ-based arrangement(3).
In this paper, we tried a short overview on aging and aging-related topics in "canon of medicine" to get more familiar with the perspective of this great scientist about geriatrics. We present these geriatric related comments according to their subjects in four topics.

Definitions on ageing
According to the “Canon of Medicine", human life is divided into four main stages:
1- Growth and development period: from birth up to 30 years old
2- Youth: from 30 years old and continues to 35-40 years old
3- Aged: from 40 years old and continues to 60 years old.
4- Senescence: that is from 60 years old up to the end of life and is associated with the onset of disability(4). (volume1, page36)
According to Avicenna there are three state for human beings: health, disease and intermediate state of health. In the intermediate state, the body is neither in perfect health nor an absolute illness. In this state, body is susceptible to various diseases. (volume1, page260) Elderly people fall in this category. Wound healing in old age is an example of this intermediate state of health. As noted in "Canon" in the expression of wound healing in the elderly, their ulcers unlike youngsters’ will hardly heal and are susceptible to dehiscence. (volume4, page6656) Recent scientific evidences are compatible with this statement(5,6,7).

Physiopathological topics
In review of the elderly vital signs, Avicenna has spoken in detail about geriatric pulse and respiration. In his opinion, older people are more prone to bradycardia (volume1, page 487). Recent scientific findings on more prevalent sinus bradycardia due to sinus node dysfunction in the elderly also support Avicenna’s idea(8). He also believed that their pulses are weaker. This is also compatible with decreasing in cardiac ejection fraction with age advancement.
Avicenna says that elderly Breath has less volume and speed than young persons. (volume3, page 3203) Modern medical data also shows that respiration in the elderly is associated with less Tidal Volume (T.V) and Forced Expiratory Volume (FEV1)(9,10.
He believes that the urine of elderly is more dilute and tends to white. That's why the formation of kidney stones is more likely in youngsters than the elderly (volume4, page 6037).

Preventive topics
According to Avicenna, prevention is more important than cure. He noted some tips to keep elderlies healthy, including adequate food, exercise, sleep and even the style of bathing in detail as below:
• Seniors should be fed more frequently and in less volume than the youth because their gastrointestinal function is weaker than youths (volume1, page291). As we know today, gastrointestinal function and motility disorders (i.e., dysphasia, dyspepsia, anorexia, and constipation) seems to become more prevalent with ageing(11).
• Increasing fruits and vegetables intake can help improve their bowel movement and prevent constipation. Among different healthy fruits and vegetables, he noted figs, plums, celery and leek for this purpose.
• Avicenna believed that elderly people need more sleep than youngsters (volume1, page 648).
• He also believed that bathing in cold water is unsuitable for elderly, and can make them susceptible to different diseases such as upper respiratory tract infections. (volume1, page 615).

Therapeutic topics
Avicenna has discussed special geriatric considerations under each disease topic in third and fourth volume of “canon of medicine” which is on therapeutics. For example in the first chapter -neurological diseases- he discussed about geriatric depression, convulsion, insomnia etc.
He has stated about fever in elderly that high grade fever is less common in this age, but is so serious if be present. (volume4, page 5776; volume4, page 5882). AS Dean C. et al. stated that Fever is the cardinal sign of infection, but this most important diagnostic clue may be blunted or absent in up to one third of infected geriatric patients conversely, the presence of fever has special significance for the older population. A large study of febrile adults presenting to walk-in clinics or emergency departments determined that the presence of fever in the elderly was much more likely to be associated with a serious bacterial or viral infection compared with younger febrile patients(12). Avicenna has also noted that the elderly cannot resist on burning fever because of general body weakness.
Avicenna was well aware about the "heart failure" as one of the important geriatric diseases. He has described two important signs of Heart failure; orthopnea and dyspnea and used traditional diuretic herbs in the treatment of this condition (volume3, page 3208).
He also noted that CVA (Cerebro-Vascular Attack) is more common in the elderly than other ages. He also considered permanent and frequent dizziness as red flags for stroke in elderly patients (volume3, page 2676). These statements are compatible with new scientific findings.

Conclusion
Historical reviews of medical topics such as geriatrics can enlighten formation route of our current knowledge on these topics and may help us have better perspective on future course of science. On the other hand such investigations do not only provide a historical view of medical sciences but will inform us about current complementary practice based on humeral system in Middle East countries and India.

References
1- Lascaratos J, Poulacou-Rebelacou E. The roots of geriatric medicine: Care of the aged in Byzantine times (324-1453 AD). Gerontology. 2000;46(1):2-6.
2- Gorji A., Khaleghi Ghadiri M. History of epilepsy in Medieval Iranian medicine. Neurosci Biobehav Rev. 2001 Jul;25(5):455-61.
3- Zargaran A., Mehdizadeh A., Zarshenas MM., Mohagheghzadeh A. Avicenna (980–1037 AD). J Neurol. 2012 Feb;259(2):389-90.
4- Avicenna. The Canon. Tehran: Soroush Press; 2008. (Translated by Sharafkandi A., in Persian)
5- Weiskopf D WB, Grubeck-Loebenstein B. The aging of the immune system. Transpl Int. 2009;22:1041.
6- DelaRosa O, Tarazona R, Casado JG, Alonso C, Ostos B, Pena J, et al. V alpha 24(+) NKT cells are decreased in elderly humans. Exp Gerontol. 2002;37(2-3):213-7.
7- Jing Y, Shaheen E, Drake RR, Chen NY, Gravenstein S, Deng YP. Aging is associated with a numerical and functional decline in plasmacytoid dendritic cells, whereas myeloid dendritic cells are relatively unaltered in human peripheral blood. Hum Immunol. 2009;70(10):777-84.
8- Frangakis N KG. Arrhythmias in the Elderly: Modern Management. Hellenic J Cardiol. 2006;47:84-92.
9- Enright P LS. Spirometry in old age: feasibility and interpretation. Eur Respir Mon. 2009;43:25–34.
10- Pistelli R AM, Baldari F, Sammarro S. Respiratory function standards in the elderly. Eur Respir Mon.43:18–24.
11- Salles N. Basic mechanisms of the aging gastrointestinal tract. Digest Dis. 2007;25(2):112-7.
12- Dean C NM, Megan Bernadette Wong BSb, Thomas T YM. Fever of unknown origin in older persons. Infectious disease clinics of North America. 2007;21(4):937-45.

Competing interests: No competing interests
20 December 2012
Mahdieh Hajimonfarednejad
Medical student
Mohammad Javad Raee, Mojtaba Heydari.
Shiraz University of Medical Sciences, Shiraz, Iran.
Zand St. Shiraz.
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