Medicine must change to serve an ageing society
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7223.1450 (Published 04 December 1999) Cite this as: BMJ 1999;319:1450
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Editor,
I read last weeks editorial with interest.1. I agree
entirely that a higher profile within the undergraduate curriculum for
Geriatric medicine and for a period of general professional training spent
within geriatric medicine would improve doctors understanding of both the
presentation and impact on diseases in the elderly.2. Indeed my own career
choice of geriatric medicine was influenced by the positive experiences of
the speciality which I experienced at medical school and a senior house
officer.3. However, I believe the underlying problem of ageism within the
health service is more complex than this.
The elderly have a low profile
in modern society, which has become obsessed with youthful images. Our
tendency as a profession to label those over 65 years as a homogenous
group without recognising the tremendous diversity within that population
does not help. The promotion of more positive images of the elderly such
as the activities of 'The University of the Third Age' would help combat
the inherent ageism which is present in our society. This would improve
the attitudes of our future doctors even before their arrival at medical
school. Only when the elderly are universally recognised as equals in our
society can ageism be eradicated.
Susie Orme
Senior Registrar
Royal Hallamshire Hospital,
Glossop Road,
Sheffield
1. Tonks A. Medicine must change to serve an ageing society. B.M.J.
1999;319:1450-1.
2. Ebrahim S. Demographic shift and medical training. B.M.J.
1999;319:1358-60.
3. Orme S. Confessions of a Geriatrician. Student B.M.J. 1997;5:433-
4.
Competing interests: No competing interests
It is most commendable that in England, thanks to the right
organizational background and competence, the debate on age-based
rationing is reaching maturity. Climbing such a steep mountain clearly
requires hard cultural and managerial work.
In Italy, there is a tendency to hush up and make little mention of
this undoubtedly sizeable problem. Nonetheless medical practitioners and
society as a whole very likely have an ageist attitude, as transpires
directly from informal conversation with the former and indirectly from
public opinion polls (1).
The editorial "Medicine must change to serve an ageing society" (2)
promotes an increase in resources and the eradication of age
discrimination. The recent one-day conference, "Medicine in an ageing
society", held at the BMA House in London on 23 November, 1999,
brilliantly summarized the impact that the greying of the population will
have on health services. A predominantly critical position towards ageism
emerged from the debate, based on the premise that all rationing criteria
which does not include a judgement on comorbidity and ability to benefit
is unethical and discriminatory. The personal view of M. Rivlin, "Should
age-based rationing of health care be illegal?" (3) polarizes the
antiageist position by promoting the adoption of a legislative instrument
which protects the elderly from discriminatory action in relation to
health services.
It is truly hard not to agree with such loyalist, nonbiased
principles of impartiality that already have legal standing, without
wishing to ignore the difficulties which arise from a culture clash forged
over the century between the various generations.
The antiageism liner has now relentlessly set sail from London
harbour: let's hope it reaches all ports.
References
1. Mariotto A., De Leo D., Dello Buono M., Favaretti C., Austin P.,
Naylor C.D. Will elderly patients stand aside for younger patients in the
queue for cardiac services? Lancet 1999; 354: 467-470.
2. Tonks A. Medicine must change to serve an ageing society. BMJ 1999;
319: 1450-1451.
3. Rivlin M. Should age based rationing of health care be illegal? BMJ
1999; 319: 1379.
Competing interests: No competing interests
Editor,
Tonks is no doubt correct in telling of the plight of the ageing.
However, my experience working in the Mental Health and Drug & Alcohol
fields is that modern medicine does not look after adolescents or young
adults either. My reading suggests this is also the case in the UK.
Given that anxiety and depression will be the largest contributors to the
global burden of illness soon and the association between these problems
and alcohol and other drug use, this seems foolish. But is it an
oversight or deliberate ageism? My observation is that those illnesses
most prevalent in the funder's age group and social class usually get the
nod, so the disempowered young and the politically inactive old will
always be overlooked. It's all a predictable part of widening social
inequality, though it's scarcely good health care.
Sincerely,
A. R. MacQueen FRACGP
Competing interests: No competing interests
Efforts to increase the span of healthy productive life - the
functional life span- are limited almost entirely to prevention and
treatment of specific diseases. But these efforts are becoming
increasingly futile because of an inborn ageing process. Ageing is an
accumulation of changes in the cells and tissues that increases the risk
of death. There is now an increasing consensus that ageing changes are
produced by free radical reactions, most of them initiated by the
mitochondria at an increasing rate with age, and that the life span is
determined by the rate of such damage to the mitochondria (1).
Society usually classifies everyone above the age of 65 as elderly.
But chronological age is only one determinant of the changes that are
pertinent to drug therapy that occurs in older people (2). Important
changes in response to some drugs occur with increasing age in some
persons. Further, general changes in the lives of older people have
significant effects in the ways drugs are used. Among these changes are
the increased incidence with advancing age of multiple diseases,
nutritional problems, reduced financial resources, secondary complications
to illnesses and changes in the compliance to drugs. In the light of these
factors that affect geriatric pharmacotherapy Tonks has well remarked that
the medical profession must eradicate age discrimination and increase the
resources available for elderly patients (3).
It is common knowledge that with advancing age there are changes in
the pharmacodynamic and pharmacokinetic profiles of patients, these
changes being augmented by pathological and psychological pressures.
Further, the positive relationship between the number of drugs taken and
the incidence of adverse effects to them has been well documented. Studies
suggest that in long-term care facilities the average number of
prescriptions per patient varies from 6.7 to 7.7 and the overall incidence
of adverse drug reactions among elderly patients is estimated to be at
least twice that in the younger population.
If medicine must change to serve an ageing population a few
principles must be adhered to: 1) a careful drug history must be taken; 2)
rational drug prescribing must be advocated; 3) the goal of drug therapy
must be defined; 4) adverse drug reactions must be anticipated and 5) the
drug regimen must be simplified.
Elderly patients usually prefer to consult with senior consultants
who are equally elderly, many of whom (at least in India) have not kept up
with the recent developments in their profession. The only updating
information that they have is what they gain from the medical
representatives. Often they cover their ignorance or avoid their practice
being labelled as obsoleteby quoting their "experience", which is another
way of saying that they have no experience in the alternatives. Again,
there is usually deep confusioon regarding drugs called nootropics. On the
one hand some authors and drug authorities deny the existence of such
drugs at all. On the other hand even those who recognise the existence of
these drugs cannot agree with which compounds may be classified as such
(4). In some countries nootropics are registered and sold either as
medicines prescribed by general MDs and specialists or as over-the-counter
drugs while in other countries they are not registered at all.
It is not the statistics of the geriatric population that must be of
concern but the standards that society sets to give them quality care. The
medical management of an octogenarian politician with end-stage renal
failure should be done with the same humaneness, skill and precision as
that of a younger patient. Political pressures, resource distribution and
domestic demands should not dictate to professional services.
I am getting older by the hour too and I know what I want. I am also
reminded that honoring the geriatric patient with the best of professional
care is an expression of obedience to the first great command which has a
promise tagged to it and good geriatric practice assures longevity - both
to the physician and to the patient.
References:
1. Harman D. Ageing and disease: extended functional life span. Ann.
New York Acad. Sci, 1996; 786: 321-336
2. Katzung BG. Special aspects of geriatric pharmacology. In, Basic
and clinical Pharmacology, Lange Publications, 7th Ed, 1998; 989-998
3. Tonks A. Medicine must change to serve an ageing society. BMJ
1999; 319: 1450-51
4. Zs-Nagy I. On the possible role of nootropics in geriatric
prevention and therapy. Ann New York Acad. Sci. 1996; 786: 444-452
5. The Holy Bible: Exod. 20:12
Competing interests: No competing interests
It's rather surprising that there was no discussion of the
possibility of recruiting retired doctors to provide direct advice and
supervision to the sick elderly. They will have had wide experience, and
so provide the "generalist" element required. They will have lived
through the same events as their patients, and been moulded by them
enabling the genuine empathy of a cohort comradeship. They will be
experiencing the progressive changes in outlook and capacity conferred or
imposed by advancing years. They will eschew mindless and unrewarding over
-investigation for investigation's sake. They will also have been
subjected to the automatic ageism of compulsory retirement, and the
automatic condemnation of being out of date and "past it". If the NHS
employers had any sense and were prepared to jettison their bias, they
might just be able to persuade some veterans to help them out.
GH Hall
"Retired" physician
Broadclyst,
Devon
Competing interests: No competing interests
The description of "More and more older people are admitted to fewer
beds for shorter and shorter steys" is relevant to many countries in the
West. It is related to the adverse
attitudes of many staff members of Acute Care Medical Centers to the
management of theses patients , so well described in book "The House of
God". It reflects the inapptitude of the staff in the care for the elderly
and the chronically ill.The comprehensive answer to this impediment in the
care for this frail population is not only in the training and education
of the doctors.
There is a need and justification to consider other
approaches which consist in revising our concepts of the organization of
the care for these patients. "Reshaping the health service around the
older patients" should involve basic reforms in the organization of the
hospitals and their design in order to accomodate the needs of this
population. For several years I try to promote the idea of developing a
"General Hospital for The Chronically Ill". This hospital will provide
lond term services for the elderly frail and nursing care but at the same
time will be able to provide high quality care for the acute conditions
that are common in these patients. A Department of Medicine that can
provide care for pneumonia, urinary tract infections and congestive heart
failure of patients who are well known to their carers does not need all
the technologies that are involved at the Acute Care Medical Centres. A
good Rehabilitation Department in such hospitals can complement the range
of services required. On the whole such a facility can provide better
professional and emotional care at a much lower cost than in the existing
General Hospitals as we know them.
There are examples of such facilities
but they have not been acknowleged as the preferred type for this
population. I believe that if we develop this kind of hospitals and let
them take care of referred cases from the community and provide good
management , including rehabilitation and with community oriented out-
reaching programs of home care and day-care services we shall make a
better use of our limited funds and improve the care of our older
generation and also use them to train the new generation of professionals.
Do we have the needed leadership to conceptualize, plan and execute such
reforms , I do hope so.
Competing interests: No competing interests
Age Discrimination
There is age discrimination in the N.H.S. Long ago we accepted that
we could discard the normal courtesies and refer to a substantial group of
the elderly by their first name or some other familiar name such as 'Pop'.
The
change from the formal to the familiar presumes our social advantage and
indicates that we have recognised the loss of independence and the
enfeeblement of the aged victim. I know that some (if not many) of the
elderly are offended by this but they recognise that they are vulnerable
and put up with it.
Words do count. We can easily list quite a few that would be totally
unacceptable as a description of people under our care. Let's add uninvited
familiarly and other terms of gratuitous ageism to that list.
G. B. Scholes, FRCS
61 Wimpole Street,
London W1M 7DE
1 Editorial BMJ 1999; 319,1450-1 (4 December)
Competing interests: No competing interests