Geriatrics literally means the care of old persons. Practically, geriatrics combines two elements: gerontology and chronic disease. Gerontology refers to the study of aging. It addresses all aspects of how aging affects individuals—physically, socially, psychologically, and economically. Geriatrics adapts this knowledge to improve the provision of care to older persons. Geriatricians must know how diseases present in older persons and how to manage
Geriatric management is likewise complicated by the presence of multiple, simultaneously inter-active problems, which often reach across several domains of life. One must treat not only the immediate illness in the context of several others, but also address their financial and social consequences. Inadequate income may make it difficult to buy needed medications. Housing may need to be altered to accommodate physical limitations. Social support may be needed to provide both direct assistance and social stimulation.
Geriatrics overlaps substantially with chronic-disease care. Most of the illnesses older people suffer are chronic. According to C. Hoffman, D. Rice, and H.-Y. Sung (1996), approximately 95 cents of every health care dollar spent on older persons goes toward a chronic illness. However, the same study notes that chronic disease is, in fact, predominant in virtually all ages—over two-thirds of the money spent on health care in this country goes toward chronic illness. Yet, somehow, the medical care system has failed to adapt to this epidemiological reality. Health care continues to be organized as it was during the era of acute disease. A substantial contribution to public health would be to translate this fundamental epidemiological observation into a more appropriate system of health care—one that changed the focus of care to extend over longer periods, that shifted attention from single clinical interactions to episodes of care, and that created a more meaningful participatory role for consumers of care.
Perhaps the most dreaded manifestation of aging is dementia. Much has been learned about dementia. It is no longer viewed as an inevitable consequence of aging, although its incidence is likely in very old age. While new drugs are constantly being developed, no effective treatments are yet available. Some currently available agents appear to be able to slow the progression somewhat, but their overall contribution is still uncertain.
Much of geriatrics involves the intersection of medicine and long-term care. For some time, these have been viewed as separate areas of endeavor, responsible to medical and social models, respectively. Here too, epidemiology has a valuable insight to contribute. Most older persons needing long-term care suffer from serious problems that have led to the loss of physical and/or cognitive abilities. The underlying conditions often require close medical attention. Thus, those in long-term care usually need more, not less, medical attention.
The goal of geriatric care is to maximize the functioning of patients. Function can be viewed as the end result of several factors. The first of these is the appropriate treatment of medical conditions. The first maxim of geriatrics is to treat the treatable. This step is not always easy. One of the most difficult differential diagnoses in medicine may be distinguishing pathological change from that simply associated with aging. Good treatment is necessary but not sufficient. The next step is to recognize the potential effects of environment, both physical and social. Much of the modern health care institution (hospital and nursing home) actually serves to dehabilitate patients, especially those who are most vulnerable. The environment is alien, the timetable suits the schedules of the providers of care, and individual patient identity is easily lost. Something as simple as a hospital bed with bedrails may create a new series of barriers for a frail older person. It is hardly surprising that delirium is common among older persons in hospitals. Perhaps most pernicious of all, the pressures for efficient care prompt staff to do many tasks for older patients, thereby creating an atmosphere of learned dependence. At the very time when they should be fostering self-reliance, institutions encourage dependency. As the advocate for vulnerable populations, public health has a duty to alter this inappropriate and dangerous system.
One of the most successful accomplishments of geriatrics has been the demonstration of the value of comprehensive geriatric assessment, or, more specifically, geriatric evaluation and management. The latter term is used to emphasize the
Geriatrics offers other opportunities for prevention. Primary prevention usually focuses on such elements as immunizations, especially for influenza and pneumococcal disease; but other risk factors can be addressed. The role of estrogens is still being explored. They seem to have a positive effect on delaying osteoporosis and heart disease, although they do carry an added risk for gynecological cancers. Exercise is widely touted as beneficial for both physical and social well-being. Smoking cessation is beneficial well into old age. Efforts have been made to prevent falls with only modest success. The most preventable problem among older persons is iatrogenic disease. Multiple medications, which transform older patients into living chemistry sets, are probably the most ubiquitous threats. Mention has already been made of the dangers of institutionalization. Misdiagnosis, including both overtreatment and undertreatment, is a recurrent problem.
Public health has an obvious stake in the health of older persons. They are the ones who are most likely to be ill. They are the most rapidly growing segment of the population and represent some of the most difficult elements of care. Approaches that are successful with older persons should be readily adaptable to serving other subgroups. Because chronic disease is endemic among older persons, they provide the impetus to develop a more effective and appropriate approach to health care, an approach that has broad applications in the face of changing demographics and a new epidemiological reality.
ROBERT L. KANE
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