The man was worried. He had come up to Outpatients for investigation of a cough and weight loss and he had not been surprised to find his worst fears confirmed. He had lung cancer. Until a couple of months ago he had been cycling 3 miles into town in order to do the shopping for himself and his daughter whom he was looking after since she had moved in with him following her stroke. His daughter was 73 and he was 100! Or there is an 105 year old patient who got his uncomfortable hernia operated on this year having been told 30 years ago he was too old to have it done! Not typical patients certainly, but, on the other hand, not that uncommon. The medicine of later life is both interesting and varied but it has not been until the last 10-15 years that we have seen its popularity increasing. So why should this have been the case, and what puts people off working with the elderly?
Myths and stereotypes
Many attitudes that society holds towards the elderly are based on myths and stereotypes. Ninety five per cent of the over 65s are fit enough to live outside residential or nursing care and even 85% of the over 85s are not demented. Yet typically the elderly are thought of as suffering from ill-health, forgetfulness, leading isolated lives, and are generally unaware of what is going on. The term 'ageism' is used to refer to this unjustly negative image of the elderly and its subtle discrimination embraces the common concept that the elderly are an homogeneous group, fitting a certain stereotype. Nothing is further from the truth. Although the young definitely see themselves as a grouping, people who happen to be chronologically old do not think of themselves as being old. They still see themselves as they always have been. Most older people who see themselves as old are those suffering from chronic disease or disability.
This is a group who are biologically rather than chronologically old. Thus it is not unusual to find the fit 85 year old who tells you that each weekend she helps the 'old people' in the local residential home! In this country at the turn of the century the legal definition of old age was over 50! Is there a definition of old age? Ogden Nash defined it as follows:
'Senescence begins and middle age ends the day your descendants outnumber your friends!'
History of geriatric medicine
Geriatric Medicine came into being principally because of the realisation by a few doctors that disease processes may manifest themselves in a different way in the old compared with the young and that 'old age' was not a diagnosis. Find the disease, give appropriate rehabilitation, understand the social situation and usually the patient could be discharged. The term 'Geriatrics' was coined in 1909 by Dr lgnatz Nacheran, an Austrian physician working in the USA, but it was a British doctor, Marjory Warren who first developed, in 1935, the concept of rehabilitation. Thus slowly the huge miserable municipal hospitals, usually old workhouses, which had been filled by row upon row of elderly bedridden patients were emptied. In those days it was not unusual for the day rooms to be unheated except for a single iron stove, and unfurnished except for wooden kitchen chairs, the smell of urine only countered by the smell of tobacco. Similarly the teaching hospitals, who often refused to take patients over the age of 65, started to end their discrimination.
Some common diseases tend to have their highest prevalence in old age and the geriatrician will therefore see more and hopefully know more about these conditions. Examples would be stroke disease, Parkinson's disease, temporal arteritis, polymyalgia rheumatica, dementia etc. The presentation of many diseases however is often different in the biologically old compared with the way they present in the young. The patient may present non-specifically with one of the four 'Geriatric Giants' of Instability, Immobility, Intellectual Failure and Incontinence. Thus the patient with postural hypotension may present with immobility while a urinary tract infection may present as an acute confusional state.
Another factor that the geriatrician is used to taking into account is the presence of multiple pathology. Traditional medical teaching is to attempt to put all symptoms and signs together to make one diagnosis but this is often not the case with elderly patients. Thus the patient presenting with falls turns out not only to have had a small stroke but was also taking nitrazepam, a long acting hypnotic, which upset his balance during the day. The fact that he was falling at home but not after admission to hospital was partially explained by the loose mats and the 20 watt light bulbs at home.
The pharmacokinetics of many drugs also change with increasing age for various reasons. The geriatrician has to be aware of these changes when prescribing and be particularly aware of drug interactions, as often the elderly are on a variety of drugs and many admissions are precipitated by drug side-effects.
I sometimes 'pull the leg' of one of my general physician friends by defining Geriatric Medicine as 'General Medicine practiced properly' . To a certain extent Geriatric Medicine is similar to any branch of medicine where one needs to look at the whole person and not just at a particular organ. Often treating somebody properly requires the contributions of several members of a multidisciplinary team, e.g. nurses, occupational therapists, physiotherapists, social workers, health visitors, to name only a few. This attitude should not be, and often is not, confined to only one specialty but these qualities are essential for geriatricians.
Another reason is based on the ageist attitudes which resulted in the birth of geriatric medicine in the first place. The elderly still unfortunately need a medical advocate to push for allocation to them of increasingly scarce and hard fought-for resources. It is only in the last 15 years that the majority of the care of the acutely sick elderly has taken place on the District General Hospital site along with the other acute specialities. Similarly the fact that an increasing number of the elderly who require long term nursing care are no longer cared for in Victorian workhouses has not been due to public pressure but due to an unforeseen quirk in allocation of social security payments. This has resulted in a proliferation of residential and nursing homes of varying standards in many parts of the country.
Palliative care specialist
Whilst not usually having the specialist's knowledge and resources of the palliative care consultant, the geriatrician must have a good working knowledge of the care of the terminally sick. Being old and seriously sick does not, of course, necessarily imply that the illness is terminal, but perhaps the most difficult decision the geriatrician and his team must make is when to judge that a patient is dying and that any further active intervention aiming at a cure rather than palliation of the symptoms would constitute 'meddlesome medicine'. We all value the sanctity of life but to pretend that life must be saved at all costs ignores reality. As one of my colleagues mused in one of his more pessimistic moments 'Life, after all, is a sexually transmitted terminal disease!'.
One of the most expensive medical decisions that can be made is not deciding that a patient should undergo a heart transplant or be put on the dialysis programme, but is to make a patient longstay! Thus, although the traditional role of the geriatrician as gatekeeper to the long-term beds has been eroded, this may be reversed as the Government sees its contribution being to support often medically unassessed patients in residential and nursing homes via income support grants rocketing to over one billion pounds a year. In the areas where private homes are few and far between 5% of the over 65s are in such places compared with up to 15% in areas where there are many homes. This does suggest that people are in these homes unnecessarily. The worry of many geriatricians is that as admission to these is only regulated by ability to pay, these will soon become the new geriatric ghettos of undiagnosed illness. A recent example of this was of a man who had previously had a stroke, but had made a good recovery. Over the course of a few weeks he became immobile, falling over whenever he tried to stand up and therefore took to his bed. It was immediately assumed that nothing further could be done and as his wife was completely unable to cope with him he was admitted to a nursing home. After two months he still had not got any better and not surprisingly at a cost of £300 a week, the money was running out! He was then referred to me for long term hospital care. On examination it was rapidly obvious that this man had severe postural hypotension as he fainted whenever an attempt was made to sit him up! Once this was treated he became mobile again and with intensive rehabilitation returned home to the delight of both the patient and his wife. (Incidentally, if he had been 40 years old would he have been consigned to a nursing home without diagnosis?!)
Geriatricians usually also control access to day hospitals which enable patients to have rehabilitation on 2 or 3 days a week, but still live in their own homes.
The rewards and the problems
For me, the greatest reward of being a geriatrician is the same as any doctor in a clinical specialty. Each day somebody will come with a problem and you, literally by the grace of God, are often in a position to help them. Although the disease may be the same, the patients will always be different so it is never boring! I love dealing with older people for although labeled as one homogeneous group there is in fact infinite variety and there is so much you can learn from listening to them. One of my regrets is that as a consultant I so often do not have the time to talk to my patients about matters other than those relevant to their medical problems. I also enjoy having the opportunity to teach about the elderly and hopefully try to counter the image of geriatric medicine as being dull, boring and a haven for doctors who couldn't quite 'make it'.
The problems however are many. As with many others who work in the Health Service I believe that the NHS is severely under-resourced, although not denying that there are still ways in which we could use the resources more efficiently. Thus we are continually trying to cut back as we overspend yet we have no control over the increasing number of patients who present to us. We lose beds and thus have to outlie our patients in surgical wards, thereby lengthening surgical waiting lists. We have still to put up with patients in long-term care sleeping in dormitories with insufficient room between beds even for a chair. Budgets are so tight that it is assumed when they are allocated that there will be a gap between a member of staff leaving and their successor starting, thus putting increasing pressure on the remaining staff who have to cover. The increasing workload put on consultants by the government reforms, involving us, in my opinion quite correctly, in management has not been balanced by increasing consultant numbers and thus hours of work have lengthened. Trying to strike a balance between your work and your family responsibilities is often difficult and too often it is the family who suffers.
Geriatric Medicine certainly has a future with the continuing growth of the very elderly population until the year 2002. Care of the elderly has been transformed over the past 50 years and this will continue as the advances of medical science get applied to the elderly. The over 65s are a formidable voting force and future governments must recognise (as the present one is just beginning to realise) that the availability of health care to all is a key election issue and one of the major issues on which any government's popularity depends.
From the medical point of view perhaps the most exciting advance is that there are now hopeful signs that we are beginning to understand the aetiology of Alzheimer's dementia and how it might be treated. The health of the population and the increasing emphasis on preventative medicine may hopefully reduce the incidence of stroke disease. These and many other reasons make geriatric medicine an exciting and rewarding field in which to work with the overall aim perhaps being best summed up by the slogan of the British Geriatrics Society, that of 'adding life to years'.