February 2001 Bulletin

Principles focus on improving care of elderly

By Kenneth J. Koval, MD; Elton Strauss, MD; David H. Solomon, MD; and John R. Burton, MD

A Statement of Principles: Toward Improved Care of Elderly Patients in Surgical and Medical Specialties was generated by representatives from the leadership of 10 specialties, working with leaders of the American Geriatrics Society. The statement identifies 10 essential objectives and recommended steps to meet them. The overall goal of the statement and of the collaborative project from which it springs is to pave the way for improvement in the day-to-day care of older patients when they are the responsibility of surgical and certain medical specialists.

The appearance of this initiative at this time results from some recent medical history that has been little noted. About 25 years ago, a handful of geriatricians toiled in the backwaters of medicine, and family physicians and internists were woefully ignorant of the special problems of older people, especially of very old people. A geriatrics renaissance has occurred during this quarter-century, slowly at first and dramatically during the past decade. The renaissance was triggered by many events, most notably the advent of the National Institute on Aging along with supportive initiatives by the Veterans Administration, the John A. Hartford Foundation and, only later, by medical schools and academic health centers.

As a result, thousands of physicians have become geriatrics specialists, hundreds have become faculty in academic departments and divisions of geriatrics, a clinical science base has been developed, and medical students and residents in internal medicine and family practice have been educated to a far greater extent regarding the emerging principles of excellent geriatric care.

Building from this foundation, the time is ripe to infuse these principles into the basic training of residents all surgical and medical specialties. The principles of geriatric care are straightforward; clinical details are well supported by research findings; patients’ outcomes are demonstrably improved by application of the principles; and only a modest amount of time in the training program can yield great benefits.

Our shared goal is that a vulnerable older patient on any inpatient service should receive general medical care of consistently high quality. Before, during and for a short time after surgery, the surgeon is the "primary care physician." This is appropriate, in fact necessary, because day-to-day decision-making must be done by the person with direct responsibility, the one closest to the patient and able to make decisions most rapidly.

Since an increasing number and proportion of patients are older adults who are often vulnerable (i.e., at high risk to become dependent or die) or frail (already functionally dependent), the specialist must not only be able to provide good general medical care, but must also understand the principles of good geriatric care in order to reach the goals of rapid recovery and maximum benefit from the surgery. Outstandingly competent surgery is necessary but not sufficient to guarantee favorable outcomes in the older population.

We should emphasize that favorable outcomes cannot be achieved through consultation alone. Certainly, geriatrics consultation should be available and utilized in the care of particularly complex perioperative and postoperative problems, but the crucial day-by-day steps in care must be "home-grown." Many of these steps can be managed by establishing enlightened protocols. For example, the secret to high-quality geriatric care in the acute hospital is the prevention or, if necessary, treatment of urinary tract infection, delirium, depression, pressure ulcers, falls, functional decline, malnutrition, dehydration, and so forth. Many of these setbacks are best prevented by standardized nurse-physician protocols that can be developed with the advice of geriatrics and applied as usual care, except where special conditions require individualized approaches.

Comment is warranted on certain of the recommendations in the statement. The first step in increasing geriatrics expertise in all relevant specialties is quite simply to discard the many derogatory myths about older people (e.g., "sick, senile, silly, sexless and sedentary," as well as inflexible, irritable, noncontributing and too late anyway for preventive interventions). Each myth is a stereotypic generalization , and like all such, does far more to inflame scorn and hatred than to describe individuals accurately and explain their difficulties. Fueled by mythology, ageism has had devastating results: inattention to the real healthcare needs of older patients; until recently, a near-absence of geriatrics from medical school curricula; difficulty in recruiting young physicians into the field of geriatrics; and an especially painful shortage of academic geriatricians trained as clinical researchers and teachers.

Ageism has not yet been replaced by "age-o-philia," but attitudes today are increasingly realistic and constructive, thanks in considerable part to the fact that opinion leadership is passing to the baby-boom generation which is itself staring age in the face. Suddenly, anything that fosters the best possible preventive and therapeutic care of older people receives wide support. So it is with the collaborative project here described, which exemplifies the healthy attitudinal shift. It has received hearty and energetic support from leading clinical and academic societies, colleges and academies in the 10 specialties.

Though much has been accomplished, much remains to be done. Many of the recommendations in the statement represent an agenda for the future of this long-term project. For example, plans for the near future include an expansion and deepening of the role of the Interdisciplinary Leadership Group, made up of leaders of the 10 specialties. It is appropriate, indeed essential, that the penetration of geriatrics into the surgical and medical specialties be monitored and guided by an involved leadership in each of the specialties and by the specialties as a collective.

Another planned initiative is to prepare for and hold a conference to develop a modern research agenda for studying issues relevant to the aged patient in each surgical and medical specialty and across all specialties. Still another is to foster the creation of a research career development award that would support outstanding young academicians in the various specialties while they undergo research training in clinical and/or basic scientific aspects of the specialty. Needless to add, such awards would not have the goal of creating geriatricians. Rather their aim would be to foster a new generation of future leaders whose special academic field would revolve about improved care of elderly patients within their specialty. Clearly, to succeed, such a program needs to be accompanied by assurance from department chairs that such a career emphasis would be likely to lead to advancement in their academic specialty.

In summary, a new era has begun, the product of creative philanthropic support from The John A. Hartford Foundation. It promises to spread the application of the new geriatrics to fields of medicine not earlier touched by the geriatrics renaissance. By this means, we can anticipate a revolution in the care provided to older patients in the surgical and medical specialties, where the average age of patients is rising rapidly and where health outcomes and costs will be strongly influenced by the quality of care provided.

Kenneth J. Koval, MD, and Elton Strauss, MD are members of the AAOS Aging Committee; David H. Solomon, MD, and John R. Burton, MD, are co-directors, AGS/Hartford Project: Increasing Geriatrics Expertise in Surgical and Medical Specialties.

The Communicate column provides helpful hints on communicating with elderly patients.

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