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Geriatric Medicine

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Geriatric medicine is the study and practice of the medical care of older adults. In the English-speaking world the development of geriatric medicine as a specialty traces its roots to Marjorie Warren in England, in the 1930s. The term "geriatrics" was coined in 1909 by an American, I. L. Nascher, who was struck by parallels with the care of children, pediatrics.

Around the world a number of models of geriatric medicine are practiced, but three predominate. One model, common in the United Kingdom, views geriatric medicine as the comprehensive care of the sick who are over the age of seventy-five years. This care is specialty-based and organized in consultation with family doctors whose practice includes older adults. A second model is similarly directed toward all people over a particular age (some recommend cutoffs at sixty-five, others seventy or seventy-five), but with the roots of the discipline in primary care. A third model does not use an age cutoff, but defines geriatric medicine as the subspecialty care of older adults who are frail. In this context, frailty is generally understood as having multiple, interacting medical and social problems, and geriatric medicine is seen as an alternative to specialties and subspecialties in which care is more focused on the problems of an organ system.

Geriatric medicine is typically contrasted with gerontology, which is the study of phenomena associated with aging. Gerontology is further distinguished by type, such as biological gerontology, social gerontology, and so on. Often the distinction between clinical gerontology and geriatric medicine is more apparent than real, and the two terms are commonly used interchangeably.

The practitioner of geriatric medicine is commonly referred to as a geriatrician, and the formal use of this term is commonly restricted, often by legislation, to people with additional qualifications in geriatric medicine. The work of the geriatrician is carried out in a number of contexts, some of which are increasingly unique to the specialty. The places in which geriatricians work include acute care hospital wards, where a multidisciplinary approach is promoted. Such wards commonly are called geriatric assessment units, or acute care of the elderly units, or geriatric evaluation and management services, to indicate that their focus is more than the medical aspects of care. Such wards emphasize patients' mobility and ability to care for themselves and the social aspects of medical problems. Rehabilitation wards are another common setting for geriatricians, again with an emphasis on integrated, multidisciplinary care. Such focus is also found in geriatric ambulatory care clinics, which serve patients who have acute problems but do not require hospital admission.

The more specialized locales of a geriatrician's practice are geriatric day hospitals and care given in the home. The day hospital has as its focus frail older adults who are able to walk. They commonly attend day hospitals two or three days a week for about six hours a day. Attendance normally is over fairly short and well-defined periods, anywhere from a few weeks to no more than three months. The day hospital particularly targets frail older adults who require investigations that they may not be able to withstand in the compressed time frame of a hospital stay. Typically, those who attend day hospitals have at least two active problems requiring help from any of the disciplines (geriatric medicine, nursing, physiotherapy, occupational therapy, social work, and others) that are represented by the day hospital team.

Geriatricians are among the few specialists who routinely make house calls, and it would not be uncommon for about 10 percent of all geriatric consultations to be carried out in the patient's own home. Indeed, some services seek to see people exclusively in their own homes. House calls require that solutions of patients' problems be tailored to their environments. By contrast, it is possible, when seeing patients in other settings, to propose therapies that are infeasible in the patient's own home. The special skills of the geriatrician include not just competence in the internal medicine of old age, but also the ability to recognize that frail older adults have complex problems. Complex problems are not amenable to single interventions. With complex problems it is not possible to do one thing without taking into account how that might affect other aspects of care. Complexity can range from the need to take into account that treatment for one problem (e.g., a nonsteroidal anti-inflammatory drug for active arthritis) may exacerbate another problem (e.g., congestive heart failure). Equally, some options that are quite feasible for some patients are infeasible for other patients in different social circumstances. The ability to address these problems is formalized in a process known as comprehensive geriatric assessment, and is at the root of what the geriatrician does.

Historically, within medicine, geriatric medicine has not been seen as a glamorous specialty, and recruitment of physicians into the area sometimes can be difficult. Nevertheless, those who practice geriatric medicine typically find that it is an intellectually stimulating and emotionally rewarding specialty well suited to physicians who like to maintain an interest in the whole person.

KENNETH ROCKWOOD

BIBLIOGRAPHY

EVANS, J. G. "Marjory Warren Lecture. Service and Research for an Ageing Population." Age and Ageing 29, supp. 1 (2000): 5–8.

HOGAN, D. B.; BERGMAN, H.; and MCCRACKEN, P. "The History of Geriatric Medicine in Canada." Journal of the American Geriatrics Society 45, no. 9 (1997): 1134–1139.

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