Geriatrics as a medical specialty Specialization in medical practice is not peculiar to the 20th century. Herodotus found that each physician in ancient Egypt treated only one type of disease. In the 18th century the development of scientific medical research focused on localized abnormalities, which led to specialization in anatomic parts and systems. Technologic advances generate technologic specialists such as radiologists. The development of pediatrics demonstrated that specialization need not be bound to specific body systems or to special techniques of diagnosis or therapy. But, do we need a new specialty to provide optimal care for the aged? To examine this question we must consider medical specialization in terms of need, special knowledge and skills, and whether it has a useful role and acceptability. Specialists in geriatric medicine are not needed solely because of the rapidly increasing proportion of the population reaching old age and having many health problems. More important is the fact that many of these problems are preventable, controllable and remediable by effective medical care. Experience in Britain has demonstrated both the need for care and the effectiveness of specialized geriatric medicine. As a result, the demand for geriatricians has expanded faster than the supply of specialists.1 Similar needs in Canada are not being met in a systematic way. Inadequate interest among health care professionals has had a negative effect on the development of appropriate facilities and programs. Despite the general dearth of facilities and programs, much knowledge has accumulated among the interested minority. Fundamental to this special knowledge is an attempt to understand the ageing process. This normal, universal, time-determined and irreversible phenomenon has attracted the attention and energies of a wide range of investigators, from molecular biologists to social scientists. The resulting insights have generated a broad
special body of knowledge called gerontology. The geriatrician has emerged as the clinician specially equipped to apply this knowledge. No diseases are unique to the aged, but the multiplicity, chronicity, atypical presentations and complex interrelations of diseases with each other and with modes of therapy in the elderly require special understanding. Analogies can be seen in comparing the special knowledge of geriatrics with that of pediatrics. The ageing process is the distal portion of the growth-and-development curve, but the point at which the continuum can be divided is arbitrary. The respective segments form the basis of normalcy for both the pediatrician and the geriatrician, but some general awareness of the process is obligatory for all medical practitioners. The special skills of the geriatrician extend into psychologic and social spheres, areas in which many practitioners usually avoid becoming deeply involved. The broad framework of geriatric practice includes an extraordinary commitment to patients. The older patient requires meticulous attention to detail, not only in treatment, but also in assessment. Patience and empathy are essential. The adaptability of younger patients usually leads to recovery, even when there has been neglect or error in management. The very old, who are characterized by impaired adaptation, do not tolerate stresses compounded by oversight or error. Treatment in geriatric medicine is based on all modes of therapy, but there are special problems in pharmaceutics. The currently popular practice of liberal drug dosage creates more illness in the aged than it alleviates. The geriatrician must have a clear understanding of pharmacology in its general application, and of the peculiarities of pharmacokinetics in the elderly. The depth and diversity of special knowledge and skills required by the geriatrician were recognized in 1977 when the council of the Royal Col-
lege of Physicians and Surgeons of Canada ratified the recommendation that a certificate of special competence be offered in geriatric medicine (Sept. 26, 1977 newsletter for area III regional advisory committee for Ontario of the Royal College of Physicians and Surgeons of Canada, page 2). Possessing these special attributes, the geriatrician has a number of possible roles. Within the present context of Canadian medicine the most useful exercise of this expertise should be in teaching and research. In the university setting the geriatrician must stimulate the system specialists to include age orientation in their curricula. They must also demonstrate the practice of geriatric medicine to undergraduate and postgraduate students in an exemplary integration of academic, clinical, psychologic and sociologic activities. The lessons to be taught are for all physicians, specialists and family practitioners, as well as trainees in geriatric medicine. As a researcher the geriatric specialist's fundamental challenge is the differentiation of pathologic and physiologic processes in clinical problems. Ageing produces morphologic and functional involution that sooner or later produces clinical manifestations. The differentiation of these clinical signs from those of disease requires normative data, which are best collected from persons followed up for a sufficiently long period. Agecorrected standards are already applied in spirometry, and are available for assessing glomerular filtration rates and glucose tolerance. However, most clinical features have not yet been characterized to allow correction for age. The five main symptoms encountered in geriatric medicine, as defined by Cape,2 illustrate the many facets of senescent decline. Four of the five symptoms (loss of balance, confusion, incontinence and homeostatic disturbance) implicate the nervous system to a large extent; however, they
CMA JOURNAL/FEBRUARY 3, 1979/VOL. 120 259
are rarely regarded by the neuroscientist as legitimate areas of research. The obligation to explore these poorly understood areas lies with the clinical gerontologist. Another important immediate role for the geriatrician is that of clinical consultant. The characteristic geriatric patient recognized by most practitioners is usually over 70 years of age and has several chronic disorders of different systems, with multiple, often nonspecific, symptoms, and apparently irreconcilable, conflicting therapeutic needs. The busy family practitioner usually lacks the time to unravel a lengthy complex history and the plethora of notable physical findings, a veritable knot woven by a slow-moving, forgetful patient. Internists, either committed to their favourite anatomic system or indifferent to psychosocial factors, often fail to serve the full needs of these patients. Family practitioners or internists may agree to providing continuous primary care, but they are frustrated by the difficulty in finding perspective or priority in the many problems these patients present. Geriatric physicians can help elderly patients as much with clinical perspective as with psychosocial insight. Additional roles for geriatricians may be found in primary care, both institutional and in the community. However, in the immediately foreseeable future, the caseload is too great, and available, trained geriatricians will remain too few to allow much scope for primary practice. Particularly in the community the geriatrician seeking to build a practice as personal physician to a group of elderly patients risks either of two undesirable outcomes. To general practitioners wishing to care for elderly patients the geriatrician may be seen as another specialist out to steal patients.3 To any practitioner uninterested in treating the aged the geriatrician would be a convenient sink into which overwhelming numbers of unwanted patients could be diverted. This must be resisted, and the analogy of pediatrics again applies. The care of children ought not to be exclusive to pediatricians, nor should the care of the aged be exclusive
to geriatricians. Special skills and knowledge should primarily serve unusual needs. Development and supervision of medical care in institutions providing long-term care or in coordinated, multidisciplinary, community-based programs is a role likely to absorb many specialists in geriatrics. Administrative capabilities, interdisciplinary cooperation, detailed knowledge of the various health and welfare agencies, and facility in communication are skills that would be required of the geriatrician. The acceptability of a new specialty must relate both to the established practitioner and to the uncommitted physician seeking opportunity and challenge. Resistance is most likely to occur among general internists who already see themselves as meeting adequately the health care needs of the aged. To many young physicians there is great attraction in the difficult diagnoses involving many abnormalities, the complex pharmacokinetics and the grateful appreciation of the aged patient. A deterrent may be the depressing institutional environment in which these patients are now too frequently found. In Britain inadequate support staff and poor facilities have led to a shortage of specialists in geriatrics.1 Will the older person seek the services of a geriatrician? Because the competent and vigorous elderly do not see themselves as aged, they probably will not see the geriatrician as the appropriate personal physician. The challenge to the idea of geriatrics as a specialty is really a challenge to current medical practice as a whole. The patients' needs must be met in a satisfactory way. C.I. GRYFE, MD, FRcP[c]
Baycrest Centre for Geriatric Care and department of medicine University of Toronto Toronto, Ont.
meTimuaL®
Prescribing Information
INDICATIONS: For the relief of chronic, atonic, spastic and rectal constipation and for the constipation accompanying pregnancy. convalescence and advanced age. For use in special diets lacking in residue and as adjunctive therapy in the constipation of mucous and ulcerative colitis and diverliculitis. Also useful in the management of hemorrhoids and following anorectal surgery.
CONTRAINDICATIONS: Presence of nausea, vomiting, abdominal pain or symptoms of an acute abdomen or fecal impaction.
Metamucil Instant Mix is contraindicated in patients who must severely restrict their dietary sodium intake. PRECAUTIONS: For patients, such as those suffering from diabetes mellitus, where rigid dietary calorie control is required: Powder-I dose furnishes 14 calories. Instant Mix-I dose furnishes 3 calories. DOSAGE: Powder-one rounded teaspoonful of powder Ito 3 times daily depending on the condition being treated, its severity and individual responsiveness. The teaspoonful of powder is stirred into an 8 oz. glass of cool water or other suitable liquid and should be taken immediately. Instant Mix-one packet I to 3 times daily depending on the condition being treated, its severity and individual responsiveness. The contents of the packetare poured into an 8 oz. glass to which cool water is then slowly added. The resulting effervescent mixture should be taken immediately. SUPPUED: Powder-a refined, purified and concentrated vegetable mucilloid, prepared from the mucilaginous porhon of Plantago ovata. combined with dextrose as a dispersing agent. Each rounded teaspoonful contains approximately 3.1 g of psyllium hydrophilic mucilloid per dose, a negligible amount of sodium, and furnishes 14 calories. Available in 6 and 12 oz. plastic baffles. Instant Mix-premeasured unit-dose packets. Each unit-dose packet contains 3.6 g of psyllium hydrophilic mucilloid with effervescent and flavouring excipients. 0.25 g of sodium as bicarbonate, and furnishes 3 calories. Available in boxes of 15 unit-dose packets.
Natumi bowel management that benefits many kinds of patients. Complete presc.bing information available on request (or consult OPS.).
References 1. Shortage specialties (E). Lancet 1: 300, 1974 2. CAPE RDT: A concept of geriatric medicine. Can Med Assoc J 115: 9, 1976 3. RICE DI: Geriatrics and the family physician. Can Fain Physician 23: 873, 1977
260 CMA JOURNAL/FEBRUARY 3, 1979/VOL. 120
Searle Pharmaceuticals
Oakville. Ontano L6H 1M5
special body of knowledge called gerontology. The geriatrician has emerged as the clinician specially equipped to apply this knowledge. No diseases are unique to the aged, but the multiplicity, chronicity, atypical presentations and complex interrelations of diseases with each other and with modes of therapy in the elderly require special understanding. Analogies can be seen in comparing the special knowledge of geriatrics with that of pediatrics. The ageing process is the distal portion of the growth-and-development curve, but the point at which the continuum can be divided is arbitrary. The respective segments form the basis of normalcy for both the pediatrician and the geriatrician, but some general awareness of the process is obligatory for all medical practitioners. The special skills of the geriatrician extend into psychologic and social spheres, areas in which many practitioners usually avoid becoming deeply involved. The broad framework of geriatric practice includes an extraordinary commitment to patients. The older patient requires meticulous attention to detail, not only in treatment, but also in assessment. Patience and empathy are essential. The adaptability of younger patients usually leads to recovery, even when there has been neglect or error in management. The very old, who are characterized by impaired adaptation, do not tolerate stresses compounded by oversight or error. Treatment in geriatric medicine is based on all modes of therapy, but there are special problems in pharmaceutics. The currently popular practice of liberal drug dosage creates more illness in the aged than it alleviates. The geriatrician must have a clear understanding of pharmacology in its general application, and of the peculiarities of pharmacokinetics in the elderly. The depth and diversity of special knowledge and skills required by the geriatrician were recognized in 1977 when the council of the Royal Col-
lege of Physicians and Surgeons of Canada ratified the recommendation that a certificate of special competence be offered in geriatric medicine (Sept. 26, 1977 newsletter for area III regional advisory committee for Ontario of the Royal College of Physicians and Surgeons of Canada, page 2). Possessing these special attributes, the geriatrician has a number of possible roles. Within the present context of Canadian medicine the most useful exercise of this expertise should be in teaching and research. In the university setting the geriatrician must stimulate the system specialists to include age orientation in their curricula. They must also demonstrate the practice of geriatric medicine to undergraduate and postgraduate students in an exemplary integration of academic, clinical, psychologic and sociologic activities. The lessons to be taught are for all physicians, specialists and family practitioners, as well as trainees in geriatric medicine. As a researcher the geriatric specialist's fundamental challenge is the differentiation of pathologic and physiologic processes in clinical problems. Ageing produces morphologic and functional involution that sooner or later produces clinical manifestations. The differentiation of these clinical signs from those of disease requires normative data, which are best collected from persons followed up for a sufficiently long period. Agecorrected standards are already applied in spirometry, and are available for assessing glomerular filtration rates and glucose tolerance. However, most clinical features have not yet been characterized to allow correction for age. The five main symptoms encountered in geriatric medicine, as defined by Cape,2 illustrate the many facets of senescent decline. Four of the five symptoms (loss of balance, confusion, incontinence and homeostatic disturbance) implicate the nervous system to a large extent; however, they
CMA JOURNAL/FEBRUARY 3, 1979/VOL. 120 259
are rarely regarded by the neuroscientist as legitimate areas of research. The obligation to explore these poorly understood areas lies with the clinical gerontologist. Another important immediate role for the geriatrician is that of clinical consultant. The characteristic geriatric patient recognized by most practitioners is usually over 70 years of age and has several chronic disorders of different systems, with multiple, often nonspecific, symptoms, and apparently irreconcilable, conflicting therapeutic needs. The busy family practitioner usually lacks the time to unravel a lengthy complex history and the plethora of notable physical findings, a veritable knot woven by a slow-moving, forgetful patient. Internists, either committed to their favourite anatomic system or indifferent to psychosocial factors, often fail to serve the full needs of these patients. Family practitioners or internists may agree to providing continuous primary care, but they are frustrated by the difficulty in finding perspective or priority in the many problems these patients present. Geriatric physicians can help elderly patients as much with clinical perspective as with psychosocial insight. Additional roles for geriatricians may be found in primary care, both institutional and in the community. However, in the immediately foreseeable future, the caseload is too great, and available, trained geriatricians will remain too few to allow much scope for primary practice. Particularly in the community the geriatrician seeking to build a practice as personal physician to a group of elderly patients risks either of two undesirable outcomes. To general practitioners wishing to care for elderly patients the geriatrician may be seen as another specialist out to steal patients.3 To any practitioner uninterested in treating the aged the geriatrician would be a convenient sink into which overwhelming numbers of unwanted patients could be diverted. This must be resisted, and the analogy of pediatrics again applies. The care of children ought not to be exclusive to pediatricians, nor should the care of the aged be exclusive
to geriatricians. Special skills and knowledge should primarily serve unusual needs. Development and supervision of medical care in institutions providing long-term care or in coordinated, multidisciplinary, community-based programs is a role likely to absorb many specialists in geriatrics. Administrative capabilities, interdisciplinary cooperation, detailed knowledge of the various health and welfare agencies, and facility in communication are skills that would be required of the geriatrician. The acceptability of a new specialty must relate both to the established practitioner and to the uncommitted physician seeking opportunity and challenge. Resistance is most likely to occur among general internists who already see themselves as meeting adequately the health care needs of the aged. To many young physicians there is great attraction in the difficult diagnoses involving many abnormalities, the complex pharmacokinetics and the grateful appreciation of the aged patient. A deterrent may be the depressing institutional environment in which these patients are now too frequently found. In Britain inadequate support staff and poor facilities have led to a shortage of specialists in geriatrics.1 Will the older person seek the services of a geriatrician? Because the competent and vigorous elderly do not see themselves as aged, they probably will not see the geriatrician as the appropriate personal physician. The challenge to the idea of geriatrics as a specialty is really a challenge to current medical practice as a whole. The patients' needs must be met in a satisfactory way. C.I. GRYFE, MD, FRcP[c]
Baycrest Centre for Geriatric Care and department of medicine University of Toronto Toronto, Ont.
meTimuaL®
Prescribing Information
INDICATIONS: For the relief of chronic, atonic, spastic and rectal constipation and for the constipation accompanying pregnancy. convalescence and advanced age. For use in special diets lacking in residue and as adjunctive therapy in the constipation of mucous and ulcerative colitis and diverliculitis. Also useful in the management of hemorrhoids and following anorectal surgery.
CONTRAINDICATIONS: Presence of nausea, vomiting, abdominal pain or symptoms of an acute abdomen or fecal impaction.
Metamucil Instant Mix is contraindicated in patients who must severely restrict their dietary sodium intake. PRECAUTIONS: For patients, such as those suffering from diabetes mellitus, where rigid dietary calorie control is required: Powder-I dose furnishes 14 calories. Instant Mix-I dose furnishes 3 calories. DOSAGE: Powder-one rounded teaspoonful of powder Ito 3 times daily depending on the condition being treated, its severity and individual responsiveness. The teaspoonful of powder is stirred into an 8 oz. glass of cool water or other suitable liquid and should be taken immediately. Instant Mix-one packet I to 3 times daily depending on the condition being treated, its severity and individual responsiveness. The contents of the packetare poured into an 8 oz. glass to which cool water is then slowly added. The resulting effervescent mixture should be taken immediately. SUPPUED: Powder-a refined, purified and concentrated vegetable mucilloid, prepared from the mucilaginous porhon of Plantago ovata. combined with dextrose as a dispersing agent. Each rounded teaspoonful contains approximately 3.1 g of psyllium hydrophilic mucilloid per dose, a negligible amount of sodium, and furnishes 14 calories. Available in 6 and 12 oz. plastic baffles. Instant Mix-premeasured unit-dose packets. Each unit-dose packet contains 3.6 g of psyllium hydrophilic mucilloid with effervescent and flavouring excipients. 0.25 g of sodium as bicarbonate, and furnishes 3 calories. Available in boxes of 15 unit-dose packets.
Natumi bowel management that benefits many kinds of patients. Complete presc.bing information available on request (or consult OPS.).
References 1. Shortage specialties (E). Lancet 1: 300, 1974 2. CAPE RDT: A concept of geriatric medicine. Can Med Assoc J 115: 9, 1976 3. RICE DI: Geriatrics and the family physician. Can Fain Physician 23: 873, 1977
260 CMA JOURNAL/FEBRUARY 3, 1979/VOL. 120
Searle Pharmaceuticals
Oakville. Ontano L6H 1M5
