Geriatric medicine and pharmacy practice: a historical perspective
Shared care models
As the average age of hospital inpatients climbed during the second half of the 20th century, and the prevalence of multi-morbidity and polypharmacy grew, geriatric expertise was increasingly needed outside of geriatric units. Geriatric consultation services (in which a geriatrician reviews patients on referral) exist in many hospitals; however, this model of care is associated with poorer outcomes compared to models in which the geriatrician is directly responsible for patient care.[30, 31] Therefore, shared care models of practice have been developed within various specialty areas and settings, especially those with a high proportion of older patients (Table 2). In these models a physician or surgeon shares patient management with a geriatrician, usually in conjunction with a multidisciplinary team, utilising the CGA approach.
Table 2. Examples of shared care models of geriatric medicine
Model Medical practitioner collaborating with geriatrician Patient group RACF = residential aged care facility.
a Hospital-based geriatric service that provides consultation, assessment, planning and/or short-term management of older people in residential aged care facilities (also known as residential care outreach).[38]
b Time-limited package of restorative and personal care delivered in the patient's home or at a residential aged care facility following discharge from hospital.[77]
Cardiogeriatrics Cardiologist Heart failure
Oncogeriatrics Medical oncologist Cancer
Orthogeriatrics Orthopaedic surgeon Hip fracture
Psychogeriatrics Old age psychiatrist (psychogeriatrician) Mental illness or dementia
Surgegeriatrics General or specialist surgeon Surgical needs
Acute care of the elderly (ACE) General medicine physician Acute medical illness
Emergency geriatrics Emergency medicine physician Acute illness or trauma
Residential in-reachb and Transition careb General practitioner RACF residents at imminent risk of hospital admission; patients discharged from hospital with functional decline
The emphasis in these models is on early assessment of function, cognition and co-morbidities, medical optimisation before surgery, prevention and early detection of complications (e.g. delirium), prevention of functional decline, management of comorbidities, early discharge planning and avoidance of re-admissions to hospital.[36-38]
The oldest and most widespread examples are psychogeriatric and orthogeriatric services, which were described over 25 years ago.[8, 39] Acute care of the elderly (ACE) units were introduced in Australia from the late 1990s,[40] but are not widespread.[12, 13] Other models such as oncogeriatrics, cardiogeriatrics and residential in-reach are more recent developments.[38, 41, 42]
There is evidence for the effectiveness of some of these models. For example, ACE units can improve patients’ functional outcomes, and reduce readmissions to hospital and discharges to residential care.[43, 44] Hip fracture patients who receive orthogeriatric care tend to have lower in-hospital and long-term mortality and lower rates of delirium
