Should geriatric medicine remain a specialty? No
BMJ. 2008 July 12; 337(7661): 79. doi: 10.1136/bmj.39533.696076.AD PMCID: PMC2453252 Should geriatric medicine remain a specialty? No
C P Denaro, director, associate professor1,2 and A Mudge, staff physician1
See Should geriatric medicine remain a specialty? Yes" in volume 337 on page 78.
The development of geriatrics has greatly improved care for older people. Leon Flicker (doi: 10.1136/bmj.39538.481273.AD) believesspecialist care remains important for this vulnerable group,butC P Denaro and A Mudge argue that age divisions are no longer relevant
Our patients have changed. The inverted pyramid is imminent. Every developed country is facing an increase in older patients.1 2 The fastest growth in emergency admission rates is in the oldest age group.2 These changes translate into major changes in the profile of our hospital patients, as older patients with multiple chronic diseases and disabilities occupy more beds. In addition, improved survival is also leading to larger numbers of younger people with chronic disease and disabilities living in our communities.3 Thus it is not just geriatricians who have to be able to manage acute and accumulated chronic diseases and to assess and manage the functional, cognitive, and psychological impairments that can influence longevity, quality of life, use of health care, and treatment decisions.
The concepts of comprehensive assessment, multidisciplinary care, rehabilitation, and planned discharge have been championed by many groups, but particularly geriatric medicine. Recognition of subtle and atypical presentations of illness in elderly people, and the decreased physiological reserve commonly recognised (but poorly defined) as frailty have been important contributions to hospital care of older people.4 Clinical and academic geriatricians have provided important leadership, and the principles they have espoused have been incorporated in the training of our hospital and family doctors and the staffing of our hospitals, which include roles such as discharge facilitators and case managers. Since most of our patients in the future will have chronic diseases or disabilities or have frailty related problems, all generalists must incorporate these holistic themes and specific knowledge into their clinical practice. So there is little point in continuing to distinguish general physicians from geriatric physicians.5
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What age is old? It is not sensible to define a specialty by chronological age. Increasing numbers of younger people with chronic disease and disabilities also require a coordinated, function focused approach to care; artificial age cut-offs into “geriatric” and “non-geriatric” services only frustrate access to such services. In addition, attitudes to and expectations of health care for older people have changed greatly in the past generation. An approach centred on gentle symptom management and functional maintenance is no longer considered acceptable. In 2005, almost half of new patients started on renal dialysis were aged over 65, and almost 10% of patients receiving coronary artery bypass grafting were over 80.15 16 The rationing of aggressive medical care is now appropriately based on individual judgments of risks and benefits, not by a number.
Health care is a continuum, and rather than breaking the patient’s journey into arbitrary steps (under 65, over 65, acute care, subacute care, etc) a patient’s continuity of care should be maximised wherever possible. There is danger if a patient with complex multiple medical conditions during their life journey sees too many doctors or has multiple handovers when admitted to hospital.
