DOI: 10.1111/ajag.12074
Advancing Research, Education, Practice and Advocacy in Ageing Advances in research, education and practice in geriatric medicine, 1982–2012 Leon Flicker Western Australian Centre for Health and Ageing, Centre for Medical Research, Western Australian Institute for Medical Research; School of Medicine and Pharmacology, University of Western Australia; and Department of Geriatric Medicine, Royal Perth Hospital, Perth, West Australia, Australia
Over the last 30 years, major advances in the provision of services for frail older people in Australasia have taken place. This has been spurred on by the accumulation of the evidence for benefits of the multidisciplinary team model of comprehensive geriatric assessment and management. Current research is now uncovering mechanisms of frailty associated with the ageing process and will lead to further interventions in the management of the health problems of older people. These interventions will almost certainly include both medical and lifestyle strategies. Although there have been major improvements in the education of health professionals in aspects of geriatrics, more concerted efforts are required for the ageing population. Key words: ageing, education, evidence, geriatric medicine, gerontology. Today, I listened to Jared Diamond speak about his new book, which partly explores the place of older people in tribal societies and the implications that this has for the present [1]. Societies throughout history have wrestled with the appropriate position of older people and the allocation of power and resources to older people. Population ageing within the last century has occurred at a dramatic and unprecedented fashion, both in the developed and developing world. Initially, this increase in life expectancy was thought to be largely due to public health measures but the continued inexorable increase in longevity suggests that health care plays at least some role. Despite older people leading healthier lives for a longer period, the ‘usefulness’ of older people has been questioned and what should be the appropriate share of health facilities. On the whole, Australia and New Zealand have done well, with universal access and reasonable quality as the hallmarks of success. The medical profession, which is innately conservative, has been forced to adapt their diagnostic and management strategies to meet demographic challenge, at a pace that is uncomfortCorrespondence to: Professor Leon Flicker, Western Australia Centre for Health and Ageing (M573), University of Western Australia. Email: [email protected] Australasian Journal on Ageing, Vol 32 Supplement 2 October 2013, 35–39 © 2013 ACOTA
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able to many within the profession. Ageing research has underpinned changes to geriatric medicine practice and education of health professionals about these new processes and systems has been essential.
Advances in research Clinical systems for older people have developed rapidly, largely driven by research. There have been considerable advances in ageing research over the last 30 years but research with primarily an ageing focus remains poorly organised in Australasia, despite these successes. There have been many reviews of ageing research in Australia over the last 30 years: for example, ‘Scoping study on ageing research’ [2], ‘Building ageing research capacity’ [3], and ‘Progressing Australia’s research agenda on ageing well’ [4], that have consistently come to the same conclusions. All types of ageing research in Australia (and most likely New Zealand) are significantly underfunded and outputs far exceed what can reasonably be expected from the inputs. Capacity for research, and in particular new researchers, are in short supply and infrastructure is weak. The lack of necessary investment in research and development has resulted in at least three major initiatives over the last 30 years to make ageing research a priority in Australia, primarily through the National Health and Medical Research Council. These initiatives have been characterised by such funding mainly going to groups with only a peripheral interest in ageing, and the eventual abandonment of these initiatives. Nevertheless, significant advances have occurred, with the Australasian region playing its part. In this period, at least one unifying theory underpinning the biology of ageing in all organisms has been described [5]. This theory explains many of the phenomena that accompany ageing and provides the basis for frailty [6], which can now be viewed as an increasing lack of redundancy [7]. An exponential increase in research into frailty has augmented our understanding of the pathways leading to the syndromes associated with ageing, such as falls and iatrogenesis. The initial attempt to describe a phenotype of ageing [8], often described as present or absent, has now been replaced by the realisation that multiple pathways result in an incremental loss of physiological reserve, which in turn may be produced by a great number of diseases and physiological changes associated with ageing [6]. This theoretical basis has many implications but this article will provide just one example. It was partly Australian research that demonstrated the composition of amyloid 35
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protein in the brain that accompanied the dementia syndrome due to Alzheimer’s disease (AD) [9]. This was considered to represent the pathogenic cause of dementia in most older people. Hopes were raised that within 10 years, effective interventions that alter disease progression would be available. Some 28 years later, such hopes are somewhat diminished. Interventions based on this hypothesis were duly tested and although they seemed to be effective at removing amyloid protein from the brain, they did not result in any clinical improvement, and in one trial of a gamma secretase inhibitor, semagacestat, resulted in worsening [10]. Adding to this complexity, recent research has demonstrated that amyloid pathology is less discriminatory in determining the clinical dementia syndrome as people age [11]. Furthermore, clinical observations suggested that not all people progress to dementia from a state of mild cognitive impairment (MCI) and that some people with MCI actually improve over time [12]. This would suggest that there is no stable pathogenic process producing AD with age (or time). Instead, dynamic models of cognitive frailty are required with some people improving over time, perhaps representing resolution of acute diseases, infections or treatments. On this basis, some groups such as Indigenous Australians may be prone to very high rates of dementia due to a high prevalence of risk factors [13]. Other seemingly innocuous lifestyle interventions, such as physical activity [14], may result in lasting cognitive improvement despite difficulties these observations have in being accommodated within the amyloid hypothesis. The currently available symptomatic treatments for AD [15], which were developed over the last 30 years, have largely been based on the cholinergic hypothesis for which observations appeared before this period. Their effects are modest but they have spurred interest in timely diagnosis of dementia, which probably had greater benefits than the medications themselves [16]. Some of the major advances in ageing research over this period have been in another area representing increasing frailty: falls. This is an area that was at least partly pioneered by a team from New Zealand [17]. The epidemiological basis of falls have been studied; clinical [18] and physiological risk factors [19] have been identified. Early reviews demonstrated that the study of falls was a legitimate medical exercise even though at that stage interventions had not been evaluated for efficacy [20]. A large number of intervention trials, many performed in Australasia, have now provided clear advice for clinicians and patients alike [21,22]. Although programs initiated in emergency departments seem to be effective [23], the evidence for programs to reduce falls in hospital is still insufficient to give clear recommendations [22]. A randomised trial (n = 1206) of a falls prevention education intervention delivered at admission only seemed to reduce falls in hospitals among cognitively intact participants [24]. Penetration of effective interventions to emergency departments remains poor and an area of active research [25]. This article has focused on just two of the syndromes of ageing: dementia or cognitive frailty, and falls. Advancements 36
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have occurred in many other areas including incontinence, pharmacological management and osteoporosis. The latter has demonstrated a massive improvement in management over this period. In 1982, not a single proven efficacious agent in osteoporosis was available, and over the last 30 years the place of vitamin D, bisphosphonates, teriparatide, denosumab and strontium have become established in treatment [26]. Clinical system research has facilitated the changes in geriatric practice and some of this accruing evidence is covered in advances in practice.
Advances in practice The resources provided to the care and treatment of older people are limited, partly by an ageist approach to rationing. Lasting improvements in clinical practice have to be guided by evidence, or any such improvements in clinical practice will subsequently be abandoned during the next downturn in funding. It is only in the last 30 years that evidence supporting the efficacy and effectiveness of geriatric assessment and management has been compiled. In 1984, a randomised trial demonstrating the effectiveness of a geriatric evaluation unit was reported [27] (incidentally, this study was designed and funded in Australia but never performed). Patients who had been assigned to the geriatric unit had lower mortality, were less likely to have spent any time in a nursing home during the follow-up period and had greater improvement in functional status and morale than the control group [27]. Since then, numerous other studies have been performed and a systematic review has confirmed the benefits of inpatient geriatric assessment and rehabilitation, with patients more likely to be alive and in their own homes at 6 months (odds ratio (OR) 1.25, 95% confidence interval (CI) 1.11 to 1.42), with decreased rates of institutionalisation (OR 0.79, 95% CI 0.69 to 0.88) and improved physical and cognitive function than controls [28]. These benefits are mainly apparent when patients are admitted to a dedicated ward area and receive care from a specialist multidisciplinary team, not in a general medical ward with a visiting team. Despite the clarity of this evidence, there is still a major knowledge-practice gap with geriatric evaluation and management units not universally available. The use of the multidisciplinary team and coordinated care has been found to be effective in stroke inpatients units as well. Organised inpatient stroke unit care reduced death or institutionalisation (OR 0.76, 95% CI 0.65 to 0.90) and lowered rates of dependency [29]. The evidence for multidisciplinary rehabilitation for older people with hip fractures does not seem to be as robust, with only a trend in reduction of poor outcome (risk ratio 0.89, 95% CI 0.78 to 1.01) [30]. Nevertheless, orthogeriatric units are widespread throughout Australasia, mainly on efficiency grounds. Similarly, although acute geriatric wards show some promise, the evidence is not extensive. A systematic review demonstrated a lower rate of functional decline (OR: 0.82, 95% CI: 0.68, 0.99) and increased likelihood of patients living at home after discharge (OR 1.30, 95% CI: 1.11, 1.52) [31]. The selection of studies Australasian Journal on Ageing, Vol 32 Supplement 2 October 2013, 35–39 © 2013 ACOTA
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for this systematic review was somewhat arbitrary and how patients were selected for the different acute care units appeared very heterogeneous. Despite their promise, acute geriatric wards are not routinely available and this suggests that further evidence will need to be accrued. There has been increasing focus on geriatric assessment and rehabilitation, often labelled as subacute care, in Australia and New Zealand over this period. This has been due not only to the evidence described above, but also to political and management issues. The dominant issue has been the way the interface between acute care, subacute care and RACFs has been managed. In Australia, in 1982, there was a burgeoning nursing home sector propelled by Federal Government subsidies with virtually no effective regulation. Models of Geriatric Assessment Teams (now called Aged Care Assessment Teams) coupled with introduction of residential care ratios eventually stemmed the tide. However, the ratio of residential aged care places fell from 90.9 per 1000 population aged 70 and over in 1996 to 82.4 by 2001 [32]. The decline of 7.6 places per 1000 was much steeper than the gradual decline of 3.1 beds per 1000 over the 5 years 1991 to 1996 [32], probably partly due to state governments decreasing their involvement in nursing homes. This steep decrease in residential care provision had untoward consequences, particularly as access to residential care was markedly reduced at the end of the 20th century, due to uneven distribution. This resulted in a ‘crisis’ where large numbers of older patients were unable to move from acute hospitals to residential care, particularly in Victoria, reducing access to acute medical care for all adults. This clear demonstration of the interdependence between residential care, subacute care and acute care had some positive consequences. The Australian Government recognised a shared responsibility in ageing and formed the Care of Older Australians Working Group (COAWG) through the Australian Health Ministers’ Advisory Council in 2001. COAWG focused on older people entering the acute care system, at risk of hospitalisation, or at risk of premature entry to aged care. It commissioned a number of projects including a hospital census on 17 April 2002, which covered over 99% of the estimated 17 745 adult patients in Australia. Approximately 14% of older patients were waiting for something else, about two thirds for residential and community services and one third for inpatient rehabilitation. This eventually resulted in ‘The National Action Plan for Improving the Care of Older People Across the Acute Aged Continuum – From Hospital to Home’ and was endorsed by the Australian Health Ministers Conference on 29 July 2004 [33]. This blueprint paved the way for the Transition Care Program and increased investment in subacute services fostered by the Council of Australian Governments through the National Partnership Agreement on Hospital and Health Workforce Reform and the National Partnership Agreement on Improving Public Hospital Services (2011). Importantly, all these programs have emphasised that it is not just bedAustralasian Journal on Ageing, Vol 32 Supplement 2 October 2013, 35–39 © 2013 ACOTA
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based services for which multidisciplinary rehabilitation is important. A host of community rehabilitation services and hospital-facilitated discharge programs have appeared. Work arising from the development of these community support systems has shown that the functional status of older people who access community services may be improved by a restorative approach [34]. Over the last 30 years, there has been development and growth of specialist multidisciplinary clinics to deal with common syndromes of ageing [35]. These are in addition to general outpatient geriatric assessment, and complement domiciliary assessment that in Australia is frequently auspiced by Aged Care Assessment Teams. These specialty clinics have largely focused on the common syndromes associated with ageing: memory, falls and incontinence. Despite their growth and acceptance by clinicians and older people, the evidence for their effectiveness is scant. To date, there has been only one trial of memory clinics, [36] that did suggest some benefits for the carers of people with dementia who presented to the memory clinic. Although there are many interventions that decrease the risk of falls, it is not clear whether formal organisation within a clinic achieves additional benefits. The data from such clinics appears to be largely observational in nature [37]. There is some evidence regarding efficacious treatment of incontinence in frail older people, but how such treatment should be delivered and exactly to whom has been relatively neglected and there have been calls for targeted research in this area [38]. The growth of new technologies may have great applicability to the practice of geriatric medicine particularly for RACFs and patients in more remote areas. Telehealth models of care have been increasingly evaluated [39].
Advances in education In the early 1980s, education in geriatric medicine in medical schools was rarely comprehensive and was characterised by its brevity. Often, it would occupy four to eight 2-hour sessions spread over as many weeks. Geriatric medicine would not be part of any formal assessment. In a course as crowded as medicine, assessment drives learning and the converse is true: knowledge and skills that are not assessed are rarely learnt, and thus, training of future doctors in geriatric medicine was substandard. The Australian and New Zealand Society for Geriatric Medicine (ANZSGM) played a major role in fostering teaching of geriatric medicine within medical schools. It produced a skeleton undergraduate curriculum and promulgated a position statement on Education and Training in Geriatric Medicine for medical students in 1996 [40]. It was difficult to be prescriptive as course structures vary greatly among medical schools, but a general guide to the extent of teaching was the equivalent of 2–4 weeks full-time in the latter half of the course. Most medical schools in Australasia have now complied with this, which is pleasing when compared with the situation in Europe, which is much more heterogeneous [41]. There are now academic 37
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geriatricians in virtually every medical school in Australasia, although this largely represents the commitment of health departments as opposed to universities. In only one or two medical schools in Australasia does the university actually provide the resources for academic positions in geriatric medicine. The importance of geriatric medicine being taught by experts within this field must be emphasised as, unlike virtually every other field of medical education, it has been demonstrated that specific geriatric medicine clerkships increase knowledge about, skills in, and attitudes towards treatment of older people [42]. Probably no other aspect has better illustrated the growth in size and expertise of the field of geriatric medicine than that in postgraduate education. In 1982, advanced training in geriatric medicine as a subspecialty within the Royal Australasian College of Physicians (RACP) had only just begun. In 1986, there were only a handful of such trainees within Australia and New Zealand. By 2012, there were 183 trainees in Australia and New Zealand. In 2012, there were only two subspecialties with greater numbers of trainees: general medicine (307 trainees) and cardiology (200 trainees). Physicians in geriatric medicine have often led the way in education reform within the RACP: for example, geriatric medicine was the first subspecialty to have a comprehensive curriculum. Unfortunately, training in geriatric medicine for general practitioners has not had the same success. Lack of additional remuneration or other incentives has hindered growth in training for general practitioners with a particular interest in geriatric medicine. This has had major ramifications for the provision of health services in residential aged care facilities, where health care is poorly organised and often associated with poor outcomes [43]. Measures to improve this situation have been proposed by ANZSGM [44].
Conclusions The period 1982–2012 has been marked by rapid growth in the field of geriatric medicine, largely stimulated by evidence demonstrating the utility of this field to improve the lives of frail older people and to facilitate efficiency in services providing health care. Continuing developments in research have suggested methods to intervene earlier in the course of frailty. It is likely that such interventions will need to be comprehensive in scope and include lifestyle as well as medical treatments. There will need to be continued growth in education and training to meet these challenges. Increasing subspecialisation of medicine and the time pressures on general practice will place pressure on the geriatric multidisciplinary team to help fill some gaps not traditionally associated with geriatric medicine: for example, younger people with complex psychosocial problems and older people requiring chronic disease management programs. It will be imperative that these new models of care are evaluated with the same rigour as traditional geriatric assessment and rehabilitation models. 38
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Key Points • Over the last 30 years advances in research have uncovered the basis of ageing, which involves increasing frailty based on an underlying loss of redundancy in multiple physiological systems. • Underpinned by evidence, geriatric assessment and rehabilitation has provided better care for older people in community and inpatient settings. • Education in geriatric medicine has been given greater emphasis in undergraduate courses and there has been a massive expansion in postgraduate trainees.
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Advancing Research, Education, Practice and Advocacy in Ageing Advances in research, education and practice in geriatric medicine, 1982–2012 Leon Flicker Western Australian Centre for Health and Ageing, Centre for Medical Research, Western Australian Institute for Medical Research; School of Medicine and Pharmacology, University of Western Australia; and Department of Geriatric Medicine, Royal Perth Hospital, Perth, West Australia, Australia
Over the last 30 years, major advances in the provision of services for frail older people in Australasia have taken place. This has been spurred on by the accumulation of the evidence for benefits of the multidisciplinary team model of comprehensive geriatric assessment and management. Current research is now uncovering mechanisms of frailty associated with the ageing process and will lead to further interventions in the management of the health problems of older people. These interventions will almost certainly include both medical and lifestyle strategies. Although there have been major improvements in the education of health professionals in aspects of geriatrics, more concerted efforts are required for the ageing population. Key words: ageing, education, evidence, geriatric medicine, gerontology. Today, I listened to Jared Diamond speak about his new book, which partly explores the place of older people in tribal societies and the implications that this has for the present [1]. Societies throughout history have wrestled with the appropriate position of older people and the allocation of power and resources to older people. Population ageing within the last century has occurred at a dramatic and unprecedented fashion, both in the developed and developing world. Initially, this increase in life expectancy was thought to be largely due to public health measures but the continued inexorable increase in longevity suggests that health care plays at least some role. Despite older people leading healthier lives for a longer period, the ‘usefulness’ of older people has been questioned and what should be the appropriate share of health facilities. On the whole, Australia and New Zealand have done well, with universal access and reasonable quality as the hallmarks of success. The medical profession, which is innately conservative, has been forced to adapt their diagnostic and management strategies to meet demographic challenge, at a pace that is uncomfortCorrespondence to: Professor Leon Flicker, Western Australia Centre for Health and Ageing (M573), University of Western Australia. Email: [email protected] Australasian Journal on Ageing, Vol 32 Supplement 2 October 2013, 35–39 © 2013 ACOTA
bs_bs_banner
able to many within the profession. Ageing research has underpinned changes to geriatric medicine practice and education of health professionals about these new processes and systems has been essential.
Advances in research Clinical systems for older people have developed rapidly, largely driven by research. There have been considerable advances in ageing research over the last 30 years but research with primarily an ageing focus remains poorly organised in Australasia, despite these successes. There have been many reviews of ageing research in Australia over the last 30 years: for example, ‘Scoping study on ageing research’ [2], ‘Building ageing research capacity’ [3], and ‘Progressing Australia’s research agenda on ageing well’ [4], that have consistently come to the same conclusions. All types of ageing research in Australia (and most likely New Zealand) are significantly underfunded and outputs far exceed what can reasonably be expected from the inputs. Capacity for research, and in particular new researchers, are in short supply and infrastructure is weak. The lack of necessary investment in research and development has resulted in at least three major initiatives over the last 30 years to make ageing research a priority in Australia, primarily through the National Health and Medical Research Council. These initiatives have been characterised by such funding mainly going to groups with only a peripheral interest in ageing, and the eventual abandonment of these initiatives. Nevertheless, significant advances have occurred, with the Australasian region playing its part. In this period, at least one unifying theory underpinning the biology of ageing in all organisms has been described [5]. This theory explains many of the phenomena that accompany ageing and provides the basis for frailty [6], which can now be viewed as an increasing lack of redundancy [7]. An exponential increase in research into frailty has augmented our understanding of the pathways leading to the syndromes associated with ageing, such as falls and iatrogenesis. The initial attempt to describe a phenotype of ageing [8], often described as present or absent, has now been replaced by the realisation that multiple pathways result in an incremental loss of physiological reserve, which in turn may be produced by a great number of diseases and physiological changes associated with ageing [6]. This theoretical basis has many implications but this article will provide just one example. It was partly Australian research that demonstrated the composition of amyloid 35
F l i c k e r
protein in the brain that accompanied the dementia syndrome due to Alzheimer’s disease (AD) [9]. This was considered to represent the pathogenic cause of dementia in most older people. Hopes were raised that within 10 years, effective interventions that alter disease progression would be available. Some 28 years later, such hopes are somewhat diminished. Interventions based on this hypothesis were duly tested and although they seemed to be effective at removing amyloid protein from the brain, they did not result in any clinical improvement, and in one trial of a gamma secretase inhibitor, semagacestat, resulted in worsening [10]. Adding to this complexity, recent research has demonstrated that amyloid pathology is less discriminatory in determining the clinical dementia syndrome as people age [11]. Furthermore, clinical observations suggested that not all people progress to dementia from a state of mild cognitive impairment (MCI) and that some people with MCI actually improve over time [12]. This would suggest that there is no stable pathogenic process producing AD with age (or time). Instead, dynamic models of cognitive frailty are required with some people improving over time, perhaps representing resolution of acute diseases, infections or treatments. On this basis, some groups such as Indigenous Australians may be prone to very high rates of dementia due to a high prevalence of risk factors [13]. Other seemingly innocuous lifestyle interventions, such as physical activity [14], may result in lasting cognitive improvement despite difficulties these observations have in being accommodated within the amyloid hypothesis. The currently available symptomatic treatments for AD [15], which were developed over the last 30 years, have largely been based on the cholinergic hypothesis for which observations appeared before this period. Their effects are modest but they have spurred interest in timely diagnosis of dementia, which probably had greater benefits than the medications themselves [16]. Some of the major advances in ageing research over this period have been in another area representing increasing frailty: falls. This is an area that was at least partly pioneered by a team from New Zealand [17]. The epidemiological basis of falls have been studied; clinical [18] and physiological risk factors [19] have been identified. Early reviews demonstrated that the study of falls was a legitimate medical exercise even though at that stage interventions had not been evaluated for efficacy [20]. A large number of intervention trials, many performed in Australasia, have now provided clear advice for clinicians and patients alike [21,22]. Although programs initiated in emergency departments seem to be effective [23], the evidence for programs to reduce falls in hospital is still insufficient to give clear recommendations [22]. A randomised trial (n = 1206) of a falls prevention education intervention delivered at admission only seemed to reduce falls in hospitals among cognitively intact participants [24]. Penetration of effective interventions to emergency departments remains poor and an area of active research [25]. This article has focused on just two of the syndromes of ageing: dementia or cognitive frailty, and falls. Advancements 36
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have occurred in many other areas including incontinence, pharmacological management and osteoporosis. The latter has demonstrated a massive improvement in management over this period. In 1982, not a single proven efficacious agent in osteoporosis was available, and over the last 30 years the place of vitamin D, bisphosphonates, teriparatide, denosumab and strontium have become established in treatment [26]. Clinical system research has facilitated the changes in geriatric practice and some of this accruing evidence is covered in advances in practice.
Advances in practice The resources provided to the care and treatment of older people are limited, partly by an ageist approach to rationing. Lasting improvements in clinical practice have to be guided by evidence, or any such improvements in clinical practice will subsequently be abandoned during the next downturn in funding. It is only in the last 30 years that evidence supporting the efficacy and effectiveness of geriatric assessment and management has been compiled. In 1984, a randomised trial demonstrating the effectiveness of a geriatric evaluation unit was reported [27] (incidentally, this study was designed and funded in Australia but never performed). Patients who had been assigned to the geriatric unit had lower mortality, were less likely to have spent any time in a nursing home during the follow-up period and had greater improvement in functional status and morale than the control group [27]. Since then, numerous other studies have been performed and a systematic review has confirmed the benefits of inpatient geriatric assessment and rehabilitation, with patients more likely to be alive and in their own homes at 6 months (odds ratio (OR) 1.25, 95% confidence interval (CI) 1.11 to 1.42), with decreased rates of institutionalisation (OR 0.79, 95% CI 0.69 to 0.88) and improved physical and cognitive function than controls [28]. These benefits are mainly apparent when patients are admitted to a dedicated ward area and receive care from a specialist multidisciplinary team, not in a general medical ward with a visiting team. Despite the clarity of this evidence, there is still a major knowledge-practice gap with geriatric evaluation and management units not universally available. The use of the multidisciplinary team and coordinated care has been found to be effective in stroke inpatients units as well. Organised inpatient stroke unit care reduced death or institutionalisation (OR 0.76, 95% CI 0.65 to 0.90) and lowered rates of dependency [29]. The evidence for multidisciplinary rehabilitation for older people with hip fractures does not seem to be as robust, with only a trend in reduction of poor outcome (risk ratio 0.89, 95% CI 0.78 to 1.01) [30]. Nevertheless, orthogeriatric units are widespread throughout Australasia, mainly on efficiency grounds. Similarly, although acute geriatric wards show some promise, the evidence is not extensive. A systematic review demonstrated a lower rate of functional decline (OR: 0.82, 95% CI: 0.68, 0.99) and increased likelihood of patients living at home after discharge (OR 1.30, 95% CI: 1.11, 1.52) [31]. The selection of studies Australasian Journal on Ageing, Vol 32 Supplement 2 October 2013, 35–39 © 2013 ACOTA
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for this systematic review was somewhat arbitrary and how patients were selected for the different acute care units appeared very heterogeneous. Despite their promise, acute geriatric wards are not routinely available and this suggests that further evidence will need to be accrued. There has been increasing focus on geriatric assessment and rehabilitation, often labelled as subacute care, in Australia and New Zealand over this period. This has been due not only to the evidence described above, but also to political and management issues. The dominant issue has been the way the interface between acute care, subacute care and RACFs has been managed. In Australia, in 1982, there was a burgeoning nursing home sector propelled by Federal Government subsidies with virtually no effective regulation. Models of Geriatric Assessment Teams (now called Aged Care Assessment Teams) coupled with introduction of residential care ratios eventually stemmed the tide. However, the ratio of residential aged care places fell from 90.9 per 1000 population aged 70 and over in 1996 to 82.4 by 2001 [32]. The decline of 7.6 places per 1000 was much steeper than the gradual decline of 3.1 beds per 1000 over the 5 years 1991 to 1996 [32], probably partly due to state governments decreasing their involvement in nursing homes. This steep decrease in residential care provision had untoward consequences, particularly as access to residential care was markedly reduced at the end of the 20th century, due to uneven distribution. This resulted in a ‘crisis’ where large numbers of older patients were unable to move from acute hospitals to residential care, particularly in Victoria, reducing access to acute medical care for all adults. This clear demonstration of the interdependence between residential care, subacute care and acute care had some positive consequences. The Australian Government recognised a shared responsibility in ageing and formed the Care of Older Australians Working Group (COAWG) through the Australian Health Ministers’ Advisory Council in 2001. COAWG focused on older people entering the acute care system, at risk of hospitalisation, or at risk of premature entry to aged care. It commissioned a number of projects including a hospital census on 17 April 2002, which covered over 99% of the estimated 17 745 adult patients in Australia. Approximately 14% of older patients were waiting for something else, about two thirds for residential and community services and one third for inpatient rehabilitation. This eventually resulted in ‘The National Action Plan for Improving the Care of Older People Across the Acute Aged Continuum – From Hospital to Home’ and was endorsed by the Australian Health Ministers Conference on 29 July 2004 [33]. This blueprint paved the way for the Transition Care Program and increased investment in subacute services fostered by the Council of Australian Governments through the National Partnership Agreement on Hospital and Health Workforce Reform and the National Partnership Agreement on Improving Public Hospital Services (2011). Importantly, all these programs have emphasised that it is not just bedAustralasian Journal on Ageing, Vol 32 Supplement 2 October 2013, 35–39 © 2013 ACOTA
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based services for which multidisciplinary rehabilitation is important. A host of community rehabilitation services and hospital-facilitated discharge programs have appeared. Work arising from the development of these community support systems has shown that the functional status of older people who access community services may be improved by a restorative approach [34]. Over the last 30 years, there has been development and growth of specialist multidisciplinary clinics to deal with common syndromes of ageing [35]. These are in addition to general outpatient geriatric assessment, and complement domiciliary assessment that in Australia is frequently auspiced by Aged Care Assessment Teams. These specialty clinics have largely focused on the common syndromes associated with ageing: memory, falls and incontinence. Despite their growth and acceptance by clinicians and older people, the evidence for their effectiveness is scant. To date, there has been only one trial of memory clinics, [36] that did suggest some benefits for the carers of people with dementia who presented to the memory clinic. Although there are many interventions that decrease the risk of falls, it is not clear whether formal organisation within a clinic achieves additional benefits. The data from such clinics appears to be largely observational in nature [37]. There is some evidence regarding efficacious treatment of incontinence in frail older people, but how such treatment should be delivered and exactly to whom has been relatively neglected and there have been calls for targeted research in this area [38]. The growth of new technologies may have great applicability to the practice of geriatric medicine particularly for RACFs and patients in more remote areas. Telehealth models of care have been increasingly evaluated [39].
Advances in education In the early 1980s, education in geriatric medicine in medical schools was rarely comprehensive and was characterised by its brevity. Often, it would occupy four to eight 2-hour sessions spread over as many weeks. Geriatric medicine would not be part of any formal assessment. In a course as crowded as medicine, assessment drives learning and the converse is true: knowledge and skills that are not assessed are rarely learnt, and thus, training of future doctors in geriatric medicine was substandard. The Australian and New Zealand Society for Geriatric Medicine (ANZSGM) played a major role in fostering teaching of geriatric medicine within medical schools. It produced a skeleton undergraduate curriculum and promulgated a position statement on Education and Training in Geriatric Medicine for medical students in 1996 [40]. It was difficult to be prescriptive as course structures vary greatly among medical schools, but a general guide to the extent of teaching was the equivalent of 2–4 weeks full-time in the latter half of the course. Most medical schools in Australasia have now complied with this, which is pleasing when compared with the situation in Europe, which is much more heterogeneous [41]. There are now academic 37
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geriatricians in virtually every medical school in Australasia, although this largely represents the commitment of health departments as opposed to universities. In only one or two medical schools in Australasia does the university actually provide the resources for academic positions in geriatric medicine. The importance of geriatric medicine being taught by experts within this field must be emphasised as, unlike virtually every other field of medical education, it has been demonstrated that specific geriatric medicine clerkships increase knowledge about, skills in, and attitudes towards treatment of older people [42]. Probably no other aspect has better illustrated the growth in size and expertise of the field of geriatric medicine than that in postgraduate education. In 1982, advanced training in geriatric medicine as a subspecialty within the Royal Australasian College of Physicians (RACP) had only just begun. In 1986, there were only a handful of such trainees within Australia and New Zealand. By 2012, there were 183 trainees in Australia and New Zealand. In 2012, there were only two subspecialties with greater numbers of trainees: general medicine (307 trainees) and cardiology (200 trainees). Physicians in geriatric medicine have often led the way in education reform within the RACP: for example, geriatric medicine was the first subspecialty to have a comprehensive curriculum. Unfortunately, training in geriatric medicine for general practitioners has not had the same success. Lack of additional remuneration or other incentives has hindered growth in training for general practitioners with a particular interest in geriatric medicine. This has had major ramifications for the provision of health services in residential aged care facilities, where health care is poorly organised and often associated with poor outcomes [43]. Measures to improve this situation have been proposed by ANZSGM [44].
Conclusions The period 1982–2012 has been marked by rapid growth in the field of geriatric medicine, largely stimulated by evidence demonstrating the utility of this field to improve the lives of frail older people and to facilitate efficiency in services providing health care. Continuing developments in research have suggested methods to intervene earlier in the course of frailty. It is likely that such interventions will need to be comprehensive in scope and include lifestyle as well as medical treatments. There will need to be continued growth in education and training to meet these challenges. Increasing subspecialisation of medicine and the time pressures on general practice will place pressure on the geriatric multidisciplinary team to help fill some gaps not traditionally associated with geriatric medicine: for example, younger people with complex psychosocial problems and older people requiring chronic disease management programs. It will be imperative that these new models of care are evaluated with the same rigour as traditional geriatric assessment and rehabilitation models. 38
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Key Points • Over the last 30 years advances in research have uncovered the basis of ageing, which involves increasing frailty based on an underlying loss of redundancy in multiple physiological systems. • Underpinned by evidence, geriatric assessment and rehabilitation has provided better care for older people in community and inpatient settings. • Education in geriatric medicine has been given greater emphasis in undergraduate courses and there has been a massive expansion in postgraduate trainees.
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