Editorial
The ElderlyandEmergency Medicine Geriatrics was fist recognized in the United Kingdom in the 1930s by Marjorie Warren, Lionel Cosin, and Sir Ferguson Anderson, all pioneer geriatricians, and was formally awarded specialty status when the National Health Service was initiated in 1948. ’ A number of important public articles published in the sixties and seventies, primarily in the British literature, reflect the foundation upon which the specialty of geriatrics has been built. In the United States, the specialty boards of internal medicine and family practice have established a certificate of special competence for geriatrics, and a certification process for fellowships has been established.* Four thousand physicians took the first certifying examination sponsored by these two boards, and 56% passed. Important clinical components of geriatric medicine include the following, over and under symptom reporting and diagnosis, nonspecific or atypical presentation of disease, multiple coexistent chronic conditions, and polypharmacy. Most experienced emergency physicians agree that they face a formidable diagnostic and therapeutic challenge when evaluating the elderly patient with several chronic diseases, taking a half dozen medications, presenting nonspecific complaints, and appearing quite ill. This situation is often aggravated by social or economic factors such as the need for home care or nursing home placement. Hip fractures and dementia are two representative examples of the potentially explosive impact on emergency departments of this growing population. In 1980, there were approximately 200,000 patients with hip fractures at a median age of 79.3 This number is projected to rise to 330,600 by the year 2000. Many of these patients become very ill, have prolonged hospital stays, and are often discharged to institutions. In the ED these patients usually need careful surveillance and significant nursing care because of their clinical fragility. There were more than 2 million people with Alzheimer’s disease and related disorders in 1980. By the year 2000 this figure will rise to 3.8 million.3 Dementia appears to have a significantly increasing incidence in the over 85 age group. A study of elderly in the South Boston area reports a prevalence of significant cognitive impairment of greater than 40% in the noninstitutionalized age group over the age of 85.4 Demented patients commonly test the resources of the ED. With the current national shortage of services for comprehensive geriatric assessment, nursing home placement, or home care assistance, it is likely these patients will be using the ED more often and resulting in great frustration and anguish for all. A recent review noted that the growing nursing home population, currently 1.5 million, suffers a number of other conditions likely to have an effect on emergency medicine.5 Dehydration is very common. Hyponatremia occurs in 18% at any one time, and up to 53% of residents in a l-year period. Ten percent to 25% of the residents have a serious fall each 270
year. About 75% have mental impairment. Infection causes 27% of all hospitalizations of nursing home residents. The use of too high a dose and of too many drugs is pandemic in nursing homes. The population of the US is changing its age distribution drastically.‘j By the year 2000 the over 65 age group will represent 13% of the population, an increase of almost 7% since 1940. By 2030, this group will represent over 21% of the population. Even more important is the fact that the fastest growing age group is the over 85 cohort, which in 1980 was 2.2 million and by the year 2000 will be almost 5 million. Under traditional assumptions of the pathophysiology and epidemiology of disease, this mushrooming of the elderly population should produce a proportionate increase in incidence and prevalence of chronic disease common in the elderly. Most authorities believe this will happen and are predicting that these large increases will give rise to a tremendous increase in demand for health care by this growing older population5 However, an alternative view has been proposed. Fries argues that in the latter part of this century, the mortality and morbidity curve has been compressed or become “squared”.’ Rather simply, this means that people will stay healthy longer, and then deteriorate more rapidly and die. Under this view, the amount of chronic disease will be less than would be ordinarily expected. While the proponents of the compression of mortality/morbidity view do offer some evidence to support their contention, most authorities regard this evidence as very skimpy. They firmly predict that the absolute volume of chronic disease patients will increase significantly as a result of people living longer. The truth may lie somewhere between both views. Recent evidence for “successful” aging suggests that some elderly do not necessarily suffer a decline in major organ function as they age.* Perhaps there is a subgroup existing within this elderly population that will live longer but healthier lives, and will die with less chronic disease than the majority of their group. More research is desperately needed on both the clinical and health care delivery aspects. The curricula of all residencies training physicians to care for adult patients and of the medical students need to be modified to reflect more accurately the common problems of our elderly patients. These problems are not limited to those of the usual healthy 70 kg man with a single chief complaint. Such relatively straight forward problems are unusual in this group, while clinical diagnoses are plentiful but unhelpful. We need to teach all health providers how to modify their usual approach to the “average” patient into an age sensitive system. Even more crucial is recognition of the importance of functional assessment.’ For every older patient, we need to ask ourselves what the impact is of the present problem on the patient’s current level of function. We in emergency
EDITORIAL
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medicine need to recognize the increasing size of this elderly population and its special needs. To make us all better educated and sensitive to this issue, we need our professional societies to develop committees, task forces, and special tracks focused on the elderly. In recognition of its similar challenge, the Society of General Internal Medicine has created a permanent Task Force on Geriatrics.” While we may not reach the biblical standard of 120 years, many of us are living much longer.” As we age, we expect high quality care oriented to our needs. Emergency medicine needs to begin the process of being able to meet our expectations. MICHAEL ELIASTAM, MD
Stanford University Hospital Stanford, California
REFERENCES 1. Rubenstein LZ: Geriatric assessment: An overview of its impacts. Clin Geriatr Med 1987;3:1-15
2. Cohen JC, Lyles KW: Geriatrics. JAMA 1989;261:28472848 3. Brody JA: Prospects for an aging population. Nature 1985;315:483-466.25 4. Besdine RW: Dementia and delirium. In Rowe JW, Besdine RW (eds): Geriatric Medicine (ed 2). Boston, Little, Brown, 1988, p 378 5. Solomon D, Judd HL, Sier HC, et al: New Issues in Geriatric Care. UCLA Conference. Ann Intern Med 1988;108:718-732 6. US Department of Commerce. Bureau of the Census America in Transistion: An aging society Series P-23, No. 128 (Washington DC: US Government Printing Office. September 1983) 7. Fries JF: Aging, Natural Death and the Compression of Morbidity. N EnglJ Med 1980;303:130-135 8. Rowe JW. Kahn RL: Human aoino: Usual and successful. Science 1987;237:143-149 - ” 9. Almy TP: Comprehensive functional assessment for elderly patients. Ann Intern Med 1988;6:70-72 10. Silliman R: Geriatrics in SGIM Society of General Internal Medicine Newsletter, February 1989, Vol 12, No. 1, p 2 11. Genesis 6:3. King James Version, New American Standard Bible
The ElderlyandEmergency Medicine Geriatrics was fist recognized in the United Kingdom in the 1930s by Marjorie Warren, Lionel Cosin, and Sir Ferguson Anderson, all pioneer geriatricians, and was formally awarded specialty status when the National Health Service was initiated in 1948. ’ A number of important public articles published in the sixties and seventies, primarily in the British literature, reflect the foundation upon which the specialty of geriatrics has been built. In the United States, the specialty boards of internal medicine and family practice have established a certificate of special competence for geriatrics, and a certification process for fellowships has been established.* Four thousand physicians took the first certifying examination sponsored by these two boards, and 56% passed. Important clinical components of geriatric medicine include the following, over and under symptom reporting and diagnosis, nonspecific or atypical presentation of disease, multiple coexistent chronic conditions, and polypharmacy. Most experienced emergency physicians agree that they face a formidable diagnostic and therapeutic challenge when evaluating the elderly patient with several chronic diseases, taking a half dozen medications, presenting nonspecific complaints, and appearing quite ill. This situation is often aggravated by social or economic factors such as the need for home care or nursing home placement. Hip fractures and dementia are two representative examples of the potentially explosive impact on emergency departments of this growing population. In 1980, there were approximately 200,000 patients with hip fractures at a median age of 79.3 This number is projected to rise to 330,600 by the year 2000. Many of these patients become very ill, have prolonged hospital stays, and are often discharged to institutions. In the ED these patients usually need careful surveillance and significant nursing care because of their clinical fragility. There were more than 2 million people with Alzheimer’s disease and related disorders in 1980. By the year 2000 this figure will rise to 3.8 million.3 Dementia appears to have a significantly increasing incidence in the over 85 age group. A study of elderly in the South Boston area reports a prevalence of significant cognitive impairment of greater than 40% in the noninstitutionalized age group over the age of 85.4 Demented patients commonly test the resources of the ED. With the current national shortage of services for comprehensive geriatric assessment, nursing home placement, or home care assistance, it is likely these patients will be using the ED more often and resulting in great frustration and anguish for all. A recent review noted that the growing nursing home population, currently 1.5 million, suffers a number of other conditions likely to have an effect on emergency medicine.5 Dehydration is very common. Hyponatremia occurs in 18% at any one time, and up to 53% of residents in a l-year period. Ten percent to 25% of the residents have a serious fall each 270
year. About 75% have mental impairment. Infection causes 27% of all hospitalizations of nursing home residents. The use of too high a dose and of too many drugs is pandemic in nursing homes. The population of the US is changing its age distribution drastically.‘j By the year 2000 the over 65 age group will represent 13% of the population, an increase of almost 7% since 1940. By 2030, this group will represent over 21% of the population. Even more important is the fact that the fastest growing age group is the over 85 cohort, which in 1980 was 2.2 million and by the year 2000 will be almost 5 million. Under traditional assumptions of the pathophysiology and epidemiology of disease, this mushrooming of the elderly population should produce a proportionate increase in incidence and prevalence of chronic disease common in the elderly. Most authorities believe this will happen and are predicting that these large increases will give rise to a tremendous increase in demand for health care by this growing older population5 However, an alternative view has been proposed. Fries argues that in the latter part of this century, the mortality and morbidity curve has been compressed or become “squared”.’ Rather simply, this means that people will stay healthy longer, and then deteriorate more rapidly and die. Under this view, the amount of chronic disease will be less than would be ordinarily expected. While the proponents of the compression of mortality/morbidity view do offer some evidence to support their contention, most authorities regard this evidence as very skimpy. They firmly predict that the absolute volume of chronic disease patients will increase significantly as a result of people living longer. The truth may lie somewhere between both views. Recent evidence for “successful” aging suggests that some elderly do not necessarily suffer a decline in major organ function as they age.* Perhaps there is a subgroup existing within this elderly population that will live longer but healthier lives, and will die with less chronic disease than the majority of their group. More research is desperately needed on both the clinical and health care delivery aspects. The curricula of all residencies training physicians to care for adult patients and of the medical students need to be modified to reflect more accurately the common problems of our elderly patients. These problems are not limited to those of the usual healthy 70 kg man with a single chief complaint. Such relatively straight forward problems are unusual in this group, while clinical diagnoses are plentiful but unhelpful. We need to teach all health providers how to modify their usual approach to the “average” patient into an age sensitive system. Even more crucial is recognition of the importance of functional assessment.’ For every older patient, we need to ask ourselves what the impact is of the present problem on the patient’s current level of function. We in emergency
EDITORIAL
271
medicine need to recognize the increasing size of this elderly population and its special needs. To make us all better educated and sensitive to this issue, we need our professional societies to develop committees, task forces, and special tracks focused on the elderly. In recognition of its similar challenge, the Society of General Internal Medicine has created a permanent Task Force on Geriatrics.” While we may not reach the biblical standard of 120 years, many of us are living much longer.” As we age, we expect high quality care oriented to our needs. Emergency medicine needs to begin the process of being able to meet our expectations. MICHAEL ELIASTAM, MD
Stanford University Hospital Stanford, California
REFERENCES 1. Rubenstein LZ: Geriatric assessment: An overview of its impacts. Clin Geriatr Med 1987;3:1-15
2. Cohen JC, Lyles KW: Geriatrics. JAMA 1989;261:28472848 3. Brody JA: Prospects for an aging population. Nature 1985;315:483-466.25 4. Besdine RW: Dementia and delirium. In Rowe JW, Besdine RW (eds): Geriatric Medicine (ed 2). Boston, Little, Brown, 1988, p 378 5. Solomon D, Judd HL, Sier HC, et al: New Issues in Geriatric Care. UCLA Conference. Ann Intern Med 1988;108:718-732 6. US Department of Commerce. Bureau of the Census America in Transistion: An aging society Series P-23, No. 128 (Washington DC: US Government Printing Office. September 1983) 7. Fries JF: Aging, Natural Death and the Compression of Morbidity. N EnglJ Med 1980;303:130-135 8. Rowe JW. Kahn RL: Human aoino: Usual and successful. Science 1987;237:143-149 - ” 9. Almy TP: Comprehensive functional assessment for elderly patients. Ann Intern Med 1988;6:70-72 10. Silliman R: Geriatrics in SGIM Society of General Internal Medicine Newsletter, February 1989, Vol 12, No. 1, p 2 11. Genesis 6:3. King James Version, New American Standard Bible
