JOURNAL OF THE

VOLUME XXVl

OCTOBER 1978

Copyright 0 1978 by the American Geriatrics Society

NUMBER 10 I’rintcd

in

1‘.S.A.

The Evolution of Geriatric Medicine* J. C. BROCKLEHURST, MD, MSc, FRCP** Department of Geriatric Medicine, University of Manchester, Manchester, England

ABSTRACT: The evolution of geriatric medicine has been associated with increasing knowledge about aging - social, psychologic and biologic -and its effect on the clinical presentation of illness. It also has been associated with varying patterns of the historical development of medical care .in different countries. Overall, two main forms of geriatric medicine are developing worldwide -one an accredited specialty practiced within a State medical service, the other based in large hospitals for the aged where physicians train themselves but are not accredited. The system of geriatric care in Great Britain is described and the importance is emphasized o f 1) assessment before admission, 2) progressive care of the patient, and 3) the day hospital. Future developments in relation to internal medicine and family practice are considered. Research into the causes of atheromatous vascular disease and senile dementia is of fundamental importance for the whole future of geriatric medicine.

I propose to consider the evolution of geriatric care from three points of view. First, the evolution of old age; second, the evolution of knowledge about aging and old age; and third, the evolution of geriatric medicine. Every great writer has something to say about old age. The quotation I have selected as the theme for this lecture is from the discussion: “De Senectute” written by Cicero in 44 BC:

“Nature has only a single path and that path is run but once; and to each stage of existence is allotted its only appropriate quality: so that the weakness of childhood, the impetuosity of youth, the seriousness of middle life, the maturity of old age, each bears some of nature’s fruit which must be garnered in its own season.” The “maturity” of old age is a very appropriate word. Words are important since they affect attitudes. For instance, your term “senior citizen” has perhaps a different and more optimistic connotation than the commonly used English phrase, “old age pensioner.” Attitudes in turn are all-important, since they determine facilities and services that society provides. There are three basic alternative attitudes

* The Willard 0 . Thompson Lecture, presented at the 35th Annual Meeting of the American Geriatrics Society, Hyatt Regency Hotel, Atlanta, Georgia, April 13-14, 1978. ** Professor of Geriatric Medicine, University of ManChester, Manchester, England. Recipient of the 1978 Willard 0. Thompson Gold Medal Award of the American Geriatrics Society. Address: University Hospital of South Manchester, Nell Lane, Manchester, England M20 8LR. 433

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toward old age in Western society today. The first is well summed up by the words of Disraeli in his novel “Coningsby”: “Youth is a blunder, manhood a struggle, old age a regret.” To see old age as a regret logically leads to a parsimonious and begrudging provision of care and facilities. To some people, and unhappily to not a few physicians, this is the dominant attitude. Old age is seen as a medically unexciting and unrewarding time of life associated with ugliness and senility. In a youth-orientated society this attitude is understandable but I am glad to say that it now seems to be diminishing. The second attitude is enshrined in the famous “Theory of Disengagement” propounded by Cumming and Henry (1)in 1961-that it is best both for the old and for society at large if the former withdraws, i.e., disengages. For some this may be true; the last period of life should be one of renunciation, contemplation and preparation for the next stage. However, for most of us, the third attitude, which is the opposite to disengagement and perhaps summed up in the activity theory of aging, is the one we would welcome most. It represents continuing involvement in society, social intercourse, friendship, creativity in arts or crafts, companionship of animals, and appreciation of the opposite sex. Therefore, the attitude of involvement is the one which should principally characterize our planning and provision of geriatric care. THE EVOLUTION OF OLD AGE The evolution of old age is really a 20th century phenomenon. Survival curves from the time of Stone Age man to 19th century man show change, but it is during the 20th century that we have seen the striking move to the right which indicates that most people alive today in Western Society will live out their allotted span. In other parts of the world, however our 20th century life expectancy is still unattainable. The evolution of old age has changed the configuration for our population from that of a pyramid with a wide base of young people and a narrow apex of old people, to that of a square; on the female side it reaches almost hour-glass proportions. This differential longevity in favor of the female is a bewildering fact-or perhaps an artefact. Although it can have no teleologic significance, it is nevertheless of real importance when we come to the provision of geriatric care.

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THE EVOLUTION OF KNOWLEDGE ABOUT AGING AND OLD AGE Geriatric medicine has both contributed to and arisen out of the evolving knowledge about aging and old age. The fundamental facts of biologic aging are still uncertain despite an increasing amount of research. It is the biologic changes in elastic and muscle tissue, fat, bone, hair and skin, which distinguish the bloom of youth from the wrinkles of old age. Whether these changes are genetically programmed, whether they are random errors in the transcription of DNA, or whether there are other causes, are matters about which a t present we abound in theories but are short on facts. However, we have more understanding of the effects of aging on organs and body systems. This applies particularly to the fundamental regulatory processes which are based within the central nervous system, where changes are so evident and so relevant to the practice of medicine in old age. Whereas perhaps the most obvious of these changes is the effect on memory, probably the most important is the effect on maintenance of the upright posture. We stand so confidently when we are young and middle-aged, but our stance is imperilled in old age by sensory impairment within the central nervous system (vision, vestibular function and proprioception) as well as by loss of muscle strength and joint stability. Sheldon’s illustration in 1963 of the progressive increase in sway in old age provides a most striking picture of the mirror image which aging and development bear toward each other. Other fundamental neuroregulatory processes affected by aging include hearing, swallowing, bladder function, thermo-regulation, vasomotor control and thirst. All of these factors tend to provide a background of precariousness that may predispose to breakdown, though the factors themselves usually are not the cause of breakdown in independent living. It is the adding together of these predisposing factors and other random or precipitating factors such as infection, toxins (especially from drugs) and vascular effects that so often leads to breakdown in old age. This change in regulation by the central nervous system underlies the three cardinal presenting symptoms of illness in old people, viz, falls, incontinence and mental confusion. Then there are the feelings of old people- the

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mental and personality changes which accompany aging. As we grow old, two facts emerge: our feelings undergo little change but our personality traits become more exaggerated. Our goals and capacities slowly alter but in ourselves we remain the same. We mature but we don’t change. The exaggeration of personality traits was well demonstrated by Reichard (2) in his study “Aging and Personality.” From his findings in elderly men, he proposed five fundamental personality patterns of psychologic aging, as follows: 1. Constructiueness. Well-integrated person, tolerant, flexible and self-aware, with happy childhood, little adult emotional stress and with continuity in life history, who accepts facts of old age, retirement and death. He retains the capacity to enjoy (food, work, drink, play, sex). He looks back with few regrets, and forward to what is still to come. 2 . Dependency. A socially acceptable, passive, unambitious person, but with fairly good selfinsight. He tends to be wife-dominated. He is glad to retire, eats, drinks and gambles too much, and has no wish to do any more work. 3 . Defensiveness. A well-adjusted, socially active, self-sufficient person. Emotionally overcontrolled, habit-bound, conventional and compulsively active. He is afraid of old age, in which he sees few advantages. He puts off retirement and ignores the prospect. 4. Hostility. This man tends to blame circumstances or others for his failures. He is aggressive and complaining, often with an unstable occupational history, minor incompetence and poor financial planning. He sees nothing good in old age, and is afraid of death. He envies the young, and so plunges into active work to defer the evil day. 5. Self-hate. This man is critical and contemptuous of himself, with a life marked by socioeconomic decline and a n unhappy marriage. He is a “victim of circumstances” who accepts the fact of aging, since he has had enough. He is not envious of the young and is looking for a “blessed relief.” The evolution of our knowledge about aging includes also the findings of sociologic gerontology and the effects of disease. For instance, the vulnerability in old age of the childless; the loneliness of the very old; the problems of old people concentrated in decaying city centers - all of these factors are highly relevant to the prac-

tice of geriatric medicine. And so is the fact of the accumulation of chronic diseases. By far the most important of these are dementia and vascular disease (particularly of the brain and heart). Disability, however, is also compounded by other accumulating pathologic entities such as osteoarthrosis, musculoskeletal disorders, osteoporosis, fractures, foot disorders, chronic respiratory disease (present in 25 percent of the over-65’s in British industrial cities), parkinsonism, cataract, or glaucoma. THE EVOLUTION OF GERIATRIC CARE We should consider the evolution of geriatric care against the background of attitudes, changes in the population, and changes related to aging and disease. Although the history of medical care of the elderly varies from country to country, the general trend in most of Western Society has been a gradual progression from ecclesiastical to secular, from church to state. In England, perhaps more than in most countries, the turning point can be determined with some precision. Because of King Henry VIII’s desire for an heir and his divorce from Catherine of Aragon in order to marry Ann Boleyn, there followed his break with the Pope and his establishment of the Church of England as a separate foundation within Christendom. This was followed by the dissolution of the monasteries and consequently the loss of the traditional form of care for the old and disabled. By the time his daughter, Queen Elizabeth I, was on the throne, the unmet need of these unfortunates was becoming apparent. Legislation was obtained in the Poor Relief Act of 1601, by which the State (in the form of local parishes) accepted responsibility for the poor, for orphans and for the aged and chronically sick (the lame, the impotent, the blind and others unable to work, as they were called). This identity of fortune (or misfortune) of the poor and the aged continued until the setting up of the National Health Service in 1948. In many parts of Europe, almshouses provided a community for the aged which was both protected and yet accessible to everyday life. Van Zonneveldt (3) has described such “Hofjes” (or small courts) in Holland built by employers for their former employees or servants: “. . by just passing through a small gate the old person

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could enter into a full life again.” These are the forerunners of special housing schemes for the elderly which, in England, are called sheltered housing. Hospices or special hospitals for the old have developed in many countries throughout the past 100 years-for instance, in France in the 19th and in Sweden in the 20th century. Many are ecclesiastically based and in several countries they provide the major share of care for disabled elderly people. If we come now to the New World (if I may use the term in this historical context), the evolution of geriatric care here seems to have been different. The United States is very consciously the nation of self-help and self-responsibility. Geriatric care has therefore been divided between those who provide it on a private basis and those who provide it through religious organizations, and there has been little State involvement except (since 1966) in paying the bill. Perhaps the great exception in your country lies in the Veterans Administration hospitals, now assuming a more prominent role in geriatric development. This would seem to be a form of State service. In the Western World, therefore, there seem to be two main patterns in the evolution of geriatric care. On the one hand there is a recognized specialty based on a state-supported system of medical practice (as in Great Britain and Sweden). On the other hand there are countries where the specialty does not have official recognition but where physicians working in large hospitals and homes for the elderly have made it their own business to become specialists in geriatrics. This includes most countries such as the United States, Canada, France, Belgium, and Australia. For a number of external reasons, the two evolutionary streams seem, over the past few years, to be moving more closely together. It would seem that an accredited specialty, taught in the medical schools and practiced within a state-funded and state-directed service, is now emerging. Let us look more closely at the British system, with emphasis on the stage we have reached in geriatric medicine and what I think we shall attain in the next ten years. Geriatric medicine has to be seen in the context of medical practice in Great Britain, which is divided fairly rigidly between primary care (general practice or family practice) and specialist medicine and surgery. Every patient is regis-

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tered with a general practitioner who receives an annual capitation fee for the patient with the understanding that the general practitioner will provide primary care when required. The capitation fee is higher for patients aged 65 or over and highest for those aged 75 or older. General practitioners work increasingly from health centers. These provide a base for groups of from 3 to 12 doctors, together with their offices community nurses and other support. A few of these physicians have hospital appointments as well, but these are as clinical assistants in specialist departments, and they do not treat their own patients when they are admitted to the hospital. Specialists (called consultants) only see patients on referral from general practitioners, apart from those patients with emergency illness who present themselves directly to hospital emergency departments. Many consultants are on a full-time basis, although the majority also have sessions devoted to private specialist practice. Geriatric physicians are numbered among the specialists who only see patients on referral by general practitioners. There are now over 300 consultant geriatricians. The objectives of geriatric medicine are twofold. The first is to maintain old people living independently in the community as long as possible - by the early ascertainment and treatment of illness and disability, by rehabilitation of the disabled (both as inpatients and a t the day hospital), by intermittent short-term admission if necessary or day hospital attendance as a form of support, and by a close liaison both with general practitioners and with the Social Services. The second objective is the management of patients requiring long-term care. All geriatric long-term beds are in charge of consultant geriatricians. Psychogeriatric long-term beds are increasingly in charge of consultant psychiatrists specializing in the psychiatry of old age - a new and developing specialty. The first objective anticipates that no elderly person will be admitted to long-term care in a hospital before being fully medically examined and treated and every possibility of rehabilitation and community support considered. The geriatric department works as an area service, as do the departments of psychiatry and obstetrics, Each geriatric department (with from one to three consultants on the staff) is respon-

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sible for the geriatric service in the area. Admission to geriatric beds is either on an emergency basis, or following a visit by the hospital geriatrician to the patient in his own home. This visit allows the geriatrician to see the problem in its totality, to obtain a good history, and to discuss the likely program of management with relatives. Admission also may follow outpatient consultation or consultation in the day hospital. There are a number of differences in the deployment of geriatric services in different parts of the country. A few departments function rigidly on an age basis, usually being prepared to manage all the internal medical problems in patients aged over 70 or 75 in their area. The majority of geriatric departments, however, receive only a proportion of elderly people in their area, i.e., patients referred by general practitioners, usually with highly complex problems involving the effects of aging, accumulated pathologic changes, and a precipitating cause of breakdown - which may constitute either an acute medical or an acute social problem. The great majority of these people are more than 75 years old. Those who are younger or who have a single medical problem (e.g., coma, hematemesis, infection) often are referred to the internist. The traditional geriatric department deploys its beds in a system of progressive care. There are three main types of provision: beds for acute illness (and assessment), beds for rehabilitation services, and beds for long-term care. Almost all patients are admitted into the assessment ward in the first place. Here the initial diagnosis and management are carried out, and the majority of the patients return to their own homes. The average length of stay is two to three weeks. Those who do not recover during that time will probably move to a second stage of care -geriatric rehabilitation beds -for physical treatment of their disabilities. A small number of patients will also be transferred to the geriatric rehabilitation beds from the orthopedic, surgical and internal medicine services. The average length of stay here is two to three months. Most of these patients return home or to a n old people’s residential home when their treatment in the rehabilitation ward is complete. Patients who do not recover sufficiently to return to independent living in the community or in an old people’s home, will then move on to the third stage - long-term care. Here, the average length of stay is two to three years. Only

about one in 10 of the patients admitted to the assessment ward ends up in the long-term ward. For such patients, the hospital becomes home. The principle of progressive care is continued logically in the day hospital where patients may be managed either following their discharge as inpatients or even without inpatient admission. The day hospital attempts to provide the therapeutic aspect of hospital care without the hotel aspect. Thus, patients may have treatment and investigation in the hospital in the daytime but remain at home in the evenings and on weekends. The day hospital plays a major role in rehabilitation and in the maintenance of independence among disabled people who have already been rehabilitated and in whom deterioration might well follow a complete withdrawal of physical therapy. The day hospital also accepts some disabled patients in order to give their relatives a breathing spell to prevent a breakdown when the domestic situation is precarious. It also undertakes a small number of medical and nursing procedures and observations, without the necessity of hospital admission. The psychogeriatric service provides a complementary form of care, again based on the assessment wards (where both geriatrician and psychogeriatrician consult together), on a day hospital, and on long-term care. TRAINING IN GERIATRIC MEDICINE Undergraduate medical students are at last being taught something about geriatric medicine. There is now a professorial chair of geriatric medicine in 12 of the 30 British medical schools. The others all have associated consultant geriatricians. The training of specialists in geriatric medicine and in psychogeriatrics is similar to the training of specialists in other branches of medicine and psychiatry. After a year as an interne, there is a period of three to four years in general professional training, based mainly on internal medicine. Then the membership examination of the Royal College of Physicians must be passed (an examination with a very high failure rate). This is followed by a period of two to four years as a senior registrar in geriatric medicine, and then appointment as a consultant geriatrician. All geriatricians are thus trained in internal medicine, are members of the Royal College of

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Physicians, and have undertaken special training in geriatric medicine itself. What is the future of geriatric medicine in Great Britain? Over the last 20 years there has been a considerable shortage of home-trained doctors in the country. This shortage has been particularly noticeable in what have sometimes been called the “less popular” specialties, including psychiatry, radiology, anaesthesiology and geriatrics. Now things are changing. The output of the medical schools was increased by one third in the 1970’s; emigration to North America and elsewhere is becoming more difficult; and so we may expect the shortage of doctors to be rectified over the next few years. This will be to the benefit of geriatrics. The development of geriatric medicine has always been very closely associated with that of internal medicine, of which it has always claimed to be a branch. Internal medicine is now becoming more and more specialized on an organ or system basis and those who remain generalists are therefore increasingly involved with emergency medicine and with the elderly. For this reason it may be anticipated that there will be some degree of rapprochement between geriatric medicine and internal medicine over the next ten years. A report of the Royal College of Physicians of London last year affirmed that geriatric medicine was a specialty in its own right, but suggested that the role of joint appointments between internal and geriatric medicine should be explored as the likely future course. Such joint appointments would create specialists involved in the emergency care of patients of all ages, a responsibility which they would share in rotation with other internists who would be specialists in a n organ or systembased specialty. The general physician with a responsibility for a geriatric service would thus have geriatric medicine as his main specialty but would also participate in the management of patients with acute illness and other forms of general illness who were below 70 years of age. Some geriatricians view these proposals with dismay. The majority, however, accept that this is a very possible form of development, and that there should certainly be such experiments. It is not easy to conjecture as to the future relationship between family practitioners and geriatric specialists. This relationship has always been good, since both realize their mutual interdependency. The possibility of specializing within a group general practice in subjects like

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pediatrics, geriatrics and psychiatry has been debated from time to time for the past 20 years. A recent report has come out strongly in favor of some form of specialization in pediatrics within family practice. If this becomes established, then it might well set a precedent for geriatrics. The advantage would be that one member of a group practice would have special training in geriatric medicine, responsibility for residential homes and for the ascertainment of unreported illnesses, and some sessional arrangement with the hospital geriatric department. However, general practitioners, as a group, are very opposed to any form of major specialization within primary care. The ascertainment of unreported illness (a form of geriatric screening) is now devolving on the health visitor (community nurse) attached to the group general practice. Through the practice, she is able to get a list of all patients aged 70 or older. Increasingly she is being encouraged to call on them and offer them a simple examination to detect the major remediable disorders which are known to be under-reported, e.g., visual and hearing disorders, congestive heart failure, foot troubles, anemia, urinary-tract disorders, depression, and dementia. It seems likely that this trend will become established and will obviate any demand that the doctors themselves should become involved in the widespread prophylactic examination of elderly people. The whole future of geriatric care will depend upon fundamental research into two overwhelmingly threatening conditions - senile dementia and cerebrovascular disease. If these could be prevented, then geriatric practice would be revolutionized. A healthy old age, free from physical and mental disability, would become a reality for 90 percent of the over-75‘s, rather than the present 50 to 75 percent.

* * * * * * * * * * * * Mr. President, I am deeply honored to be able to present this lecture in honor of Willard Owen Thompson who died 24 years ago. As a past president of your distinguished society, as the mainspring in the founding of your journal and as a physician who cared deeply about old people, I am sure he would be glad to know of the progress which the practice of geriatric medicine has made in the quarter of a century since his death. Perhaps he would feel that this progress has been too slow but I think rather that he

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would acknowledge that all major systems of medical practice must emerge gradually and be built on solid foundations. As a specialty, geriatric medicine has grown slowly-all too slowly in some parts of the world. Nevertheless, the 1970’s have seen considerable acceleration of this growth, and with Arthur Clough we well may say. . . “Tis not by Eastern windows only When morning comes, comes in the light.

Far out the sun climbs slow, how slowly, But Westward, look, the land is bright.” REFERENCES Cumming E and Henry WE: Growing Old. New York, Basic Books, 1961. Reichard S, Livson S and Peterson PS: Aging and Personality: A Study of Eighty-Seven Older Men. New York, John Wiley, 1962. Van Zonneveldt RJ:The Netherlands, in Geriatric Care in Advanced Societies, ed. by J C Brocklehurst. Lancaster, M.T.P., 1975.

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JOURNAL OF THE VOLUME XXVl OCTOBER 1978 Copyright 0 1978 by the American Geriatrics Society NUMBER 10 I’rintcd in 1‘.S.A. The Evolution of Geri...
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