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PubMed2000

In defense of a department of geriatrics.

Departmental status for geriatrics offers many advantages, all of which are related to strengthening academic and clinical programs in aging. The training programs and the content of medical school curriculum in geriatrics remain inadequate under the current structures. A department of geriatrics can provide a stronger faculty base and allow effective interaction with other departments (including but not limited to internal medicine) that need geriatric training. A department of geriatrics also focuses on a model of care that involves working closely with other disciplines, such as nursing and social work. This interdisciplinary model helps expert providers work efficiently throughout the spectrum of care, strengthening continuity. The department can include other medical specialists, such as family practitioners, psychiatrists, and physiatrists, who work with caregivers and patients throughout a course of treatment to manage chronic illness and help maintain and enhance function and independence as long as possible. Comprehensive care and proper care management also substantially benefit institutions by expanding the patient population, reducing length of stay, and avoiding unnecessary hospitalization of older patients through effective discharge planning and transitional care. This requires strong relationships with long-term care providers, a characteristic strength of geriatricians. Although not all research in aging needs to be housed in a department of geriatric medicine, the presence of a critical mass of basic and clinical researchers creates an environment that can stimulate new initiatives and attract external funding. Additional research bridging basic translational and clinical phases relevant to the elderly population is best encouraged by maintaining relationships with other basic science and clinical departments.

Academic Medical Centers↗
PubMed2003

Development of geriatrics-oriented faculty in general internal medicine.

The need for adequate geriatrics training for the physician workforce has been recognized for decades. However, there are not enough academic geriatricians to provide for the educational needs of trainees, and this situation is not expected to change in the future. General internists are often responsible for teaching medical students and internal medicine residents to care for elderly patients in inpatient and ambulatory settings. These academic general internists could play a pivotal role in providing geriatrics instruction. To characterize what is being done to develop geriatrics-oriented general internal medicine faculty, we identified current practices, "best practices," goals and targets, and barriers to achieving those goals and targets. We reviewed the literature on faculty-development programs for general internal medicine faculty, and we held focus groups and structured interviews with general internal medicine unit chiefs and directors of Geriatric Centers of Excellence at 46 medical schools throughout the United States. We found a need for programs to develop geriatrics-oriented academic general internists. Although general internal medicine faculties seem receptive to further geriatrics training, important obstacles exist. These include inadequate time and resources as well as motivational and attitudinal challenges. We discuss potential solutions for overcoming these barriers and the implications of these solutions for stakeholders.

Faculty, Medical↗
PubMed2003

Geriatrics training in general internal medicine fellowship programs: current practice, barriers, and strategies for improvement.

To ensure its growth and prosperity, general internal medicine will need to embrace care of the elderly, research on aging, and geriatrics education as components of its core mission. Experts agree that general internal medicine fellows could benefit from increased opportunities in research on aging and geriatrics education; however, important barriers will hamper efforts to integrate geriatrics training into general internal medicine fellowship programs. This article reviews the barriers to integration and proposes solutions for overcoming those barriers. As a result of interviews and meetings with a broad representation of general internists, geriatricians, funding agencies, and policymakers, we propose 2 interventions: 1) the development of institutional program grants to foster collaboration between general internal medicine and geriatrics faculty in the training of general internal medicine fellows and 2) the creation of a 3-year fellowship program combining general internal medicine and geriatrics. This article discusses the importance of evaluating these and other programs intended to increase the geriatrics experience of general internal medicine fellows, and it describes the potential implications of these changes for a broad array of stakeholder institutions.

Curriculum↗
PubMed1979

Geriatric medicine: whose specialty?

The recommendation of the 1978 report of the Institute of Medicine, Washington, D.C., states that there should not be "a formal practice specialty in geriatrics." The United Kingdom has a comprehensive geriatric service based on a separate specialty of geriatric medicine. This speciality was developed before the National Health Service in 1948. The future of geriatric medicine is not clearly defined. It should continue, I believe, as a separate speciality but with deliberate policies to bring it back into "mainstream medicine." This will involve closer integration with family practice, internal medicine, and psychiatry. While I realize that the operation of the geriatric service in Edinburgh, where I work, could not simply be transplanted into an American setting, the principles of geriatric care ought to be applied within a specialist service if the increasing problems of the aging in American society are to be adequately met.

Aged↗
PubMed1981

Geriatric medicine: a statement from the Federated Council for Internal Medicine.

The body of knowledge pertinent to the care of the elderly lies largely within internal medicine and its subspecialties. A growing number of elderly persons have great need for medical and social services. The Federated Council for Internal Medicine (FCIM) recommends increased emphasis on geriatric medicine in the medical school curriculum, the medical residency, and continuing medical education; new affiliations of medical schools with geriatric care institutions; and the development of postresidency advanced training in geriatric medicine, aimed primarily at creating teacher-scientists, but also preparing for a consultant role. The FCIM opposes the creation of separate medical school departments and favors inclusion of an administrative mechanism for geriatrics within the department of medicine, preferably linked to the division or section of general internal medicine. The FCIM encourages the American Board of Internal Medicine to continue to explore forms of recognition of advanced training and particular competence in geriatric medicine but opposes the creation of a separate certifying board for geriatrics.

Clinical Competence↗
PubMedDate not supplied

Why do doctors choose a career in geriatric medicine?

Reforms to postgraduate training in the U.K. may affect recruitment to geriatric medicine. In 2005, a questionnaire survey was undertaken to determine the factors favouring geriatric medicine as a career choice and whether these might be used to influence recruitment. In all, 1036 responses to the questionnaire were received (response rate 56.4%); 4% of the respondents decided to specialise in geriatric medicine as students, 3.8% of consultants and 8.6% of registrars decided as pre-registration house officers while 39% of consultants and 7% of registrars chose geriatric medicine while a middle grade in another specialty. The strongest influences on choice were clinical aspects of the specialty (34.1%) and inspirational seniors (26.2%). However, 9.2% of consultants and 10.1% of registrars subsequently regretted their career decision. Geriatric medicine seems to be a career choice for doctors of increasing maturity and including more posts in foundation programmes may not improve recruitment as anticipated. Although a small number of doctors regretted choosing geriatric medicine as a career, this was rarely to do with core aspects of the specialty.

Attitude of Health Personnel↗
PubMed1989

Interface between geriatric and general medicine.

Information about their practice has been obtained from 652 consultant physicians in geriatric medicine representing 203 (78%) of the 259 health districts in the United Kingdom (UK). Joint appointments in general and geriatric medicine are held by 19.6%. Admissions policies included admissions selected by suitability for the department (58%) or on an age-related basis (37%)--the most common cut-off age being 75 years. In only a minority, however, were all medical patients above the designated age accepted. The policy generally applied only as long as empty geriatric beds were available. Integrated service (admitting geriatric and internal medicine patients of all ages to a common pool of beds) was practised in 5% of districts. Only one provided long-term care alone. Specialist interests within or in addition to geriatrics were reported by 26% of whole time and 48% of joint appointees. 'Pure' geriatrics remains the most popular form of practice.

Age Factors↗
PubMed2000

A case-oriented web-based curriculum in geriatrics for third-year medical students.

OBJECTIVES: This paper describes the development, implementation, and evaluation of a case-oriented, web-based curriculum in geriatric medicine for third-year medical students. DESIGN: Single cohort, pre/post trial. SETTING: University of Kansas School of Medicine, Kansas City, Kansas. PARTICIPANTS: Third-year medical students (n = 130). INTERVENTION: A web-based curriculum, offered during a clinical geriatrics clerkship, is composed of 13 case-oriented, web-based modules spanning key topics in geriatric medicine. Each module topic is also reviewed in a post-module, faculty-led discussion session. MEASUREMENTS: A pre-and post-rotation test of knowledge was completed. Student feedback about the curriculum was collected through web-based and written evaluation. MAIN RESULTS: Pre-and post-rotation comparison of examination scores demonstrated an average increase of 13 correct items on a 40-item exam. Seventy-five percent of students rated each module favorably at the time of completion (range 53-89%). Most modules (10/13) were rated as excellent or good after all modules had been completed. CONCLUSIONS: A case-oriented web-based curriculum in geriatrics was rated favorably by third-year medical students. Students' knowledge increased in key geriatric topics. Student feedback allows for continuous improvement of the curriculum. This model of curricular innovation may be useful for other institutions seeking to develop or enhance geriatric medicine content in the medical school curriculum.

Attitude of Health Personnel↗
PubMed2003

The Medical College of Wisconsin's program to strengthen geriatrics education.

Medical care for geriatric patients requires physician training that promotes the acquisition of attitudes, knowledge and skills that will permit future practitioners to meet the health needs of increasing numbers of aged patients. MCW has strengthened its traditional curriculum by focusing on student attitudes in the early pre-clinical years through outreach and interest groups programs. Knowledge is integrated throughout the 4-year curriculum using our aging virtual patients. These patients are a teaching resource to the entire faculty. Attitudes, knowledge, and skills in geriatrics are further developed through an M3 geriatrics medicine option and the M4 Integrated Selective. Geriatric-specific skills are emphasized through the use of standardized patients and objective structured clinical examinations in the M4 Selective. It is anticipated that these students efforts will create interest in a novel residency experience (Med-Ger) that will ensure that upon successful completion of the program, residents are expert in geriatric medicine practice and meet criteria for board certification in geriatric medicine.

Curriculum↗
PubMed1992

Use of comprehensive geriatric assessment techniques by community physicians.

BACKGROUND: Research has shown that comprehensive assessment techniques have several clinical benefits for geriatric patients. The purpose of this study was to determine how frequently community practitioners used comprehensive geriatric assessment techniques to identify factors related to use of those techniques. METHODS: The study group included 54% of the 100 community-based family physician preceptors who participate in the University of Mississippi's family medicine training programs. On-site interviews were conducted in each physician's office to measure the percentage of physicians who performed comprehensive geriatric assessment. RESULTS: The majority of physicians employed some selected age-related assessment techniques, but less than 25% performed functional assessment techniques considered unique to the geriatric patient, such as mental status assessment and evaluation of activities of daily living. Most physicians' personal and practice characteristics were unrelated to the use of assessment techniques. CONCLUSIONS: Although many physicians use some techniques of geriatric assessment, most practicing physicians do not perform comprehensive assessment of geriatric patients.

Adult↗
PubMed2004

Geriatric all-terrain vehicle trauma.

More than 300 all-terrain vehicle (ATV) trauma deaths occur annually. Most experience to date focuses on the pediatric trauma. However, senior citizens constitute the fastest growing segment of ATV enthusiasts. We queried our trauma registry from January 1988 to December 2002 and found 200 total ATV accidents. There were 8 patients over age 60. We compared geriatric and nongeriatric riders for presentation and outcome data. The anatomic distribution of injury was similar. Younger patients were more likely to have used ethanol or drugs. Tachypnea and hypotension were generally absent at presentation. The geriatric patients had worse predictive physiologic scores. Clinical outcomes for the geriatric group trended toward longer hospital stays, and they had significantly worse functional outcomes. The geriatric group nonsignificantly trended toward a higher mortality (12.5% vs 3.45%). Our study reflects the recent national trend toward a dramatic rise in geriatric ATV-related trauma. We recommend that geriatric ATV safety programs be instituted.

Accidents, Traffic↗
PubMed1992

[The subacute function in a geriatric department].

The Subacute Geriatric Department in Glostrup Hospital was established on 1 Oct. 1990 as the first in Denmark. Elderly patients with composite disease and who may be anticipated to be discharged after geriatric treatment for one to two weeks, are admitted after referral from the geriatric team. A total of 116 patients were admitted to the eight beds in the department during the period 1 Oct. 1990-31 Mar. 1991. The average period of hospitalization was 9.1 days. The majority of patients were referred from the two medical departments. 20% were admitted directly from the casualty or admission department while 10% were referred by their general practitioners. In this department, diagnostic activity corresponding to that offered in medical departments could be performed. Simultaneously, all of the patients were assessed by a physiotherapist on the day of admission. Ninety-seven patients (84%) were discharged to their homes. On follow-up investigation after three months, 72% were still in their own homes. By means of multi-disciplinary cooperation in the department, it has proved possible to combine intensive investigation and treatment with early geriatric rehabilitation. Discharge is planned already on the day of admission. The majority of the patients were referred from other medical departments of the hospital. This supports the theory that the Subacute Geriatric Department covers a hitherto unfulfilled requirement for early geriatric treatment among many elderly patients in medical departments.

Aged↗
PubMed1992

[Teaching of geriatric dentistry; training of "mobile dental service" dentists].

Quebec presently has 650,000 people over 65 years of age and as many as 900,000 will be alive at the beginning of the 21st century. Quebec epidemiological studies have shown that this group's dental condition is very poor. They feel no need to see a dentist, but 96% of them need treatment and the time elapsed since their last dental visit averages 13 years. It is forecasted that the dental needs of this group will rise, not only because of their increase in number but also because they will retain more teeth. Training in geriatric dentistry is presently deficient in the United States, Canada and particularly Quebec. Researchers have concluded, after studying the U.S. dental schools' current status of geriatric dentistry educational activities, that unless dental students receive training in geriatrics while at dental school, it is likely that they will not treat a lot of seniors in their practice. The teaching of geriatric dentistry is in full swing in the U.S. but knows a difficult birth in Quebec. There is no formal, extensive training program in geriatric dentistry given by the three dental schools in the province. Practicing geriatric dentistry requires special knowledge and skills. If treatment is to be successful, the practitioner must adopt a humanitarian approach and develop close relations and a better understanding of the feelings and attitudes of the elderly. The dentist must know and understand the special dental problems that makes them different from other groups.

Aged↗
PubMed2006

[Comprehensive geriatric assessment in hospitalized patients aged 80 years and more].

Comprehensive geriatric assessment during hospitalization, taking into account the specificity of geriatric patients could be used both in acute and long-term care. We analyzed 63 patients aged at least 80 years, born on odd days and hospitalized at the Department of Internal Medicine and Geriatrics, University Hospital, Kraków. We examined patients using Geriatric Assessment Chart which consisted of Barthel Index (used to determinate motor activity), MMSE, GDS (Geriatric Depression Scale), abbreviated Tinetti Test, Waterlow Index (used to determine the risk of pressure sore development), delirium risk factors scale, and social evaluation. The data were analyzed according to sex, marital status, level of mood, and residence status (free living or institutionalized). The mean age of 47 women and 16 men was 85.0 +/- 4.34 years. Dementia was been found in 60% of examined patients. Depression (usually mild) was encountered in 55.4%. Motor activity was moderately to severely impaired in the entire group, with high level of risk of falls and development of pressure sores. Thirteen per cent of the patients have been admitted with already developed ulcers. The results suggest the need for the comprehensive geriatric assessment both in hospitalized patients and in post-hospital phase of care.

Accidental Falls↗
PubMed2006

[Limited geriatric assessment of the elderly in Kibbutzim of the Upper Galilee].

BACKGROUND: Since comprehensive geriatric assessment (CGA) is very time and money consuming, its implementation is limited in Israel. OBJECTIVE: Implementation of the ambulatory limited geriatric assessment (LGA). TARGET POPULATION: Persons over 65 years of age living in Kibbutzim in the Upper Galilee. METHODS: As in the case of CGA, the emphasis in LGA is mainly placed on the functional status of the elderly. In order to identify geriatric syndromes, we used routine screening methods. According to the agreement with Clalit Health Services, a geriatrician is allowed to spend one hour per person. The elderly to be checked were selected by the medical staff. At the time of LGA, medical staff and patients' relatives supplied all information needed, including this data in computerized ambulatory cards. In such a way, a considerable amount of medical, functional, epidemiological, and psychosocial information was retrieved thus enabling a geriatrician to elaborate individual programs of follow-up and treatment. A geriatrician could request additional consultations and analyses. Two years later the medical staff in the kibbutzim completed anonymous questionnaires referring to the remote results of LGA. RESULTS: A total of 121 elderly persons were included in the LGA, performed during the period 2001-2003. The main causes of patients' referral to LGA were the known geriatric syndromes, namely functional and cognitive decline, anxiety and depression, falls etc. We assessed: (1) epidemiological data: age, gender, familial state, education, number of children, place of residence, (2) clinical data: number of both geriatric syndromes and drugs, recent changes in weight, hearing, and vision, (3) functional status: activities of daily living (ADL) and instrumental activities of daily living (IADL), falls, risk of self-inflicted injury, work, hobbies, social activity, the need for familial and social support, (4) cognitive and psychosocial status including depressive symptoms and anxiety, sleep disturbances, casualties in families or among friends, changes in mood and fears. After conducting the LGA, we recommended changes in the drug treatment, nursing, rehabilitation, institutionalization, and social help, if needed. Analysis of anonymous questionnaires showed that both medical staff and elderly in kibbutzim were satisfied with LGA implemented at the old persons' residence, they noted availability and high professional levels of LGA, additionally, they reported on the successful implementation of recommendations. The method became routine in the Upper Galilee. CONCLUSION: Since CGA is a very time- and money-consuming procedure, LGA has been tested and appears to be effective in the identification of geriatric syndromes. Within one hour of assessment, a geriatrician could retrieve a lot of the relevant information that allowed him to build individual programs for follow-up, prophylactic measures, drug and rehabilitation treatment and institutionalization.

Aged↗
PubMed2006

[Gerodontology teaching program at the geriatric dental clinic in Yad Sarah].

OBJECTIVES: World demographic changes show an increase in the elderly population worldwide. Due to increase in life span, the continuously growing elderly population requires extra attention. This has a great effect on private medical practice. A long term result is the necessity of training dentists in the practice of geriatric dentistry. Geriatric patients have problems that are age dependent, general health problems and specific dental problems. These problems require special skills on the part of the dentist. Yad Sarah has undertaken responsibility for this important task and provides dentists with a geriatric dental (gerodontology) training program. Elderly patients in need of geriatric dental treatment are served in both stationary and mobile clinics. The program includes both theoretical and practical studies. For this purpose, the Hebrew University-Hadassah School of Dental Medicine and Yad Sarah have created a three-year program at the end of which the dentists, working voluntarily, receive a diploma in geriatric dentistry. The purpose of the present study is to evaluate the teaching program in the past few years. METHODS: All the lectures given in the program from 2001 to 2005, both theoretical and practical, have been summarized and categorized by subject. RESULTS: In 2001-2002, the teaching program was theoretical only. Starting from 2003 practical studies were added to the program so that now it includes both theoretical and practical studies. The results presented do not include the many clinical teaching hours during supervised treatment that are given privately to the dentists, from the preparation of the dental treatment plan until the conclusion of treatment. The result shows a steady increase in teaching hours during the years 2001-2005. Not only has the quantity increased; the content has changed too, because of the changes in the needs and the character of work in the geriatric dentistry field. The increasing activity through the mobile dental clinic for homebound patients has led to stepped up teaching in subjects that are related to this kind of treatment, such as oral medicine, systemic disease and oral rehabilitation relating to at-home treatment. The increase in implant treatments created the need to train the dentists in the surgical and rehabilitative aspects of care. The area of oral medicine (26%) and oral rehabilitation (24%) received the most teaching hours, while endodontics (4%) received the least. CONCLUSIONS: The teaching program at Yad Sarah is need-dependent--needs of the patients and of the volunteer dentists as well. At Yad Sarah the dentists come to volunteer, to give needy people quality dental treatment that they cannot afford themselves at regular clinics. An additional motive of these dentists is to advance themselves professionally. The Yad Sarah Dental Clinic offers a unique teaching program that contributes to enhancing knowledge in gerodontology. As the needs at the clinic change, so does the teaching program.

Aged↗
PubMed1987

Research and development in geriatrics in the Netherlands.

This article presents a survey on the developments of geriatrics in the Netherlands in the past few decades. It is described how a small number of pioneers in the sixties and seventies indicated the necessity for special care of geriatric patients. This, finally, lead to full recognition of geriatrics as a clinical specialism in 1983. The developments appear to be fast now. Considerable growth of geriatricians and geriatric hospital beds is necessary to cope with the increased numbers of elderly patients in the future. Scientific research has to be continued with much effort. From this literature survey it becomes clear that in the beginning especially epidemiological research with emphasis on care facilities, was done. Research on particular subjects followed, such as nutrition, drugs, cardiovascular diseases, neoplasms, infections, dementia, etc. The number of geriatric textbooks and monographs has grown in recent years and raises expectations for the future. Bottle-necks at this moment are the relatively small numbers of training possibilities for geriatricians-to-be and lacking structural attention for medical gerontology and geriatrics in the medical curricula of our universities.

Aged↗
PubMed1994

[Preserving of independence: effectiveness of multi-dimensional geriatric assessment].

Comprehensive geriatric assessment (CGA) is defined as the process of determining an elderly person's medical, psychosocial, functional, and environmental resources and problems, linked with an overall plan for treatment and follow-up. The principles of geriatric assessment, including the advantages and disadvantages of using quantitative instruments for multi-dimensional evaluation, are reviewed. The findings of a recently published meta-analysis on comprehensive geriatric assessment are discussed and its policy implications addressed. The meta-analysis includes data of 28 controlled trials comprising 4959 subjects allocated to one of five CGA types, and 4912 control subjects. Original investigators provided additional unpublished data from published reports to supplement the data base of this meta-analysis. The combined odds ratios of outcomes in CGA-assessed patients versus control patients were obtained by pooling data from individual trials with a multivariate logistic regression approach. The combined odds ratio (95% confidence interval) of home survival at 1 to 4-year follow-up was 1.7 (1.2-2.3) for inpatient geriatric evaluation and management units, 1.5 (1.1-2.0) for post-discharge home assessment services, and 1.2 (1.1-1.4) for preventive in-home assessment services. Based on these research findings, the establishment of interdisciplinary units with staff trained in multidimensional geriatric assessment for inpatient evaluation and management of frail elderly patients, is recommended. In addition, research to improve geriatric assessment technology and promote its integration into primary care has a great potential for disability prevention and nursing home use reduction in older persons.

Aged↗