The New Geriatrics

It has been 2 years since the editorial stewardship of the Journal was passed on by Gene Stollerman.1 Because geriatrics is in an exponential growth phase, it has been a particularly exciting time to manage the editorial affairs of the Journal. For this reason it seems a propitious time to reflect on the recent advances in geriatrics and what the future of geriatrics might bring. Certainly the strength of geriatrics in the last 2 years has been the acceptance by the medical community at large of the utility of geriatric assessment techniques. The benefits of comprehensive geriatric assessment were clearly stated in the article by the American Geriatrics Society Public Policy Committee.2 These opinions have been reiterated in a number of articles in major general medical journals.3–5 A randomized, controlled trial of a geriatric assessment unit in a community rehabilitation hospital6 confirmed the positive benefits of such units (improved functional status, decreased admission to nursing homes, and improved mortality) originally demonstrated by the study of patients at the Sepulveda Veterans Administration Medical Center Geriatric Evaluation Unit.4 It also confirmed the importance of targeting assessment services to those frail older adults who are most likely to benefit from them.6–7 In addition, the decision of the Department of Veterans Affairs to rename these units Geriatric Evaluation and Management (GEM) units highlights the important role of active intervention in the success of these units. In contrast to the success of these inpatient evaluation units stands the failure of randomized trials to demonstrate a salutory effect of a geriatric consultative team on elderly hospitalized8 or ambulatory patients.9 A major flaw in both these studies was the failure to target the intervention to patients most likely to benefit. Certainly, both of these studies8,9 and a recent study on outpatients over the age of 70 years10 have shown a high prevalence of undetected functional, nutritional, and psychological impairment in older persons. It would seem that this information could be used to develop appropriate targeting and management of these patients in future studies. In addition, the availability of more sophisticated assessment tests may improve our ability to choose patients who will benefit optimally.11 There has been an increased awareness that the frailty seen in some older persons is not irreversible but is highly responsive to simple interventions. Fiatarone et al12 found that high-intensity strength training led to significant improvement in muscle bulk and strength and functional mobility in nonageriarians. In another study, Fiatarone et al13 reported a significant increase in natural killer-cell activity in older individuals during exercise and suggested that this could conceivably explain the reduction in cancer seen in association with moderate exercise. Physical training has also been shown to improve exercise duration and peak oxygen consumption in patients with chronic heart failure secondary to ischemic heart disease.14 Shepherd15 reviewed the risks and benefits of exercise in older individuals and concluded that training can “make a major contribution to the quality of life by maximizing residual function.” Others have studied the effects of the anabolic hormone, growth hormone, on muscle strength and nutritional status. Both growth hormone and insulin growth factor I (somatomedin C) decrease in about one third of older individuals.16 Studies have shown that 6 months of growth hormone injections induce an important increase in muscle bulk and a corresponding decrease in body fat.17 In addition, growth hormone has been shown to reverse the catabolic status of older patients with protein-energy malnutrition.18,19 Low testosterone levels are commonly seen in older men.20,21 Studies are presently underway to examine whether testosterone replacement can have positive effects in frail older men. Since the beginning of time, sex and life have been closely intertwined. Snowdon22 has provided evidence that age at menopause is an excellent biological marker of aging and a predictor of death. Numerous studies have attested to the positive effects of estrogens on cardiovascular disease, osteoporosis, and possibly muscle strength in women.16 On the male side of the fence, Korenman et al23 have demonstrated that impotence in older subjects is easily treated with external vacuum temescence devices. In view of the high prevalence of impotence in older men and the negative effects sexual dysfunction can have on quality of life, the availability of a relatively simple, cost-effective treatment for impotence is an important advance in improving the care of older individuals.24 Impotence due to vascular disease has been shown to be an indicator of generalized atherosclerotic disease and to be a harbinger of future myocardial infarction or cerebrovascular accident.25 Most impotence in older men is due to vascular disease. Protein-energy malnutrition has been widely recognized as a common and important problem in older individuals.27,28 Low body weight,29,30 a decreased midarm circumference,31 and low cholesterol levels32 are often found. Many such patients respond well when the cause of their decreased food intake (e.g., depression, digoxin, or anorexia tardive) is identified and appropriately treated.33 At the other end of the spectrum, an ethical argument has mushroomed concerning when life-sustaining measures, such as insertion or maintenance of a feeding tube, should be discontinued. This argument surfaced to the general public when the U.S. Supreme Court agreed to hear on appeal the decision of the Missouri Supreme Court that the parents of Nancy Cruzan, a young woman in a persistent vegetative state, could not order the removal of a gastrotomy tube. Recognizing the importance of this area to geriatrics, the Journal published eight articles on this subject in May 1990.34–41 One major conclusion of this colloquy was that many of these ethical problems could be avoided if there were near-universal preparation of written advance directives. Interestingly, the decision of the U.S. Supreme Court in the Cruzan case, announced in June of this year, reinforced this conclusion. It was a mixed decision. In support of those who would prefer to see a feeding tube removed when there is no hope of sentient life, the Supreme Court held that nutrition and hydration provided by artificial means is not a “feeding” but rather a medical treatment. Further, the majority found that even a person in a persistent vegetative state shares with other Americans the right to determine what medical treatment shall be applied. However, the Court denied the petition of the Cruzans to remove the tube on the grounds that clear and convincing evidence of Nancy Cruzan's wishes was not available. This decision has led to a flood of requests to advance directive forms and will also lead to a set of explanatory and interpretive papers in an upcoming issue of this Journal. Another momentous ethical argument is being played out on the issue of using age as a criterion for health-care rationing, as proposed by Daniel Callahan of the Hastings Center.42 Certainly, few geriatricians or ethicists favor this approach,43,44 and even Callahan has modified his position.45 Should rationing of health care become inevitable, we would strongly argue that decisions should hinge on functional status rather than age and that in all cases the principle of patient autonomy should be maintained. Seneca said, “I will not escape by death from disease so long as it may be healed, and leaves my mind unimpaired. … But if I know that I must suffer without hope of relief, I will depart.” The ethical conundrums associated with euthanasia have been brought to the attention of the modern geriatrician due to the acceptance of euthanasia by many in Holland46 and by the recent physician-assisted suicide of Janet Adkins, a woman with possible Alzheimer's disease. These occurrences are forcing society to reexamine the fine line between passive and active suicide and the absolutely distinct line between a physician relieving suffering and a physician deliberately causing death. In the end, the decision concerning these ethical issues will have to be made by the body politic. However, as geriatricians we have a responsibility to inform patients and families that disease may be misdiagnosed and that depression, which is usually treatable, is often missed in older individuals.47 A major area of current concern is the use of physical restraints, a form of elder abuse that is unique to the United States. Numerous studies have shown that physical restraints can lead to injuries, death by strangulation, and deconditioning.49 A recent Canadian study found no significant increase in falls when restraints were dramatically reduced in a nursing home.49,50 Restraints also have been reported to increase agitated behavior.51 Most important, the application of restraints has been found to involve little discussion by members of the health-care team.52 Clearly, the time has come to let our people (the elderly) go, if only because tomorrow we will be them! There have been major advances in the recognition, diagnosis, and management of incontinence.53 The development of simple bedside testing to demonstrate the cause of incontinence has been valuable.54 The utility of biofeedback55 and electrical stimulation56 therapies, as well as advances in the pharmacological treatment of incontinence,57 have markedly enhanced the options for the incontinent patient. However, as is often the case in geriatrics, it has been the increased awareness of the worth of a very simple technique, i.e., frequent toileting, that has perhaps yielded the greatest benefit in the care of older individuals with incontinence.58 The new geriatrics is teaching us to reevaluate normal values and practices in older individuals. Analysis of the study by the European Working Party on High Blood Pressure in the Elderly has shown a U-shaped mortality curve in relationship to both systolic and diastolic blood pressures.59 It appears that ideal systolic blood pressures are approximately 146 to 158 mm Hg and ideal diastolic pressures 92 to 98 mm Hg. Similarly, there is some evidence that cholesterol values in the range of 240 to 280 mg/dL may be optimal for survival in older individuals.60 Coulston et al61 have questioned the utility of using an American Diabetes Association diet in residents with diabetes mellitus in nursing homes, and the benefit of dietary therapy for treating elevated cholesterol levels in older subjects has also been questioned.62 Studies such as these advance our knowledge of the unique approaches to the management of older individuals. In contrast, the typical drug study continues to exclude older participants. An example of this is the recent study of intermittent cyclical administration of etidronate for the management of osteoporosis that used an age of 75 years as an exclusion category.63 Geriatricians need to beware of falling into the trap of accepting that those therapies with proven efficacy in middle-aged subjects will be equally efficacious and safe in older individuals. There have been major advances in our understanding of how to manage patients in nursing homes.64 The realization of the unique needs of nursing-home patients and the concept that the nursing home is a major arena for teaching the care of the elderly65,66 are important outcomes of the geriatric revolution of the 1980s. Unfortunately, as demonstrated by a recent study, teaching nursing homes have not necessarily recognized the need to focus on improved care as the essential ingredient in the teaching process.67 Teaching nursing homes had significantly more falls and pressure sores and nonsignificantly more drug reactions and medication errors than nonteaching nursing homes! Some geriatric teachers need to learn to practice what they (or we) teach! The last few years have been an exciting period for research into Alzheimer's disease. Genetic linkage studies have led to the identification of the gene for the B-amyloid protein on chromosome 21.68 Other work has demonstrated that a large array of neurotransmitters, especially neuropeptides, are altered in patients with Alzheimer's disease.69 Neuropeptide Y has been shown to be a potent physiological stimulator of memory processing in the hippocampus,70 and the number of receptors for neuropeptide Y are decreased in the brains of patients with Alzheimer's disease.71 Deprenyl may delay the downhill progress of Parkinson's disease72,73 and even, perhaps, prolong life in these patients.74 This exciting new frontier in geriatrics was heralded by animal studies showing that this monoamine B oxidase inhibitor can prolong life in “parkinsonian” rats75 as successfully as dietary restriction does.76 Deprenyl is a designer drug originally developed by Knoll in Hungary for the management of Parkinson's disease; it subsequently gained widespread popularity when it was demonstrated to prevent the localized destruction of the substantia nigra produced by the meperidine analog MPTP (1-methyl-4 phenyl-1,2,3,6,-tetrahydropyridine.77 Molecular biology is slowly making inroads into the care of the geriatric patient. Recombinant growth hormone, erythropoeitin, insulin, and thrombolytic agents are being utilized widely. We are learning that aging alters the functioning of DNA itself. For example, DNA from older persons is less susceptible to degradation than DNA from young persons.78,79 Finally, the genome-mapping project will eventually allow the ultimate in preventive gerontology, i.e., the deletion or modification of lethal genes such as that for Huntington's disease. At the other extreme, your editors continue to marvel at the usefulness of the case report to illustrate geriatric principles. Among our favorites in this regard was the lady who developed dysphoria after cataract removal,80 the man who suffered penile encrustation due to a condom catheter,81 and the description of musical hallucinations, “the sounds of silence.”82 However, the ultimate case report appeared in the Christmas issue of the British Medical Journal.83 A feline developed self-neglect after the death of her 89-year-old owner. She refused food and refused to emerge from her housing, an unused toilet. The diagnosis of senile dementia was made and a treatment course of euthanasia charted. However, a second opinion suggested the diagnosis of depressive dementia and after intensive psychotherapy the cat made a complete recovery. Could there be a better way to illustrate the importance of exploring atypical presentations and treatable causes of dementia in older individuals? One of the most exciting events has been the creation of the Certificate of Added Qualifications in Geriatric Medicine for internists and family practitioners.84 This examination has allowed geriatrics to take its legitimate place alongside other subspecialties. Steel et al85 provided a statistical analysis of the first certifying examination in geriatric medicine. Unfortunately, although the authors concluded that the examination tested a unique geriatric content, careful perusal of the article leads to the opposite viewpoint. The only robust correlation coefficients were with performance on the primary certifying examinations (r = 0.56 for internal medicine and 0.70 for family practice). In contrast, there was only a modest correlation between duration of training and test score (r = 0.18); the same was true of the history of having trained in the “better training programs” (r = 0.14). Furthermore, the authors failed to make a statistical adjustment for the possibility that diplomates with more training and from “better training programs” would have scored better on the primary certifying examination. The fact that the questions on which the candidates performed least well were overwhelmingly likely to be more specialized suggests further a paucity of geriatric knowledge in those passing the examination. The argument that these questions were more difficult is unsupported by the fact that performance on rehabilitation questions was poor. These questions were clearly pertinent to geriatrics and certainly no more difficult than many of the general medicine questions, provided the examinee had specialized knowledge in this area. As eloquently stated by Subers,86 “If we are to be recognized as a unique area of medicine, we must emphasize and test those features which make us unique.” It should be noted that the majority of physicians who took the first qualifying examination were mainly involved in primary care (75% of family practitioners and 73% of internists).87 Further, Reuben et al88 have recently calculated that there is a need for 1,225 additional academic geriatrics faculty to allow adequate residency education and training in geriatrics. Based on all of this, we conclude that the new geriatrics needs to define more comprehensively the content that is uniquely geriatric, to achieve nationwide consensus on it, and to increase enthusiasm among residents to enter high-quality training programs in geriatrics. The new geriatrician must reproduce efficiently if the species is to survive. In recent years, much has been made of the concept of successful aging, wherein it is believed that the study of those fortunate elderly who survive into the ranks of the old-old without developing disease will allow us to discover the secretes of preventive gerontology for the middle-aged and the young-old.89 However, perusal of the pages of the Journal in the last 2 years suggests that most geriatricians spend the majority of their time dealing with older individuals who have one or more illnesses and would be more comfortable setting “effective” aging as a goal, as suggested by Curb et al.90 For this reason, we suggest that it will be more profitable for the new geriatrics to focus on coping rather than on successful aging. Specifically, a worthy goal is to foster the ability to cope with the chronic diseases associated with old age and thus maintain a good quality of life. A specific example of coping successfully is the 70-year-old woman who was famous for her ability to make quilts. Unfortunately, she developed arthritis and could no longer crochet. Rather than allowing her disease to she by the of She of become a in years, a positive between the geriatrician and patient can certainly lead to the of many It is our hope that the new geriatrics will make the many of the medical well in only old we hope that our patients will all to one and a we not that this can be because a they It is our that the of the new geriatrics is preventive and that it is the active between the geriatrician and the older patient that will in the patient aging