Health Feb 2007
Health April 2007
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Senior Health, Geriatrics
Geriatrics is the branch of medicine that focuses on health promotion and the prevention and treatment of disease and disability in later life. The term itself can be distinguished from gerontology, which is the study of the aging process itself. The term comes from the Greek "geron" meaning "old man" and "iatros" meaning "healer". It is cognate with Jara in Sanskrit which also means old
Scope
In the United States, geriatricians are primary care physicians who are board-certified in either family practice or internal medicine and have also acquired the additional training necessary to obtain the Certificate of Added Qualifications (CAQ) in geriatric medicine.
In the United Kingdom, most geriatricians are hospital physicians, while some focus on community geriatrics. While originally a distinct clinical specialty, it has been integrated as a specialism of general medicine since the late 1970s.[1] Most geriatricians are therefore accredited for both. Specialized geriatrics services include orthogeriatrics (close cooperation with orthopedic surgery and a focus on osteoporosis and rehabilitation), psychogeriatrics (focus on dementia, depression and other conditions common in the elderly), and rehabilitation.
Rehabilitation may also take in intermediate care, where patients are referred by a hospital or family doctor, when there is a requirement to provide hospital based short term intensive physical therapy aimed at the recovery of musculoskeletal function, particularly recovery from joint, tendon, or ligament repair and, or, physical medicine and rehabilitation care when elderly patients get out of synch with their medication resulting in a deterioration of their personal health which reduces their ability to live independently.
Current Trends
Perhaps the most pressing issue facing geriatrics is the treatment and prevention of delirium. This is a condition in which hospitalized elderly patients become confused and disoriented when confronted with the uncertainty and confusion of a hospital stay. The health of the patient will decline as a result of dilerium and can increase the length of hospitalization and lead to other health complications. The treatment of delirium involves keeping the patient mentally stimulated and oriented to reality, as well as providing specialized care in order to ensure that their needs are being met. The Hospital Elder Life Program, HELP, is a system that was created at Yale New Haven Hospital and has been introduced to several hospitals. The goal of the program is to prevent delirium and thus improve the quality of care provided to the elderly. Yale New Haven Hospital has since developed HELP into the more comprehensive Elder Horizons Program, whose goals in addition to preventing delirium include maintenance of mobility and of functional and cognitive states.
Pharmacology
Pharmacological constitution and regimen for older humans is an important topic, one which is related to changing and differing physiological and psychological processes and requirements. In situations of pharmacological necessity and related administration, several factors are involved. Some of these considerations include drug interactions, treatment patterns and medication management.
Certain physiological aspects of aging and drug effects include changes in the gastrointestinal system, oral protective reflexes (dryness of the mouth caused by diminished function of the salivary glands), delayed esophageal emptying, altered gastric pH and differing gastric emptying rates, and possible slower transit times. Oral and esophageal changes, while perhaps not having a direct effect on absorption, “may affect oral administration of certain dosage forms” (Gidal 2006). Instance of reduced intestinal function may actually “increase the overall extent of absorption, and, hence, systemic drug exposure” (Gidal 2006), and emptying of solids and liquids may be delayed. Eating small meals throughout the day may result in lower stomach pH only in the morning hours, which may in turn affect drugs that “may display pH-dissolution and/or activation profiles” (Gidal 2006). Delayed gastric emptying may restrict speed of absorption, and may alternatively also facilitate dissolution and subsequent increased absorption. Age-related changes in the intestine, such as manometric patterns (patterns in liquid level and effected pressure), may also affect transit times and related drug absorption process.
Another area of importance is the potential for improper administration and usage of potentially inappropriate medications (PIM), and possibility of errors which result in dangerous drug interactions (DDI). Research done on home/community health care found that “nearly 1 of 3 medical regimens contained a potential medication error” (Choi et al, 2006). The medications found most to be inappropriately prescribed include tricyclic antidepressants, antihistamines, urinary antispasmodics, narcotic analgesics, long-acting benzodiazepines, and muscle relaxants. Occurrence of statistically significant PIM was 31%, with DDI at 10%. The study showed that polypharmacy was a predictive factor in both PIM and DDI, in comparison to those receiving between and 1 to 3 medications, with instance increasing with the number of medications. Concurrently, the study noted the importance of polypharmacy increasing since a similar study done in 1996-1998. Factors that could have possible affected the study is that it was centered in a general Midwestern area, as well as demographics on prescribing physicians (Cannon et al, 2006).
One other important consideration is that of elderly persons (particularly those experiencing substantial problems of memory loss or other types of cognitive impairment) being able to adequately monitor and adhere to their own scheduled pharmacological administration. A study done by Hutchinson, Jones, West & Wei (2006), found that 25% of participants studied admitted to skipping doses or cutting them in half. Self-reported noncompliance with adherence to medication schedule was reported by a striking one-third of the participants. Further development of methods which might possibly help monitor and regulate dosage administration and scheduling is an area that deserves further attention.
Links:
American Board Family Medicine
Edited by Norman Bliss