Science Space
Geriatrics as a response to demographic change in Medicine
Luís Mieiro
Intern of the Complementary Internship in Internal Medicine, Service of Medicine III,
Pulido Valente Hospital, Northern Lisbon Hospital Centre
Collaborator at the Geriatrics University Unit
Independent Assistant of the Subject Introduction to Ageing Sciences, Faculty of Medicine, University of Lisbon
luis.mieiro@gmail.com
Geriatrics as a response to demographic change in Medicine: An Experience at the Geneva University Hospitals
Early in my undergraduate training I became familiar with the approach to elderly patients. As an Erasmus student at the Hôpital Henri Mondor in Paris, I was invited to complement the internships in various medical specialities by working shifts, in the afternoon, at the Emergency Room. At the time, I saw it as an opportunity to strengthen not only my acquired knowledge but also practice the French method of collecting clinical histories. I quickly realised that working in the ER would give me the opportunity of being in contact with all specialities and that this ongoing dialogue would advance me professionally. It was in this context that I came across Geriatrics and became acquainted with its mission and commitment to restore the autonomy of elderly patients, which made it an attractive field in all senses.
Demographic change is a fact that requires no further evidence. Each population census only confirms what we could have predicted 60 years ago. The post-war baby boom allied to the revolution brought about by the discovery of penicillin has led to the current elderly boom which has reversed the demographic pyramid. This was to be expected and many countries adapted quickly to this transformation. It is no coincidence that the birth of Geriatrics as a medical speciality took place in the UK by the hand of Marjorie Warren, who structured the evaluation of elderly patients, and quickly crossed the Channel and the ocean.
I chose Internal Medicine because I could not see myself working in any other speciality, and because I believe in its scope and holistic approach to patients. However, it was precisely in Internal Medicine that I felt limited about how to approach elderly patients. The distance between being an independent patient living at home, to whom an acute episode brings into hospital and lies in a bed, leading to dependence, is very short. This is the type of cure that brings limitation, loss of autonomy and rapid decline of functionality. This daily reality that I refuse to accept allied to the support and enthusiasm of Professor Gorjão Clara, my director at the time, took me to the Hôpital des Trois-Chêne in Geneva for an internship in Geriatrics and to learn not only how to manage normal physiological ageing, but also geriatric pathologies and prevention measures recommended for this population cohort.
Hôpital des Trois-Chêne is the geriatric hospital of the University Hospitals of Geneva and one of the major research centres in geriatrics in the world. As a guest doctor I was asked to be part of care units as any other intern doctor. The hospital has 18 functional units, of which half are geriatric ones, where elderly patients with acute medical condition are admitted without significant loss of their autonomy; the other half are Internal Medicine Rehabilitation units, which admit patients with one or more acute pathologies, or worsened chronic conditions which involve loss of autonomy. Some of the rehabilitation units specialise in more prevalent geriatric pathologies which require intensive approaches,such as: Bone Diseases Unit, the Dementia and Acute Pathology Unit, and the Medical-Psychiatric Integrated Geriatric Unit.
At the beginning of the internship I joined the Bone Diseases Unit, which admitted both patients after surgery and for rehabilitation of fractures, and those who had fallen and had high risk of falling for conservative treatment. All patients need to undergo a Comprehensive Geriatric Assessment, which consists of: Mini-Mental State Examination, Clock Test, Geriatric Depression Scale, Index of Independence in basic and instrumental activities of Daily Living, Mini Nutritional Assessment – Short Form, Timed Up-and-Go Test, Five Times Sit-to-Stand Test, Tinetti Scale for gait and balance and also calculation of risk of fracture according to the FRAX?.The intervention is always personalised and based on the deficits found in each item of the CGA. At the same time, all the medical intercurrences are optimised, allowing the patient to be more involved in his own rehabilitation. For example, a patient suffering from chronic obstructive pulmonary disease and heart failure will not be able to undergo intensive physiotherapy until his morbid condition is as compensated as possible. But even when their chronic diseases are compensated, patients will not gain maximum benefit until their nutritional, vitamin and sensory deficits have been identified and improved, not to mention the implications of cognitive deficit and depression. Of the patients hospitalised in this Unit, I had to identify those who met the criteria to join the programme CHEOPS (French acronym for Falls and Osteoporosis), which is an intensive physiotherapy and occupational therapy programme which aims to restore greatest possible independence in daily activities. Patients are trained in all activities tested by the independence indexes, such as dressing, personal hygiene, transfer, bathing, sphincter control, nourishment, medication management, use of public transportation, shopping and preparing a meal without accidents, among others.
For the second part of my internship, I worked at the unit which admits patients already diagnosed with dementia and who are admitted for acute medical condition. This unit has specialised nurses and intervention strategies appropriate to this type of disease. I had the opportunity to learn various neuropsychological tests and how to clinically evaluate dementia according to the deficits found. It is a fascinating world where the drugs we have available are few and of limited effectiveness but where an intervention focusing on the environment in which the patient is part of effectively prevents complications and provides better quality of life.
I was further invited to analyse all the episodes of physical restraint at the hospital for a period of 15 months and to compare the differences found between the dementia unit and the rest of the hospital. I presented the findings from this work at the 7th Congress of the European Union Geriatric Medicine Society in September this year in Malaga.
In addition to having deepened my knowledge in geriatrics, this experience offered me the opportunity to become familiar with an approach to reality and to understand why some centres are, in fact, of excellence.
Intern of the Complementary Internship in Internal Medicine, Service of Medicine III,
Pulido Valente Hospital, Northern Lisbon Hospital Centre
Collaborator at the Geriatrics University Unit
Independent Assistant of the Subject Introduction to Ageing Sciences, Faculty of Medicine, University of Lisbon
luis.mieiro@gmail.com
Geriatrics as a response to demographic change in Medicine: An Experience at the Geneva University Hospitals
Early in my undergraduate training I became familiar with the approach to elderly patients. As an Erasmus student at the Hôpital Henri Mondor in Paris, I was invited to complement the internships in various medical specialities by working shifts, in the afternoon, at the Emergency Room. At the time, I saw it as an opportunity to strengthen not only my acquired knowledge but also practice the French method of collecting clinical histories. I quickly realised that working in the ER would give me the opportunity of being in contact with all specialities and that this ongoing dialogue would advance me professionally. It was in this context that I came across Geriatrics and became acquainted with its mission and commitment to restore the autonomy of elderly patients, which made it an attractive field in all senses.
Demographic change is a fact that requires no further evidence. Each population census only confirms what we could have predicted 60 years ago. The post-war baby boom allied to the revolution brought about by the discovery of penicillin has led to the current elderly boom which has reversed the demographic pyramid. This was to be expected and many countries adapted quickly to this transformation. It is no coincidence that the birth of Geriatrics as a medical speciality took place in the UK by the hand of Marjorie Warren, who structured the evaluation of elderly patients, and quickly crossed the Channel and the ocean.
I chose Internal Medicine because I could not see myself working in any other speciality, and because I believe in its scope and holistic approach to patients. However, it was precisely in Internal Medicine that I felt limited about how to approach elderly patients. The distance between being an independent patient living at home, to whom an acute episode brings into hospital and lies in a bed, leading to dependence, is very short. This is the type of cure that brings limitation, loss of autonomy and rapid decline of functionality. This daily reality that I refuse to accept allied to the support and enthusiasm of Professor Gorjão Clara, my director at the time, took me to the Hôpital des Trois-Chêne in Geneva for an internship in Geriatrics and to learn not only how to manage normal physiological ageing, but also geriatric pathologies and prevention measures recommended for this population cohort.
Hôpital des Trois-Chêne is the geriatric hospital of the University Hospitals of Geneva and one of the major research centres in geriatrics in the world. As a guest doctor I was asked to be part of care units as any other intern doctor. The hospital has 18 functional units, of which half are geriatric ones, where elderly patients with acute medical condition are admitted without significant loss of their autonomy; the other half are Internal Medicine Rehabilitation units, which admit patients with one or more acute pathologies, or worsened chronic conditions which involve loss of autonomy. Some of the rehabilitation units specialise in more prevalent geriatric pathologies which require intensive approaches,such as: Bone Diseases Unit, the Dementia and Acute Pathology Unit, and the Medical-Psychiatric Integrated Geriatric Unit.
At the beginning of the internship I joined the Bone Diseases Unit, which admitted both patients after surgery and for rehabilitation of fractures, and those who had fallen and had high risk of falling for conservative treatment. All patients need to undergo a Comprehensive Geriatric Assessment, which consists of: Mini-Mental State Examination, Clock Test, Geriatric Depression Scale, Index of Independence in basic and instrumental activities of Daily Living, Mini Nutritional Assessment – Short Form, Timed Up-and-Go Test, Five Times Sit-to-Stand Test, Tinetti Scale for gait and balance and also calculation of risk of fracture according to the FRAX?.The intervention is always personalised and based on the deficits found in each item of the CGA. At the same time, all the medical intercurrences are optimised, allowing the patient to be more involved in his own rehabilitation. For example, a patient suffering from chronic obstructive pulmonary disease and heart failure will not be able to undergo intensive physiotherapy until his morbid condition is as compensated as possible. But even when their chronic diseases are compensated, patients will not gain maximum benefit until their nutritional, vitamin and sensory deficits have been identified and improved, not to mention the implications of cognitive deficit and depression. Of the patients hospitalised in this Unit, I had to identify those who met the criteria to join the programme CHEOPS (French acronym for Falls and Osteoporosis), which is an intensive physiotherapy and occupational therapy programme which aims to restore greatest possible independence in daily activities. Patients are trained in all activities tested by the independence indexes, such as dressing, personal hygiene, transfer, bathing, sphincter control, nourishment, medication management, use of public transportation, shopping and preparing a meal without accidents, among others.
For the second part of my internship, I worked at the unit which admits patients already diagnosed with dementia and who are admitted for acute medical condition. This unit has specialised nurses and intervention strategies appropriate to this type of disease. I had the opportunity to learn various neuropsychological tests and how to clinically evaluate dementia according to the deficits found. It is a fascinating world where the drugs we have available are few and of limited effectiveness but where an intervention focusing on the environment in which the patient is part of effectively prevents complications and provides better quality of life.
I was further invited to analyse all the episodes of physical restraint at the hospital for a period of 15 months and to compare the differences found between the dementia unit and the rest of the hospital. I presented the findings from this work at the 7th Congress of the European Union Geriatric Medicine Society in September this year in Malaga.
In addition to having deepened my knowledge in geriatrics, this experience offered me the opportunity to become familiar with an approach to reality and to understand why some centres are, in fact, of excellence.