Pathy's Principles and Practice of Geriatric Medicine. Группа авторов
of strategies to improve care for these syndromes needs to be developedResearch that evaluates the impact of different models of care against trajectories of physical and cognitive function
Teaching geriatric medicine
The teaching of medical students about the medical care of sick elderly people had long been recommended, but it was not until 1949 that Lord Amulree was appointed to University College Hospital, a London teaching hospital. Further advance had to wait until 1965, when Sir Ferguson Anderson became the first UK Professor of Geriatric Medicine. After this, progress was slow; but by 1998, almost all the London teaching hospitals had a professorial chair in the specialty, and increasing numbers of chairs in geriatric medicine were made in the country as a whole. These academic departments were usually based on an active geriatric unit with good community links. The curricula vary but could include biological and sociological gerontology in addition to clinical geriatric medicine. Postgraduate research courses leading to the degrees of MSc and PhD had been set up. Some universities have a cluster of associated chairs, such as the University of Manchester with two chairs in geriatric medicine and one each in cognitive gerontology, old‐age psychiatry, gerontology, biological gerontology, and social gerontology.
However, research on attitudes of medical students toward older people has shown that they tend to lose their initial interest and empathy for older people as they train and qualify. A survey of their attitudes before qualification showed that they had empathy for, and a ‘bedside interest in’, the elderly, which disappeared after graduation when the doctors considered their career prospects.22 Parkhouse and McLaughlin23 found that no doctor who had graduated in 1974 wished to enter geriatric medicine. Lambert et al.24 showed that little had changed in a review of career preferences among newly qualified doctors: preferences for geriatric medicine remained very low at 0.9%, well below general medicine and surgery, although above genetics. Factors blamed included the prejudice of medical teachers against geriatric medicine, poor image/role of the geriatrician, and mediocre working conditions. As a result, recruitment of medical staff into the specialty was poor. The Royal College of Physicians responded in 1972 and 1977 with a range of recommendations, including integration of geriatric medicine with general medicine, appointment of consultant physicians with a special interest in geriatric medicine, and rotation of junior training posts between the two specialties.25,26 The College also introduced the Diploma of Geriatric Medicine in 1986 to encourage general practitioners to gain interest in the care of older people.
Achievements of geriatric medicine
Gerontology: the science of the ageing process
Interest in gerontology in the UK was stimulated by the support of charitable foundations and the enthusiasm of a few individuals. The Nuffield Foundation created a medical and biological Research Committee, which gave grants to Howell for his research, to Dr Alex Comfort to work with Sir Peter Medawar at Birmingham and later at University College London, and to Professor Sir Frederick Bartlett at the University of Cambridge to establish a research unit to investigate the psychological aspects of ageing. The Nuffield and Ciba Foundations supported Vladimir Korenchevsky (1880–1959), a Russian biologist who had studied under Pavlov and Metchnikoff. His enthusiasm for the science of ageing culminated in his becoming director of the Oxford Gerontological Institute. He was a driving force behind the creation of the International Association of Gerontology (IAG). The Ciba Foundation supported the IAG, which held its first meeting in 1950 in Liège, Belgium. The first meeting of the clinical section of the IAG was held in Sunderland in the UK in 1958 and was chaired by Dr Oscar Olbrich. A later meeting was held in Manchester in 1974, which was organised by Professor John Brocklehurst. The Ciba Foundation maintained its interest in old age by establishing a series of special colloquia in London, which were attended by many international experts on ageing, and supported the British Society for the Research in Ageing, which was founded by Korenchevsky.
As the new‐style treatment methods were applied to the previously neglected chronic sick, clear evidence emerged of its effectiveness, particularly in hospitals. Official health data sources, such as Hospital In Patient Enquiry (HIPE) data collection, the Office of Health Economics and Health and Personal Social Services Statistics for England, showed that the number of deaths and discharges of elderly people and patient turnover from geriatric wards steadily increased while the average and median lengths of stay decreased. In 1980, the Chief Medical Officer for England and Wales was able to report ‘the average length of stay for patients in hospital departments of geriatric medicine is steadily diminishing – more so than in any other hospital specialty. Only 10% remain in hospital for more than 6 months; the median length of stay is only 21.7 days’.27 Progress was such that in 1984, the Nuffield Provincial Hospital Trust was able to comment, ‘It [geriatric medicine] has established its expertise and has had notable success in developing and raising the standards of services for the old’.28 Concomitant with these developments, individual geriatricians began to create differing styles of practice: whereas some did not take emergency admissions, others took increasing numbers of acutely ill patients, and still others reintegrated with general medicine, taking part in unselected acute medical intake and joint ward rounds with their general physician colleagues.
Problem areas
The birth of geriatric medicine in the UK was hampered by the indifference of the medical profession to elderly patients for many reasons. The care of the aged and infirm lacked the dramatic appeal of acute illness in the young. Physicians questioned why elderly people should be put through extensive rehabilitation when they had only a few years to live. Complete recovery was rarely possible, and the result was often disproportionate to the effort required. Chronic sick patients were often accommodated in poorly equipped and staffed hospitals. General physicians feared ‘bed blocking’ if they admitted elderly patients, appeared uninterested in deciding what was normal or abnormal in this age group and in learning what treatment could achieve, were displeased at the diversion of resources from general medicine to geriatric medicine, and were unenthusiastic about the considerable social/nonmedical components of geriatric medicine. Geriatricians were viewed as ‘second‐rate’ physicians.
Another concern was the quality of care given to older people in hospitals. This culminated in the publication in 1967 of Sans Everything: a Case to Answer, which alleged inappropriate care in hospitals for the elderly and mentally ill. Official investigations found that the complaints were inaccurate, vague, lacking in substance, misinterpretations, or over‐emotional.29 Following yet another allegation of improper care in a unit for the mentally subnormal in 1967, the Secretary of State for Health created the Hospital Advisory Service (HAS) in 1969, which was to act as his ‘eyes and ears’. It was to be responsible only to him and was to be independent of the Department of Health. Visits to hospitals for the elderly and mentally ill started in 1970 and were carried out by teams of ‘in‐post’ professionals: consultant geriatricians or psychiatrists, senior nurses, paramedical staff, administrators, and later social workers. It is best considered as a form of ‘peer review’. Later its remit was extended to cover community services, at which time it was renamed the Health Advisory Service.
The development of specialist service for the elderly mentally ill lagged behind that of the physically ill. Not infrequently, these patients were inappropriately admitted to geriatric wards, where staff had limited experience in managing them. Sometimes they were admitted to large general mental hospitals where the general psychiatrists did not welcome them. The Ministry was aware of the problems presented by these patients and published advisory documents.30,31 Eventually, guidelines were introduced to ensure admission to an appropriate ward: assessment by a multidisciplinary team was recommended. Joint assessment units with input from the local authority, psychiatrists, and the geriatrician were set up, although they tended to silt up owing to the failure to move the patients on to suitable wards or accommodation. Psychogeriatric day hospitals were opened, which provided a useful community function. Local authority residential homes were encouraged to take more mentally ill patients. However, it was not until the 1970s that consultant psychogeriatricians were appointed.