Navigation

Clinics In Geriatric Medicine

Introduction

Most physicians practising in geriatric medicine manage, in varying degrees, acute illness, rehabilitation and continuing care. In hospitals where geriatric medicine is involved predominantly in rehabilitation and continuing care, most acutely ill elderly people are treated by general physicians. This was the case in most hospitals throughout the country until the 1970s. Where, in this `traditional' model of service, the definition of what constituted a `geriatric' admission was left to general physicians, Departments of Geriatric Medicine found difficulty in obtaining adequate resources and were seen as providing a second-rate service to patients not wanted by other hospital departments. Age-defined admission policies were introduced in an attempt to resolve these difficulties [1-3].

An age-defined service

In an age-defined service elderly patients above a defined age attending Accident and Emergency or referred by their general practitioner are admitted under the care of a physician specializing in geriatric medicine. This policy usually will be applied flexibly, allowing admission under an appropriate specialist if that is in the best interest of the patient. A significant proportion of older people admitted to hospital with an acute medical illness will be unable to be discharged home immediately that acute condition has resolved. Delay in discharge may occur because of persistent ill health, functional and psycho-social problems.

Where an age-defined service operates these patients are identified and have immediate access to the care of the multidisciplinary team. The involvement of a `geriatric evaluation unit' involving a multidisciplinary team of doctors, nurses, therapists and social workers has been shown to be beneficial in this situation [4]. In a system where general medicine deals with acute illness in old age, delays may occur whilst a patient is referred to the geriatrician and further delay occurs while transfer to one of his beds is awaited.

Facilities required for an age-defined service

Physicians operating an age-defined service require adequate resources. Where resources in terms of bed numbers are limited they will be forced to select or have selected for them those patients who appear appropriate for `geriatric care'. Once their beds are filled all acute admissions will be managed in general medical beds. This can lead to a situation where the geriatric' wards have relatively young patients, recovering from strokes, while acutely confused people of very advanced age are being managed on acute medical wards by consultants and doctors in training who, understandably, have other priorities and sometimes without access to multidisciplinary care teams.

In order for an age-defined service to succeed, the unit must be able to take all acute admissions over a specified age and have access to the same resources as the acute general medical service. Thus access to hospital for medical conditions in ill people of whatever age is guaranteed (provided the hospital itself has adequate resources) and the patient can be re-admitted under the same consultant providing continuity of care. An age-defined service for the elderly run by consultant geriatricians cannot be regarded by managers as a cheap option since medical and nursing staffing should be similar to that found in departments of general medicine.

The advantages and disadvantages of an age-defined service

The claimed advantages of the age-defined admissions system include: 1. The GP's have a simple referral system; 2. Geriatricians can concentrate on older people

without the distraction of younger ones; 3. The defined roles and responsibilities for the

geriatric services facilitate planning. The suggested disadvantages include: 1. Patients are allocated to separate departments on the

basis of age rather than need; 2. Rotational training schemes for junior medical staff

may be less easy to establish; 3. There is a potential wasteful duplication of

resources; 4. The geriatric service may be less well resourced than

the parallel general medical service.

What age for an age-defined policy?

The age of definition will depend on resources available to a department and, to some extent, on the nature of the local population. O'Brien et al. [1] in Oldham and Pathy [5] in Cardiff were able to offer admission facilities to patients with medical problems over the age of 65. Such a policy would not be appropriate for a retirement area such as the South Coast of England where the over-65s account for as much as one-third of the total population. In the Crawley and Horsham Health Service an over-65-years age-defined policy was operated until 1991 when the age limit was raised to 70 to reduce the overflow into general medical wards. The service is run by two consultants with a senior registrar, registrar, SHO and house-physician. The consultants and doctors in training also share `on-call' with the department of general medicine which has similar staffing levels so that all doctors are working a 1:4 rota. Patients are admitted to any of the medical wards according to bed availability, but one of the wards is staffed by nurses with particular expertise at managing the very disabled and takes these patients if possible.

Hodkinson and Jefferys [6] suggested that the age at which patients are likely to require the skills of a `geriatric service' is nearer to 80 than 70, since it is in their late 70s that patients are likely to present with multi-system disease rather than disorders of a single organ. However, there are potential advantages to hospital staff and patients of having a younger age limit. Involvement with patients with disorders such as acute myocardial infarction or gastro-intestinal bleeding allows the physician to maintain medical skills acquired in training. The presence of a geriatrician on the intensive care/coronary care unit helps guarantee access for older people to these facilities. Many units deny older people access to coronary care units and thrombolytic therapy based on age [7] and also to intensive care units, despite evidence that survival depends on the severity of the presenting illness rather than age alone [8].

This involvement with acute illness is valuable in training both doctors and nurses. They see seriously ill older people treated actively and, in many cases, returning to independence, having looked after them throughout their hospital admission. As a result the department is perceived as being successful with a beneficial effect on the morale of staff and patients.

Conclusion

An age-defined service is an effective way of delivering hospital medical care to older people. It allows the patient ready access to appropriate acute medical services and the time and the facilities required to allow their return to independence.

It provides a satisfying mode of practice for doctors and other health-care workers. It identifies also who is responsible for the provision of a service to a defined population thus facilitating assessment of the quality of their care.

References

[1.] O'Brien TD, Joshi DM, Warren EW. No apology for geriatrics. Br Med J 1973;4:277-80. [2.] Bagnall WE, Datta SR, Knox J, Horrocks P. Geriatric medicine in Hull: a comprehensive service. Br Med J 1977;2:102-4. [3.] Dasgupta PK. Developing an active geriatric service in Scunthorpe. Public Health (Lond) 1980;94:155-60. [4.] Rubenstein LZ, Josephson KR, Wieland GD, English PA, Sayre JA, Kane RL. Effectiveness of a geriatric evaluation unit. N Engl J Med 1984;311:1664-70. [5.] Pathy J. Operational policies. In: Coakley D, ed. Establishing a geriatric service. London: Croom Heim, 1982. [6.] Hodkinson HM, Jefferys PM. Making hospital geriatrics work. Br Med J 1972;4:536-9. [7.] Dudley NH, Burns E. The influence of age on policies for admission and thrombolysis in coronary care units in the United Kingdom. Age Ageing 1992;21:95-8. [8.] Bellamy PE, Oye RK. Admitting elderly patients to the I.C.U. Geriatrics 1987;42(Mar):61-8.

COPYRIGHT 1994 Oxford University Press
COPYRIGHT 2004 Gale Group