The Choices Facing Geriatrics

These words of Browning suggest that to achieve anything worthwhile, a person should attempt even those things that may turn out to be impossible. Canadian geriatricians have tried to abide by this dictate, but it has not always worked out as well as hoped. We have spread ourselves thinly in our efforts to both improve the lives of older persons and fulfill our academic responsibilities. As a relatively new discipline, we have striven to respond to requests from colleagues in other fields, academic leaders, health-care managers, and administrators. Our efforts at multi-tasking have likely made us less, not more effective.(1) History tells us that “to do two things at once is to do neither.”(2) With our small and currently static number, we have no recourse other than to focus our finite time and energy on what is truly important and where we can, in collaboration with colleagues from medical fields and health professions, be most effective. But what should that be? Many both within and outside our field argue that we should first attend to the care of hospitalized older persons for four primary reasons. Firstly, older Canadians disproportionally use this expensive and limited resource. In 2003–2003, the approximately 13% of the Canadian population 65 years and older accounted for one-third of all acute care hospitalizations and almost half of total hospital bed-days.(3) There is every reason to believe that these proportions will increase in the coming years. Seniors admitted to hospital are more likely to have multiple morbidities, impaired cognition, and higher levels of disability (including mobility) than younger adults.(4-7) They present unique challenges (multiple morbidity and, in its shadow, polypharmacy, cognitive impairment, and disability) that play into our particular areas of competency. Secondly, a hospital admission is a dangerous time for seniors. An acute care stay can have long-lasting deleterious effects on the functional abilities of older patients.(8,9) There is a growing body of literature attesting to the ability of geriatric programs to mitigate this danger.(10,11) Thirdly, hospitals are still the site where the lion’s share of clinical teaching in internal medicine takes place. It is where we can share our expertise with students and residents, as well as excite them about geriatrics. All this speaks to the need for us to be there. The final force pulling us into acute care is not directly related to either the care of older patients or our academic mission. Departments of Internal Medicine and hospitals need physicians to care for unattached patients whose problems do not qualify them for care by other hospital services. This leads to the ticklish question of finances. Especially in jurisdictions without an alternative payment system, sessional fees, or preferential billing codes, rotations on a busy hospital service can generate enough income to allow geriatricians to support the less remunerative aspects of their work. There is also, we would argue, a need for us to have a presence as medical directors and consultants in long-term care institutions and supportive housing settings where medical care can be suboptimal. Poor adherence to treatment guidelines,(12) limited recognition of treatable conditions such as depression,(13) and inappropriate pharmacotherapy(14) are some of the problems prevalent in these facilities. While geriatricians as medical directors and consultants can help address these issues, to deal effectively with them would require organizational changes, better funding, and improvements in the quantity, mix, and training of staff. These settings are being increasingly used to provide sub-acute and palliative care. We feel these services would benefit from the active involvement of consultants in geriatrics and linkages with specialized geriatric services. And then there is the community, where the majority of frail and/or disabled older persons reside. Increasing emphasis on community-based care is surely the future of our health-care system. There is growing evidence that complex community-based interventions can help older patients live safely and independently for longer,(15) while the utility of targeted home visits and ambulatory consultations is confirmed by experience in this country and others.(16,17) We need to The Choices Facing Geriatrics