Gerontology is essential to the identity of geriatric medicine
The concept of the preeminence of multidimensional functional status in health care, one of the first achievements of geriatric medicine, has been endorsed by diverse sources, and is now a cultural patrimony of medicine. One of the main goals of geriatric medicine is to allow older people to remain as independent as possible for as long as possible. The integrated research of geriatricians and gerontologists has been at the forefront of the development, testing, and application of tools to assess functional status, including activities of daily living, gait and mobility, cognition, psychological status, depression, and social support.
Although geriatric medicine is recognized in most European countries, in some of them, it is not yet established as an independent specialty, and in some others, it is a subspecialty of another specialty, mainly internal medicine. The standard European training requirements for a specialist in internal medicine, according to the European Union of Medical Specialists (UEMS), indicate “multi-morbidity and ageing” as a primary area of expertise of an internist. The standard states that “all internists should be competent in the diagnosis and management of common and important disorders of internal medicine and related specialties” … “particularly those that affect the ageing population, and common co-morbid conditions affecting patients” . However, gerontological competences are not mentioned in the internal medicine standard requirements.
A cultural gerontological approach is becoming essential for the identity of a specialist in geriatric medicine. Geriatricians need to have internal medicine skills, but the gerontological background is an essential part of the competences needed for the appropriate care of older persons.
A patient requiring hospital admission for an acute condition may need continuity of care in a nursing home and/or home care, where gerontological competences are crucial. Geriatricians are trained to take care of patients in each of these settings. Residents in internal medicine still receive very little medical and gerontological training at sites outside the hospital and traditional ambulatory settings. In acute geriatric care, non-specific presentations of the diseases are common, as well as abnormal physiological responses to acute illness. There is strong evidence that a comprehensive geriatric assessment (CGA) followed by specific treatments is associated with greater independence and reduced need for long-term care .
Geriatric medicine is complex and the treatments need to be individualized, focusing on personalized care, dealing with patients in which social, psychological, and physical problems are more integrated than in other periods of life. Thus, a geriatrician needs to be a proficient internist, while being aware that his/her skills as internist are not sufficient to be a competent geriatrician. Gerontological competences are an essential part of being a geriatrician.
We have traditionally tended to make an unhelpful distinction between a technical, medical geriatric medicine model and a psychosocial, gerontological, compassionate approach, which is probably a cultural mistake. In the respect of the mutual competence and professionality, an integrated geriatric/gerontological vision is essential in order to better assess frail older people, to better treat underlying causes of deterioration, and to guarantee the health promotion and the best care for older people.
Geriatricians need to understand that a gerontological humanistic approach is not only a compassionate personal care, but it is essential to develop strategies to maximize strength, vigour, and physical well-being, as well as to preserve cognitive and functional independence. On the other side, gerontologists need to acknowledge the possible role of disease and related functional loss on the social and psychological trajectories of ageing and age-related functional decline. A gerontological approach also includes to balance the focus on what the patient has lost to incorporate and evaluate the resilience potentialities of the older persons. Understanding this balance is key to discern counterintuitive gerontological insights and to improve the cure of diseases.
Resilience is not generally considered in ordinary clinical care, also because the tools for the assessment of resilience in our patients are lacking, and classical medical treatments are mainly focused on active disease elimination, and much less on supporting resilience. The spectrum from robustness to frailty reflects the amount of physiological potential one has to react to stressors, while physical and psychological resilience refers to the fruition of that potential . Measures to increase resilience, to promote active and healthy ageing need to become an essential part of a geriatrician’s background, and may help to shift the perception of geriatric medicine as a new model of medicine related to wellness of older people. Understanding the complex and different ways in which older persons respond to illness and adversity is also part of our medical art. To understand and acknowledge the interindividual variability, which is one of the hallmarks of ageing, is a major challenge in geriatric medicine. While specific specialties guidelines often do not apply to geriatric multimorbid patients, older people, instead of being assured of age-adjusted, effective services that account for the complexity of age-related syndromes and frailty, are still frequently treated through practices that focus on single-organ diseases.
A geriatrician with a strong gerontological background needs not only to provide treatment for the age-related disorders, but also to play a supportive and educational role in the prevention of new diseases and likely complications of the ageing-related diseases . This would include educational support for diet, exercise, and cognitive therapies, in an integrated and coordinated work with nurses, social workers, psychologists, physiotherapists, and caregivers to allow a continuity of care for the older patient.
A gerontological approach may also help to fight ageism as discrimination against older people due to negative and inaccurate stereotypes. Among the challenges of geriatric patients, the ageistic restricted access to investigations and therapies that may benefit people of all ages, and the failure to incorporate gerontological principles into everyday care are key barriers to the provision of gerontologically adjusted health care . Both, a negative perception of ageing as well as a too idealistic representation of successful and healthy ageing, do not help to incorporate into clinical practice the consideration of vulnerability in old age while dealing with older people with varying states of physical and cognitive disability. Cultural gerontology provides useful tools for better understanding the complex integration of resilience and richness with age-related vulnerability and frailty, and the meaning and individual experience of ageing .
A cultural gerontological approach in geriatric medicine means not only to cure the disease and/or increase the ability of our patients to perform activities of daily living, but also having attention for their quality and satisfaction of life, their joys, their passions, their creativity, their spirituality, their goals and purpose in life. All these aspects, not commonly considered by traditional medicine, are instead well connected to healthy ageing and longevity. Geriatricians need to be equipped with the complexities of dealing with losses, death and dying but also with the richness, gains, and growth in later life. Ageing is a dynamic process that leads to new abilities and knowledge that we need to understand and consider in our medical work to include medical humanities into the healthcare system . Engagement with the patient is set within a humanistic moral framework that recognizes the older person in front of us as a valuable person, respecting his/her dignity and values, in every situation including psychosocial perspectives, and accomplishing a patient-centred, humanistic care. This skill is also crucial to the geriatrician’s identity that needs to be highly proficient and attuned to the situation in a way, which is shaped by the patient’s responses. It is necessary that geriatricians and patients work together to define the goals of care and discuss individual preferences. Cultural and ethnic backgrounds, values, and personal preferences should be included in the project of care for a successful management of chronic conditions, and are fundamental to appropriate clinical decision making. Geriatricians are daily confronted with complex individuals who may be experiencing significant anxiety, vulnerability, and fear because of some real or imagined diseases or illness. Understanding and compassion are a necessary element in geriatric medical practice.
Geriatric medicine is an “art” that needs to value the human being who is experiencing the symptoms, and understand what that experience is like for this particular person, to ensure that the best and more accurate prescription is also the more acceptable and likely to be complied with. A humanistic approach, giving the patient as many opportunities as possible to exercise freedom of choice, to express opinions, to make decisions, to talk while the doctor really listens, is one of the missions and the cores of geriatric medicine.
Cultural and social gerontology also takes inspiration from arts and humanities to help improving the relationship between the geriatrician and the patient. The crucial importance of integrating social and cultural gerontology into the basic knowledge and practice of the geriatricians is still underestimated. Further developing the medical humanities in geriatric medicine represents an important enrichment of the geriatrician’s profession [6, 7].
Environmental gerontology and what we may call “ecogerontology” should also be part of a geriatrician’s background because of the cumulative recognition of the importance of guarantee safe and beneficial settings (home, hospital, long staying institutions, and/or in the community), where old people live or are temporarily admitted. Environment is also central to understand how a current residential setting influences its occupants’ emotional responses, behaviours, successful adaptations, and overall quality of life. A favourable setting is important to help older adults to maintain or recuperate independence and warrant the continuity of care. Geriatricians together with architects, environmental designers, occupational therapists, and policy makers should collaborate to create settings for older persons that better fit their changing lifestyles and abilities.
An increasing concern for geriatricians is to guarantee safety to older people who wish to continue living at their homes. Politicians and policy makers should also be aware of the importance of creating older age-friendly environments and more accessible, barrier-free livingtowns, with parks and gardens, helping older people to cope with a decline in their functional abilities to carry out everyday activities . A cultural change is needed to improve public health, embracing the importance of promoting a healthy lifestyle to favour an active and healthy ageing. This cultural change requires strong social support in the form of policies, medical education, public health actions, and urban planning.
In conclusion, the modern geriatric medicine requires a distinctive attitude with strong clinical and gerontological competences, a comprehensive integrated multidimensional approach, studying and finding ways to treat not just the physical, but also the mental, emotional, and social problems of the ageing patients. Compassion and respect are essential to the art of being geriatrician. Cultural and social gerontology should be integrated into training and continuing professional development in geriatric medicine, and in the clinical practice. Geriatricians must articulate key elements of modern care of older people, such as resilience, frailty and comprehensive geriatric/gerontological assessment, to further engage older people, in seeking a more gerontologically attuned care.
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Conflict of interest
The authors declare that they have no conflict of interest.
This article does not contain any studies with human participants or animals performed by any of the authors.
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- 1.Training Requirements for the Specialty of Internal Medicine. European Standards of Postgraduate Medical Specialist Training (2016) https://www.uems.eu/__data/assets/pdf_file/0017/44450/UEMS-2016.13-European-Training-Requirements-Internal-Medicine.pdf. Assessed 19 Aug 2019