Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
Geriatrics : Ancient History
Though the need to care for frail older adults has always been an important responsibility of nearly all cultures, interest in and recognition of the special needs of older adults is relatively new in Western medicine (Brubaker JK, 2008).
Doctors and philosophers of antiquity commented on age associated illness.
Hippocrates (460 BC–377 BC) noted conditions common in later life.
Aristotle (384 BC–322 BC) offered a theory of aging based on loss of heat (Grimley-Evans J, 1997).
Galen (c.129–200 AD) consolidated the Hippocratic and Aristotelian theories of ageing into one (Ritch A, 2012).
He considered that disease was contrary to nature, and as ageing was a natural and unavoidable process, it could not be considered pathological. However he did not believe it was completely healthy, but rather a state peculiar to itself, between health and illness. In this regard, he was certainly ahead of his time (Parkin TG, 2003).
Galen developed the concept of gerocomy, namely the care of the aged, in his treatise De Sanitate Tuenda.
His fifth book on dietetics focused almost exclusively on the care of older people (Powell O, 2007).
Despite Galen's teaching, including his theories of ageing which remained authoritative until the Renaissance, the view that old age was an illness remained prevalent in nonmedical literature (Minois G, 1989).
The writer of Psalms 92:14 promised, “They shall bear fruit even in old age, they shall be ever fresh and fragrant.”
Special considerations of elderly health is found in Greek and Byzantine medicine (324-1453 AD) (Lascartos J, 2000).
Galen's system of medicine was consolidated within Islamic medicine by Ibn Sina (980–1037AD), also known as Avicenna, one of the most outstanding and influential Persian physicians and philosophers
(Gorji A, 2001).
Avicenna's Canon of Medicine (c. 1012) is the most famous work among his more than 450 treaties on medicine.
It has been described as ‘Galenic in its anatomy and Hippocratic in its theory’, and includes definitions of ageing, as well as chapters on physiology, pathology, prevention and therapeutics
(Gruner OC, 1970).
Interest in old age and ageing increased from the late Renaissance period into the sixteenth century.
Gabriele Zerbi’s Gerontocomia revived Galen’s concept of gerocomy (Zerbi G, 1489).
It concentrated on hygiene in older people, accepted that the diseases described could not be cured, and differentiated between natural death as a result of the loss of innate heat, and death following illness (Thane P,1993).
Francis Bacon's History, Natural and Experimental, of Life and Death or of the Prolongation of Life (Bacon F, 1623) proposed a scientific program of epidemiological investigations into the longevity of people living in different places and under different conditions (Strahan G, 1996)
Bacon (1561-1626) rejected Galen’s humoral theory, countering it with a new concept of ageing based on ‘spirit, or body pneumatical’ through which the body functioned and which declined in old age as a result of unequal repair to different parts, so that eventually the whole body decayed, leading to natural death.
Medecina Gerocomica: Or the Galenic Art of Preserving Old Men’s Healths, published in 1724 by Sir John Floyer of Lichfield (1649–1734), was considered influential by twentieth-century historians (Floyer J, 1724).
It is the first monograph to be printed initially in English on geriatrics (Grant RL, 1963) and marked the beginning of modern geriatrics (Freeman JY, 1979).
Although still based on the humoral theory, Floyer’s text elaborated on the current state of medical knowledge of older people, suggesting many therapeutic remedies.
The view that old age was itself an illness remained prevalent in the literature well into the eighteenth century, and for some physicians, as late as the twentieth century.
In his doctoral thesis entitled That Senescence Itself is an Illness, published in Germany in 1732, Jakob Hutter reflected the prevailing idea of the times, especially that of his more well-known teachers, Friedrich Hoffman and Hermann Boerhaave (Hutter J, 1732).
His theory of the ageing process postulated that there was a ‘progressive hardening of all fibres of the body,’ which started from youth and resulted in obstruction to the blood supply. As a result of the weakened blood flow, stagnation led to ‘fatal putrefaction’, and thus old age caused death by direct means.
The importance of this theory lay in its emphasis on old age as a medical condition, which paved the way for the later development of geriatrics (Shafer D,2002).
During the 18th and 19th centuries several physicians wrote specifically about the diseases of later life and their treatment.
By the late eighteenth century, it was generally accepted that death in most old people was due either to one illness or several with a cumulative effect (Kondratowitz HJ von, 1991).
Morgagni, in De Sedibus et Causis Morborum published in 1761, was sufficiently astute to point out in his study of anatomy and diseases that many diseases in old age, but especially chronic ones, can remain symptomless for many years (Benjamin A, 1769).
Two hundred years later this concept formed the basis of much clinical research on the unreported medical needs of older people.
Benjamin Rush, an American physician, emphasised that old age was rarely the sole cause of death in his Account of the State of the Body and Mind in Old Age, with Observations on its Diseases and Remedies, published in the USA in 1793 (Rush B, 1793).
Rush struck one of the last blows at the idea that old age is itself a disease (Grant RL, 1963)
However, it was another hundred years before the concept of ‘old age infirmity’ ended and Rosin wrote ‘old-age infirmity is no illness (Kondratowitz HJ von, 1991).
Charles Durand-Fardel’s practical treatise, Traité Clinique et Pratique des Maladies des Vieillards, published in 1854, has been referred to as both pioneering and a masterpiece (Durand-Fardel M, 1854).
It covered the whole field of disease in old age, while attempting to link pathology with accurate diagnosis (Zeman FD, 1979).
Charcot’s lectures on the medicine of old age aroused scientific interest in the field and became available in English translation in 1882 (Charcot JM, 1882).
He recognised that specific diseases existed in older people, such as osteomalacia and brain atrophy, that the ‘gravest disorders manifest themselves by slightly marked symptoms’ and that conditions occurring at any time of life ‘present special characteristics’ in later life. Charcot pioneered the use of the rectal thermometer as he was aware that peripheral temperature measurement did not reflect core temperature accurately in older people.
In his first lecture of the series, he promoted the idea of a specialty: ‘The importance of a special study of the diseases of old age cannot be contested at this day’ (Charcot JM, 1881)
France was the world leader in this area at the time.
The basis for much of the research were the institutions known as ‘hospices’.
They were set up by royal edict in the mid-seventeenth century to serve a range of functions, including prisons, asylums for the insane and residential homes for older people.
They were transformed into primarily medical institutions after the French Revolution of 1789.
They were not reserved exclusively for older patients, but admitted those of all ages with chronic disability, including children.
The Salpêtrière, which admitted only women, became the greatest single centre for geriatric research at that time, partly because of its association with Charcot.
In the mid 1850s however, only 5–12% of physicians declared a specialty designation. The most common were surgical, namely general surgery, dentistry, obstetrics, orthopaedic surgery and ophthalmology, but psychiatry was also popular (Ackerknecht EH, 1967).
By1884, the number of specialists had increased by 150% and the number of medical specialties expanded to include dermatology, venereology, neurology and sub-specialties such as gastroenterology, respiratory medicine and cardiology (Weisz G, 1994).
Despite the existence of specialty hospitals for treating older people, geriatric medicine was not a recognised discipline.
There are three possible reasons for this: the lack of specific therapeutic or diagnostic procedures, the inevitability and incurability of diseases of old age, and the fact that the elderly generated little public interest (Weisz G, 2006).
Research failed to progress, mainly because it had been pathologically based.
Few therapeutic possibilities existed to manage disease in old age and physicians at that time did not interact with older patients to any great extent because they only had contact with the small proportion who were admitted to the hospices.
As medical interest in older people declined, geriatric medicine did not become a specialty in France until after 1950 (Stearns PN, 1977).
The most notable publication of the nineteenth century was A Practical Treatise on the Domestic Management and Most Important Diseases of Advanced Life by George Day.
In his book he complained that the diseases of old age had been neglected by physicians in the previous fifty years (Day GE, 1848).
One of the few papers on disease in old age published in the English literature at the time was A Practical Treatise on the Diseases and Infirmities of Advanced Life by Daniel Maclachlan.
He drew attention to the difficulty of diagnosis in older people where several diseases often coexisted.
Maclachlan suggested caution be taken when prescribing drugs for older patients, and recommended that modification of the dose was necessary in frailer patients as drug action became less certain as old age advanced.
Maclachlan concluded by stating that the medicine of old age was an important branch of medical knowledge (Maclachlan D, 1863).
The word “geriatrics” was invented by Ignatz L Nascher, a Vienna-born immigrant to the United States in 1909 (Nascher IL, 1909).
Nascher’s initiative provided a stimulus for social and biological research on aging, but clinical geriatrics did not flourish in the United States.
The American Geriatrics Society was founded in 1942, but as a thriving and influential medical specialty geriatric medicine was essentially a product of the British NHS (Achenbaum WA, 1995).
From the years following the founding of the United States up to the period before World War II, the majority of ongoing care of the elderly in the United States and Great Britain was provided in three sites:
- homes of those older adults or the homes of family members
- grouped with the poor (poor homes or work farms)
- grouped with the mentally ill (asylums).
Placement within these sites was determined primarily by economics rather than by medical illness or functional status.
Physicians made little distinction between the care of older patients and treatment of any other adult, other than to spend less time in diagnosis and therapy of older patients, especially if those patients were suffering from chronic diseases.
The achievement of longevity was unusual. Surviving to retirement slowly became more common throughout the twentieth century (Forciea MA, 2008).
Along with increases in longevity during the twentieth century, several other developments contributed to changes in the care of older adults:
- increased professionalism in medicine and nursing
- standards in training of physicians and nurses
- increasing standards of research into clinical problems of older patients
- large numbers of WWI wounded veterans who needed chronic care were forced into existing institutions
- large numbers of conscientious objectors assigned to chronic care hospitals began to write about
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