Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
Geriatrics : Modern History - U.S.A.
To the beginning of the 21st century
The United States is facing a crisis in physician expertise to care for its aging population.
With the number of elderly increasing from 3.1 million in the 1900s to 70 million by 2030, training health professionals in geriatric care is vital to ensure that older persons receive high quality medical care.
Over the last 25 years progress has been made in developing medical education, research, and clinical programs in geriatric medicine.
The history of geriatric medicine prior to 1975 in Great Britain and the U.S. has been described (Libow LS, 1990).
Early work by Ignatz Leo Nascher in the U.S. and several pioneering British geriatricians, led by Marjorie Warren, established the foundations for modern geriatric medicine. Dr. Nascher chose the term “geriatrics” as a name parallel to “pediatrics.”
Dr. Warren established a Department for the Aged in London’s West Middlesex Hospital in 1935. These pioneers recognized that illness can present and evolve differently in the very old and that new approaches to care and treatment were required.
E.V. Cowdry edited the proceedings of an early U.S. conference on the problems of aging. This book, Problems of Ageing; biological and medical aspects, was published with funding from the Josiah Macy, Jr. Foundation in 1939. It significantly increased academic interest in gerontology and geriatrics (Cowdry EV, 1939).
After the Second World War, the British established geriatric medicine as a component of its new National Health Service (NHS). The NHS founders established several geriatric specialist positions at major teaching hospitals, and these leaders wrote the early textbooks for geriatric medicine (Cassel CK, 1995).
In 1941, Nathan Wetherell Shock, PhD, became the first chief of the newly formed Unit on Gerontology of the Division of Physiology of the five-year-old National Institute of Health. He later built the Gerontology Research Center of the National Institute on Aging and was the catalyst for the emergence of aging research in the United States.
Dr. Shock insisted that aging was not a disease and focused research on two questions: “What are the underlying biological factors that produce what we perceive as aging?” and “What are the mechanisms that produce impaired performance with age?”
In the late 1950s, he and his colleagues began the Baltimore Longitudinal Study of Aging.
The American Geriatrics Society was founded in New York City in 1942 when a group of physicians interested in advancing medical care for older adults met with the intention of forming a specialty society dedicated to geriatric medicine.
Among those physicians were Leo Nascher, Dr. Malford W. Thewlis who was named the first executive secretary, and Dr. Lucien Stark, who became the first AGS president.
Some universities established gerontology programs beginning in the 1950s, but medical school interest in geriatric medicine was quite limited well into the 1980s.
This slow development occurred despite the landmark passage of the Medicare and Medicaid Acts in 1965.
By the mid-1970s British geriatricians had identified and begun to address the challenging clinical syndromes unique to old age, e.g., multiple interrelated diagnoses, adverse events associated with medications, injuries from falls, delirium and dementia, and urinary incontinence.
A commitment of resources to develop the new discipline’s scientific basis was now needed. In the U.S., Robert Butler published Why survive? Being old in America (Butler RN, 1975) and this led a successful effort during 1974 - 1976 to establish the National Institutes of Health’s (NIH) National Institute on Aging (NIA).
This critical event gained the attention of the American academic medical community. NIA’s small earlier annual budgets rapidly grew as an intramural program in Baltimore and extensive extramural programs were developed elsewhere.
By the early 1990s NIA’s annual budget exceeded $300 million and it has more than doubled over the past decade.
Veterans Health Administration
The number of veterans over age 65 was projected to increase from 3 million in 1980 to 9 million in 2000.
The Veterans Health Administration (VHA) began funding the training of geriatric medicine fellows in 1980, and over the next decade trained 275 geriatricians.
The VHA remains the most important source of training funds for geriatricians in the U.S.
The Geriatric Research, Education and Clinical Centers (GRECC) program was another of the VHA’s responses to the growing challenge of caring for the elderly.
The goals of the GRECC program are to advance scientific knowledge regarding medical, psychological and social needs of older veterans, to develop improved and innovative models to provide clinical services for them, and to advance the quality of education in geriatrics and gerontology throughout the VHA health care system.
The GRECCs are affiliated with accredited medical schools that provide education in geriatrics for medical residents, nurses, and allied health care students.
The first GRECC was organized in 1975. Between 1975 and 1980, GRECCs were established at 8 VHA medical centers: Bedford and Brockton/West Roxbury, MA; Little Rock, AR; Minneapolis, MN; Palo Alto, CA; St. Louis, MO; Seattle and American Lake, WA; Sepulveda, CA; and West Los Angeles, CA.
In 1980, Public Law 96-330 authorized the VHA to establish 15 additional GRECCs.
This law also developed a Geriatrics and Gerontology Advisory Committee, charged with evaluating existing and future GRECCs. In 1985, PL 99-166 increased the number of GRECCs from 15 to 25 (Goodwin M, 1994).
Currently there are 21 funded centers.
Developments Resulting from Institute of Medicine Reports
A series of national reports sponsored by the Institute of Medicine (IOM) highlighted the challenges facing the medical profession as the population ages.
The IOM, under the leadership of Paul B. Beeson, MD, published the first of these reports, Aging and Medical Education, in 1978, calling for increased physician training in geriatric medicine (IOM, 1978).
The report recommended that all medical schools and teaching hospitals include curricula on aging for medical students and residents.
These recommendations led to the “Teaching Nursing Home” projects funded by the NIA and the Robert Wood Johnson Foundation in the early 1980s.
The Beeson report also included projections of the future need for geriatric medicine manpower in the U.S.
This careful analysis, published in 1980, estimated that 8,000 geriatricians would be needed by 1990 (Kane R, 1980).
In 1985, the Bureau of Health Professions (BHPr) established the first Geriatric Education Centers. The goals of these multidisciplinary training programs include improving the training of health professionals in geriatrics through curriculum development and educational programs for students and practitioners.
In FY 2001, 45 Geriatric Education Centers were established and 35 were receiving BHPr funding.
The second IOM study written by the Committee on Leadership for Academic Geriatric Medicine was published in the Journal of the American Geriatrics Society in 1987.
This report recommended rapidly developing the capacity to train academic leaders in geriatrics, establishing “centers of excellence”, launching a national campaign to attract medical students, residents, fellows, and practicing physicians into geriatrics, and developing a coordinated approach to public and private commitments of financial resources to support geriatric medicine (IOM, 1987).
In 1991, the IOM published its third report, A National Research Agenda on Aging: Extending Life, Enhancing Life (IOM, 1991).
This report, funded by the Commonwealth Fund and the Pew Charitable Trusts, outlined opportunities for improving health and functioning of older adults through new research.
The IOM emphasized research-training programs’ needs for additional funding.
In 1993, the IOM published its fourth report, Strengthening Training in Geriatrics for Physicians (IOM, 1993), documenting the considerable progress that had been made in the 16 years since the Beeson report was published.
This report was enhanced by information from a background paper prepared for the Committee on Strengthening the Geriatric Content of Medical Education (IOM, 1994).
The fourth report recommended expanding expectations for training primary care physicians in geriatric medicine. It also recommended establishing a new emphasis on providing geriatric medicine training for medical sub-specialists and non-primary care and surgical specialists.
The latter recommendation resulted in important new initiatives led by the American Geriatrics Society and funded by the John A. Hartford Foundation.
A program to integrate geriatric medicine content into the subspecialties of internal medicine, begun in 1994, is being led by William Hazzard, MD.
This program is encouraging the leadership of each medical subspecialty (e.g., cardiology, infectious diseases, nephrology) to integrate new curricula and research activity in aging into their training programs.
A parallel initiative, led by David Solomon, MD and John Burton, MD is engaging 10 surgical and related specialties (anesthesiology, emergency medicine, general surgery, gynecology, ophthalmology, orthopedic surgery, otolaryngology, physical medicine and rehabilitation, thoracic surgery, and urology) in a similar effort to increase recognition of aging in most aspects of medical practice.
The late Dennis Jahnigen, MD was a leading force behind this project, which grew out of his recognition of the importance of including geriatrics training for physicians in all specialties.
Certificate of Added Qualifications
The Beeson Report sidestepped the controversial strategy that was being suggested by some, of developing a new medical specialty of geriatric medicine, independent of internal medicine and family practice.
In Great Britain, geriatric medicine had already been established as a freestanding medical specialty, but many American medical leaders opposed this approach.
Within general internal medicine and family practice, practitioners and academic leaders firmly stated that the care of the older adult was central to their practice.
The 1987 IOM report compromised and stated that geriatric medicine should become a recognized academic discipline within relevant medical specialties.
These recommendations led to an important political decision by the American Boards of Internal Medicine and Family Practice (ABIM and ABFP).
In 1987, with considerable opposition from many of their sister organizations, the ABIM and ABFP requested permission from the American Board of Medical Specialties (ABMS) to jointly develop a Certificate of Added Qualifications (CAQ) in Geriatric Medicine.
The CAQ would certify and recognize academic and practicing geriatricians, but stopped short of developing a new specialty board.
Under this arrangement board certified internists and family physicians would need to maintain their primary board certification to be eligible for the geriatrics CAQ.
This innovative agreement by the ABIM and ABFP resulted in formal certification of geriatric medicine training programs by the ACGME. In 1988, the first jointly sponsored (ABIM/ABFP) geriatric medicine certifying examination was administered.
The ABIM and the ABFP report that since 1988 more than 9,900 family physicians and internists have obtained CAQs in geriatric medicine.
The 1988, 1990, 1992, and 1994 examinations were open to practicing physicians without fellowship training.
Subsequently, entry to the examination required completion of an accredited geriatric medicine fellowship.
The American Board of Psychiatry and Neurology (ABPN) offered the first certifying examination for a CAQ in geriatric psychiatry in 1991.
There have been over 2,500 certificates in geriatric psychiatry awarded.
The American Board of Osteopathic Family Practice (ABOFP) and the American Board of Osteopathic Internal Medicine (ABOIM) began certification in geriatrics in 1991.
Currently, 503 certificates in osteopathic geriatric medicine have been earned.
Centers of Excellence
As the training and certification of geriatricians were gaining credibility, the IOM sponsored a second study as a follow-up to the Beeson report.
This 1987 paper by the IOM Committee on Leadership for Academic Geriatric Medicine (IOM, 1987) documented slow progress toward implementing the educational objectives outlined in the earlier report.
Medical student and resident geriatrics education was still voluntary in most medical schools.
In the mid-1980s fewer than 100 physicians completed geriatric medicine fellowships each year. The 1987 IOM report promoted a Center of Excellence (CoE) strategy, designed to create critical levels of faculty and other resources at selected medical schools.
These academic training centers were to produce the needed number of geriatric medicine faculty for all medical schools.
The CoE program had three central goals:
1) to develop training programs that would attract learners and produce future faculty,
2) to implement research programs that would add to the discipline’s knowledge base and provide research training, and
3) to provide clinical training in a variety of settings.
The model was partially based on the VHA’s GRECCs.
However, as the IOM report pointed out, the GRECCs’ mission did not include training and placing academic faculty.
The CoE strategy was to expand on the GRECCs’ mission in this regard.
With funding from the John A. Hartford Foundation of New York City, the CoE strategy was implemented.
In 1988, the Foundation initiated its first CoE program, the Academic Geriatrics Recruitment Initiative, to address the critical shortage of geriatric faculty members in American medical schools. The program’s purpose was to enhance and increase academic geriatric programs and training, with the goal of increasing the nation’s capacity to provide effective and affordable care to its rapidly growing elderly population.
This project yielded positive results, including producing many scientists, teachers, and clinicians knowledgeable in geriatrics and a higher level of recognition and appreciation for the discipline throughout medical centers, universities, and affiliated clinical service settings.
In 1997, the Foundation’s trustees renewed and expanded the previous CoE concept by increasing the geographic range of funded CoE and expanding training capacity, particularly in dealing with the country’s increasingly diverse elders.
By identifying and funding CoE nationwide, more institutional attention will be brought to the field, and faculty will be able to become the leaders the field.
The American Federation for Aging Research (AFAR) serves as the CoE coordinating center, and its activities include systematization within seven previously funded and 11 new CoE, as well as the seven CoE Designation Award sites.
The CoE program was enhanced in 1991 when Congress gave the NIA additional dollars to establish aging research and education centers across the country.
These centers are named for Claude Denison Pepper (1900-1989), a Florida congressman known nationwide for advocacy for older adults’ rights.
The centers’ primary goal reflects his interest in helping older Americans maintain their independence as long as possible.
The research conducted by the Pepper Older Americans Independence Centers supports this goal by developing ways to delay or even prevent chronic diseases that disable so many older people and cause them to become dependent on others.
As an educational resource, the Pepper Centers are educating and encouraging older adults by sharing free health promotion information that addresses ways to improve their health and better their lives.
Originally, 3 Pepper Centers were funded and in 2001 there were 9 funded centers.
The total budget for these centers increased from $3,860,000 in 1991 to $13,074,000 in 2001.
Alzheimer’s Disease Centers
The NIA began funding Alzheimer’s Disease Centers (ADCs) in 1984 and currently funds 29 centers at major U.S. medical institutions.
Researchers at these centers are working to translate research advances into improved diagnosis and treatment for Alzheimer’s Disease (AD) patients while, at the same time, focusing on the program’s long-term goal of finding a way to cure and possibly prevent AD.
Areas of investigation range from the basic mechanisms of AD to managing symptoms and helping families cope with effects of the disease.
Center staff conduct basic, clinical, and behavioral research, and train scientists and health care providers new to AD research.
Although each center has its own unique area of emphasis, a common goal of the ADCs is to enhance research on AD by providing a network for sharing new ideas and research results.
The National Alzheimer’s Coordinating Center in Seattle, under the direction of Walter Kukull, PhD, coordinates data collection and fosters collaborative research among the ADCs.
Many ADCs have satellite facilities that offer diagnostic and treatment services and collect research data in underserved, rural, and minority communities.
Nathan Shock and Edward R. Roybal Centers
The NIA began the Nathan Shock Centers for Excellence in Basic Biology of Aging in 1995.
The goal of this center grant program is to enhance already well-developed institutional programs in basic research on aging.
Current funded centers are established at Harvard, the University of Texas at San Antonio, the University of Michigan, the University of Washington, and at the Lankenau Medical Research Center/Jefferson Health System in Philadelphia.
The NIA began the Edward R. Roybal Centers (named for the former U.S. congressman from Los Angeles) for Research on Applied Gerontology in 1993.
Funded by the NIA’s Behavioral and Social Research Program, the goal of these centers is to conduct applied research utilizing existing basic knowledge about cognitive and psychosocial aging.
Current funded centers are established at Boston University, Cornell University, the University of Alabama at Birmingham, the University of Illinois at Chicago, the University of Michigan, and the University of Miami.
Two new educational initiatives hold promise for the near future.
The Association of American Medical Colleges (AAMC), with funding from the Hartford Foundation, is supporting 40 U.S. medical schools’ efforts to enhance the quality and quantity of their medical student geriatric medicine curricula.
The central goal of this effort is initiating a required geriatric medicine curriculum for each student in all four years of medical school training.
In addition, the Donald W. Reynolds Foundation of Las Vegas recently funded ten medical schools (approximately $2 million per school over 4 years) to build comprehensive geriatric medical education programs for medical students, residents, and practicing physicians.
The Foundation currently anticipates funding 20 additional schools under this initiative over the next five years, for a total commitment of $60 million.
Efforts are also well underway to develop the next generation of academic leaders.
Research career awards through the NIA, VHA, the American Geriatrics Society, and the American Federation for Aging Research are supporting numerous young investigators, and ADGAP recently announced a new program to identify and support young leaders.
Challenges for the Future
In addition to the need to continue developing the next generation of academic leaders, researchers, and educators, the field of geriatric medicine will face challenges related to Medicare over the coming decade.
These include the need to promote careful use of Medicare dollars. Medicare expenditures are heavily invested in reactive and highly expensive technical hospital care. Critical components of care such as preventive medicine, primary care, prescription medication benefits, psychiatric services, and long-term care services are arguably either un-funded or under-funded.
In summary, geriatric medicine remains a young discipline.
Over the past 25 years academic geriatric medicine programs have been implemented at most U.S. medical and osteopathic schools, and thousands of practicing geriatricians have been certified.
This is a significant accomplishment, yet much remains to be done.
Academic programs at many American medical colleges are still small and fragile.
Time to insure that our health system will be able to respond effectively to an aging America is limited.
Although recent research has documented a trend toward declining disability in the elderly (Cutler DM, 2001), without major changes in the health status of our older population, health care costs will escalate rapidly (Schneider EL, 1990).
Further investment in basic and clinical research and in training all physicians in the care of the aged remains a critical priority.
This review is part of a publication by :
Gregg A. Warshaw, M.D., Elizabeth J. Bragg, Ruth W. Shaull : Geriatric Medicine Training and Practice in the United States at the Beginning of the 21st Century. The Association of Directors of Geriatric Academic Programs (ADGAP)
Longitudinal Study of Training and Practice in Geriatric Medicine - July 2002
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