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Professor Richard SainsburyDepartment of Medicine
University of Otago
Christchurch
12:00 - 12:30 Reflections on a Career in Geriatric Medicine
SOUTH GP CME 2018 19th August 2018
REFLECTIONS ON A CAREER IN GERIATRICMEDICINE
DICK SAINSBURY
UNIVERSITY OF OTAGO CHRISTCHURCH
Funding: Nil Conflict of Interest: Nil
• How did I get there?
• Regrets (I’ve had a few, but then again too few too mention)
• What has improved?
• Future challenges?
Two Cogent Observations
• ‘Old Physicians let their patients die; Young Physicians investigate
their patients to death’. 76 year old woman. Hastings Sussex 1980.
• ‘Old age used to be a privilege; now everyone wants to make it a condition’. 84 year old
woman. Nottingham 1981.
WHAT ITS ALL ABOUT
•Preservation of Function
•Quality of Life
• But it can be about life extension in some circumstances
FEATURES OF ILLNESS IN THE ELDERLY
• Multiple pathology
• Non-specific or atypical presentation of disease
• Rapid deterioration of illness if untreated
• High incidence of secondary complications
• Prolonged recovery phase
• Importance of ecological factors -housing, income, social support etc
THE GIANTS
Immobility - “Off legs”
Instability - “Falls”
Incontinence
Intellectual Impairment - Delirium
- Dementia
-- - - - - - - - - - - - - - - - - - - - - - - - - - - - -
-Iatrogenic
Vigorous intervention or ‘let Nature take its course’?
• The problem is Nature’s third, and often most frequent option, worsened disability and increased frailty
• Before we ‘don’t treat’, we need to be sure what we are not treating.
• Older people can also suffer from under investigation and under treatment
MEANINGLESS HARMFUL PHRASES
• Acopia
• Social Admission
• Bed Blocker
• ‘For Nursing Cares’
Not helped by ‘The House of God’ Samuel Shem (Bergman) 1978.
The Medication Conundrum
• Older people often have a number of medical conditions
• Medications for some conditions have a preferential benefit for older people
• Medications are not tested on frail older people in drug trials
• Metabolism of drugs is slowed in older people with some medical conditions and sensitivity to drugs increases
• Iatrogenic illness accounts for around ten per cent of hospital admissions over 70 years of age
• Regular review of medications particularly with a view to reducing or stopping is an important part of health checks
WHAT HAS IMPROVED?
• Stroke management and rehabilitation
• Falls prevention and management (Prof John Campbell)
• Delirium recognition and management
• Dementia recognition and management
• Community rehabilitation initiatives
• Research Quality: InterRAI tool, Frailty, Falls, Service evaluation and Innovation
• Advanced Trainees: Australia and New Zealand 3 in 1983 plays 200 in 2017!!
FUTURE CHALLENGES
• DEMOGRAPHIC CHALLENGE
• PUBLIC EDUCATION AND ADVOCACY FOR LONELINESS AND SOCIAL ISOLATION
• DEVELOPING ELECTRONIC MODELS TO SUPPORT OTHER SPECIALISTS (e.g polypharmacy programmes for GPs)
• UTILIZING THE LARGE DATA BASE TO ENHANCE CARE
• DISTANCE PROGRAMMES
Thinking Ahead
• Driving
• Enduring Power of Attorney
Finance and Property
Health and Welfare
• Advanced Directives
Cardiopulmonary Resuscitation
Ceilings of Care
CAPACITY ASSESSMENT
Four Domains. Not Just Cognition.
• Communication
• Cognition
• Judgement
• Insight
Second opinion if doubt or dispute
Advanced Directives
To be encouraged but be aware of limitations
• They can’t cover every contingency
• Old Mexican Proverb: “the character of the bull changes when it enters the ring”.
• Should be used for consulted guidance.
KEY POINTS
• Preservation of function is the aim
• There may only be one chance
• Abnormal presentations may delay diagnosis
• The ‘giants’ are symptoms not diagnoses (with the exception of Iatrogenic)
• Regular Medication reviews
This drug really still needed?
This dose really still needed?
• Patient driven goal setting
• Be prepared to make an informed stop
The content of Geriatric Medicine
The content of Geriatric Medicine
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