“.....never send to know for
whom the bells tolls; it tolls for thee."
“Devotions Upon Emergent Occasions, and several
steps in my Sickness- Meditation XVII” John Donne,
Dean of St. Paul’s Cathedral, London- written in 1624
Sir Christopher Booth (June 1924 - July 2012), medical
historian, Dean of Northwick Park Hospital, in London, "one of
the great characters of British medicine”, is better known to
us as the researcher who discovered that B
12
absorption was from the distal small gut. His “
On Being a
Patient” [1], the first chapter of the last edition of
the Oxford Textbook of Medicine, ought to be made compulsory
reading for all doctors and medical students. He writes with
sadness but with detachment about his transition from youth to
old age, from a healthy carefree existence to dependence to
hospital: he reminds us how, as one gets older,
disability strikes suddenly, severely, ferociously, furiously,
with the person and his family often totally unprepared.
A young doctor in India, just out of medical school, learns to
take a good history and make a thorough physical examination-
even his final examination is often on a young adult. With
children, he is less comfortable, but with an old person, he
frequently feels very exasperated. It is not unusual for
him to lose his cool when he finds that the patient brought in
on a wheelchair is often deaf, possibly incontinent, unable to
comprehend, has hallucinations, is in pain and gives rambling
answers. A full examination is difficult, there are
innumerable questions from relatives who demand ‘quickfix’
solutions. The myriad problems and protean manifestations of
the same disease may baffle a novice. Hyponatemia,
hypercalcemia, hyperglycemia, any infection, even faecal
impaction, may all manifest identically - with confusion,
abnormal behaviour, even aggression. There may be no
lateralising neurological deficit or fever and the doctor has
no clue about what is wrong with this lethargic, confused,
restless, often agitated individual in front of him. Time and
again, the junior doctor labels him/her as ‘uncooperative’.
Was it urinary or chest infection, stroke, electrolyte
abnormality, a drug or something else that landed this person
in hospital? What is his prognosis? And honestly, no one is
very sympathetic! In his medical curriculum, the medical
student here has never had any exposure to such a situation.
This Workshop is intended to create an awareness of this
problem.
It is estimated that those > 60 will outnumber children the
world over by 2020. The population of 60+age group in the
world is set to double from 12 to 22% between 2015 and 2050.
Life expectancy in India was 49.7 years in 1970-75; it has
gone up to 69 years, in Kerala it is 74.9 years (72 for men,
77.8 for women). More and more retired persons have their
parents to look after. In addition to their individual
ailments, there are frictions between the generations that
have to be addressed. Loss of a partner, depression, dementia,
deafness and visual loss add to the loneliness and isolation.
Are we ready to face this medical crisis looming up before us?
The background for this workshop was the awareness (or lack of
it!) among the doctors who normally examine and treat the
older individual.
Geriatrics and Gerontology
Physicians have always accepted that managing disease in the
old demands tact and considerable finesse. Our ancient
treatises teach about ‘
Jara’ –the wrinkles of old age.
Mythology has it that the Gods invented
Chyavanaprash to
keep people young. Charaka in his
Samhita described
the changes caused by severe exertion in older persons and
advocated a light but nutritious diet for them. Similar
references to caring for older persons are found in Roman and
Arabic texts.
Geriatrics (Gk : γέρων geron
= “old man”+ ιατρός iatros = “healer”) is a
sub-specialty of medicine which deals with
diseases of
older individuals and health care of the Elderly.
It aims to promote health by preventing illness, treating
diseases and disabilities in older adults. The word
‘Geriatrics’ first coined in 1909 by Ignatz Leo Nascher,
Austrian-American doctor, then Chief of Mount Sinai Hospital,
New York, translates into ‘care of aged people’ on lines
similar to ‘
Paediatrics’. A Geriatrician is a physician
who specializes in the care of elderly people.
Marjorie Warren, after working for several years in Isleworth
Infirmary and the adjacent Warkworth House Workhouse in
London, analyzed her own experiences and wrote seminal
articles in the
BMJ [2] and
Lancet [3] of
1960, to point out that keeping older patients well fed till
they died was not good enough. If their ailments could be
diagnosed and treated, they could be rehabilitated to become
useful members of society. She campaigned for the creation of
a medical specialty of Geriatrics within the newly formed NHS
and the starting of special such units in general hospitals.
She felt strongly that medical students should be taught early
in their career the basics of care of the elderly by senior
doctors who had interest and expertise in this field. She was
one of the eight doctors who founded the Medical Society for
the Care of the Elderly, which went on to become the British
Geriatrics Society.
We owe it to Prof. Bernard Isaacs of the University of
Birmingham, who after joining this unfashionable specialty in
its early days, made it highly popular and challenging by
infusing it with his great enthusiasm and energy. He listed
the four ‘Giants’ of Geriatrics - Immobility, Instability,
Incontinence and Intellectual impairment; he also identified
the four common causes for admission to a Geriatric
unit: expectation of therapeutic recovery, medical
urgency (the need for hospital care), basic care (being unfit
to fend for themselves in providing food, warmth, cleanliness
and being unsafe) and relief of strain on relatives. He
established a gait laboratory in his hospital to study balance
problems and the causes for falls and also a Centre for
Applied Gerontology to promote awareness among architects,
service providers and others in society of the needs of the
old.
Geriatrics is a well established specialty now in the West.
To find out for themselves whether they like Medicine as
a vocation, aspiring medical students do community service in
long-stay and short stay hospitals for the Elderly; they thus
notch up ‘points’ for entry into medical school. Rotations
through geriatric units give medical students good exposure.
An article in The Daily Telegraph, London, of 29th March 2012
quoted a study which suggested that “Elderly patients could
spend much less time in hospital if they were assessed earlier
by
geriatricians or General Physicians who understand
their health problems”. My exposure to Geriatrics started when
I worked for Prof. M.R.P. Hall at the University of
Southampton, U.K. We had several old people in our own family
and the experience has been invaluable. I can never forget a
hitherto fit 90 year old admitted to our unit with an acute
upper G.I bleed. As a new Registrar, my first response was
‘leave her alone, considering her age’. My Consultant insisted
on an Endoscopy, a duodenal ulcer was found,
transfusions arranged, H
2
antagonists given, and she walked out of hospital to her
independent existence after she was declared safe at home,
restored to her own environment, well.
Gerontology (Gk,
geron = “old
man” +
logos = “study of”) was a term coined in 1903
by Ilya Ilyich Mechnikov [Élie Metchnikoff] (1845
–1916), who shared with Paul Ehrlich for work on Phagocytosis
the 1908 Nobel Prize. It is the study of the social,
psychological & biological aspects of ageing, the
study
of the ageing process itself, its Science.
Gerontologists are researchers and practitioners in
various fields of biology, medicine, pharmacy, nursing,
public health, optometry, dentistry, social work, physical
& occupational therapy, psychology, psychiatry, sociology,
economics, political science, architecture, housing &
anthropology - different aspects of Aging.
Geriatrics is sometimes called Medical Gerontology.
There is no set age at which patients may be under the care of
a geriatrician or general physician, the decision determined
by the individual patient's needs and the availability
of a specialist. By convention, an Older adult is > 65
years. But then there is the “young old” & the
“old….old” !
The Workshop on Geriatrics and Gerontology
The concept of this Workshop started as a one-day minimalist
affair to flag off the
WHO Decade of Healthy Ageing,
2020-30, after discussions Prof. Kichu Nair from
Newcastle, Australia had at Trissur with Prof. K. Mohanan,
Vice Chancellor of The Kerala University of Health
Sciences (KUHS). Baby Memorial Hospital, Kozhikode volunteered
to conduct the first of a series of CMEs in North Kerala to
sensitize doctors in our midst: dates chosen were February 29
and 1st March 2020, with Dr. K.P. Dipu as Organising
Secretary.
It was for Geriatrics a first serious CME in Kerala. We had
one under CALFIM at Calicut years ago, there have been a few
more. Many aspects are being discussed now. KUHS hopes it will
stimulate research in various aspects of Health Care in
Kerala.
This time we had a wide range of topics with eminent speakers
- many of them after decades of experience in General
Medicine, had opted to spread the message of Geriatrics
because of their passion for the care of the Elderly and
dedication to training students and doctors in this fledgling
specialty in India. We chose them to sensitise doctors and
carers of the Elderly, help them identify problems - intervene
where possible, draw the line where they could not. Obviously
all aspects could not be covered by such a short workshop. Our
own experts are sharing their wisdom - their experience ought
to benefit us all. Profs. P. Sugathan, Roy Chally, N.J Mani,
Ashokan Nambiar, K.V Sahasranam, K.S. Shaji came on
board first, we then expanded the repertoire to
include Profs. Alka Ganesh on the Clinical
Manifestations of Ageing, Prabha Adhikari on Comprehensive
Geriatric assessment, Prof. Prasad Mathews on the Perils
of Polypharmacy, the last a major issue in older persons.
We include here among the references below a link to the
Updated Beers Criteria [4] which ought to be useful.
The boundless enthusiasm of Prof. M.V. Pillai and Prof. M.R.
Rajagopal made this snowball into a major event for BMH, KUHS
and Pallium India. Palliative Care includes managing pain, a
source of universal apprehension and helplessness. Prof. Lulu
Mathews, paediatrician by training, accepted our invitation to
speak on this. Several aspects of Geriatric care, Palliation
and End-of-Life Care are discussed, all live, burning issues.
Mr. V, 96, had led an active life: he enjoyed long walks,
reading, writing, working on his i-Pad. Medically he was
fit, ECG, Echo etc had been normal. Over the years, he
became progressively unsteady and insecure, his peripheral
neuropathy made him convinced there was water on the floor;
repeated falls caused intense pain from vertebral fractures.
He lost his confidence, was apprehensive of finding himself
on the floor unable to summon aid. His wife, equally frail
but intellectually active, concurred with his decision to
move to their daughter’s house nearby. He had left clear
instructions: he did not wish to be taken to hospital at
all, certainly no tubes, ventilators or interventions. He
sustained a fall and consequent inter-trochanteric femoral
fracture. That he needed surgery was clear -
leave him alone in bed, and he risked pneumonia, DVT,
bedsores and worst of all, intense psychological morbidity.
In hospital, he collapsed, was found to be very
dehydrated-the smart doctors in the ED identified this when
the probe over the Inferior vena cava revealed it had been
reduced to a slit. His ECG showed left bundle branch block
and Ejection fraction was very low but Troponin was normal -
so the cardiac events were fairly old. They did not have to
put long lines to monitor- mercifully he was well pre-op.
The Cardiologist helped the family decide – and he
went through surgery easily. Post-op, he aspirated, Oxygen
saturation fell. He became confused. N.G feeding was
instituted with his consent. A bronchoscopic aspiration was
attempted. Ventilation was on option – but this was
declined. He had a sudden bradycardia, the ECG became a
straight line. No energetic attempt was made to
resuscitate.
This is the story of what happened to my father-in-law in
February, after this Workshop was planned. There were several
questions raised:
1. Should my in-laws have given up their independent existence
and privacy by moving out of their own house?
2. Should we have respected his wishes and managed him at home
after the fracture?
3. Should we have agreed to have long lines inserted to
monitor his circulation? What about intubation, ventilation as
the next logical step to get him better?
4. Was it right to shift him into the ICU knowing that he
would be lonely and lost, unable to see his dear ones, should
surgery have been postponed in an attempt to stabilise his
fluid status? But then the question was for how long
? It could have been an indefinite wait.
5. Did he ‘give up’ after he heard someone discuss within
earshot the grave prognosis?
How do you reconcile the patient’s wishes with the need for
early ambulation after a ‘quick, simple’ procedure? Was it
ethically correct at all to take him into hospital? But how
could one leave him in pain - and in bed with a bleak future
and no prospect of rehab?
This is the subject of this Workshop.
The Monograph
The range of subjects to be discussed was so vast - all
aspects could not be included, Gastroenterology, Pulmonology,
Neurology, Cardiology, Diseases of Women, to mention
just a few. This Workshop was meant to be the first of a
series - so we started with assessment and basics. We
leave it to other centres to emulate and excel !!
Any workshop or CME however well-conducted, leaves nothing
permanent behind. Something accessible either on paper or the
net would be useful, long term. So we thought of a
Monograph - and invited experts to contribute.
It had to be a free access, online version, so we got rid of
glossy paper and waste. Revisions would be easy. Even a formal
text-book might evolve, who knows? And wisely, in retrospect!
Many have not been able to meet our short deadline.
We asked several experts to write off hand. The articles did
not have to be erudite, but the reader could clear a doubt or
get information through the links provided by the writer, who
after all had decades of experience to bank upon. Length was
no issue, but readability was. Anything useful in the care of
the elderly was welcome. We have tried to avoid copyright
issues.
We were moved and overwhelmed by the response. Prof. Thomas
Mathew set the ball rolling by starting to write on the
‘Ageing Kidney’. Others took up the idea. The very first
article to reach us was Prof. C. Ravindran’s on the ‘Ageing
Lung’. We thank everyone - Profs. M.V. Muraleedharan,
Kasi Visweswaran, M. Narendrandranathan, S. Sreekumari,
Jame Abraham - who made it an interesting experience for us as
editors. Prof. Nandini Kumar writes on Ethical Aspects of
Research in the Elderly. Kathryn Mannix, retired British
Consultant in Palliative Care, whose “With the End in Mind”
elicited favourable reviews, has contributed a wonderful
piece.
The Monograph is being launched as a Supplement at the already
existing BMH Journal website archived at Index Copernicus
International. The link for its access is
https://www.babymhospital.org/BMH_MJ/index.php/BMHMJ/issue/view/31.
Prof. Johnson Francis and Dr. Robin George have worked long
hours and deserve full credit for their efforts.
The Monograph has several articles, which discuss many common
problems, interpretations. You will find a new perspective,
there are links in case someone wishes to follow a lead. It is
not intended to be a compendium of facts. If a distraught
physician can get some guidelines for management, or find
pleasure reading it or contacting the author via email, it
would have served its purpose.
Articles are still coming in, and we will add them on. Do let
us have your feedback and comments. We hope you will enjoy
browsing through the monograph. We had a great time collating
it, we hope you will cherish it.
I am thankful to all the participants, speakers,
Chairpersons at the Workshop and contributors to the
Monograph, most so, my ‘team’ notably led by Dr. K.G.
Alexander from the front, Prof. M.V. Pillai, Prof. M.R.
Rajagopal, Prof. K. Mohanan, VC of KUHS, for making this event
possible.
Taking up Geriatrics calls for commitment and compassion. With
mounting numbers of the elderly in our very midst in Kerala,
we are fast catching up with the West. Many of these senior
citizens had important jobs, were pillars of society, are
still mentally agile, want to retain their independence and
dignity. Managing their welfare and medical problems is
something we can ill afford to ignore. Our young doctors must
know how best to care for the elderly, understand that the
approach to an ill older person is not the same as for a young
adult, that personal preferences, family concerns have
all to be taken into account while handling these patients.
References
1. Christopher Booth in Oxford Textbook of Medicine (5
ed.-2010) Eds. David A. Warrell, Timothy M. Cox, and John D.
Firth
2. Warren MW. Care of Chronic Sick. Br Med J. 1943 Dec
25;2(4329):822-3.
3. Warren MW. Care of the chronic aged sick. Lancet. 1946 Jun
8;1(6406):841-3.
4. By the 2019 American Geriatrics Society Beers Criteria®
Update Expert Panel. American Geriatrics Society 2019 Updated
AGS Beers Criteria® for Potentially Inappropriate Medication
Use in Older Adults. J Am Geriatr Soc. 2019 Apr;67(4):674-694.