Who wants geriatric medicine?
No-one likes going to the dentist. There may be relief if it solves a problem such as pain, but at best the experience is neutral, at worst it is unpleasant. We go, nonetheless. Is it the same with geriatric medicine?
In the latest 50th Anniversary commentary published in Age and Ageing, Professor Des O’Neill, geriatrician and cultural gerontologist from Trinity College Dublin, reflects on the problem of the strange disconnect between geriatric medicine and the population we seek to serve.
His film to introduce this is at the bottom of this page.
Geriatric medicine is fabulously successful. We address difficult problems with a combination of therapeutic skill and practical attention to problems. We work across multiple diseases, systems and disciplines. We espouse teamwork, listen to people and their families, and exercise good judgement, taking account of opinions, preferences, relationships and social situations. We navigate access to appropriate healthcare whilst trying to protect people from ineffective or unwanted medical interference. We have an evidence base that shows that what we do works. But patients rarely clamour to come and see us. Rather they get sent.
Geriatric medicine remains a Cinderella speciality. Increasingly, super-specialisation demands that heart failure is referred to a cardiologist, cancer to an oncologist and dementia to a psychiatrist. Geriatricians have been at the forefront of confronting ageism, but care by geriatricians can be seen as second best. Yet super-specialists, who can be fantastic at managing problems in the non-frail, can be less good than geriatricians when managing the same problems in the context of multimorbidity, disability and frailty. When the COVID-19 pandemic struck, epidemiologists and intensivists were asked what to do. Even when it was clear that older people were most affected, no one thought to ask geriatricians, initially at least.
It is striking that there is no national advocacy or support group for older people that combines medical and lay concerns, such as we see for single conditions like diabetes, Parkinson’s disease or dementia. These groups raise awareness and funds, provide peer support, enable research, and lobby for improved services. The British Geriatrics Society has good and collaborative relations with charities concerned with ageing and older people, but there is no one unifying body of and for older people that brings together the medical and clinical with wider social issues of ageing.
Why the paradox? There are many possibilities. We do not have well-funded pharmaceutical backers. Maybe, as a society, we would rather not face illness, loss of abilities and the approach of death that is part of the human condition. We all want to retain our identity as capable adults as we age, despite illness and waning abilities, which acts as a powerful deterrent to proactivity. Geriatricians are great collaborators but lurking inter-specialty rivalries may persist. Social care has been suspicious of over-medicalisation.
Professor O’Neill argues that the problem originates from our reliance on a ‘failure model’ of ageing. Ageing and older people are portrayed as a problem, a threat to our prosperity, way of life and medical services. Instead, he suggests we should reframe ourselves as ‘guardians of the longevity dividend’. To do this we must broaden our outlook, certainly beyond the hospital, probably away from our predominant role in reacting to crises. We must sharpen our use of positive and constructive language. We should see ageing in the context of the whole life course. We should engage more with other ‘gerontological’ disciplines, which are widespread both academically and in society in general. The policies of dementia-friendly communities and the current UN Decade of Healthy Ageing both recognise this. The UN Decade prioritises goals to change how we think, feel and act towards ageing, and to ensure that communities foster the abilities of older people, alongside goals to deliver person-centred care, primary health services and access to long-term care for older people who need them.
Please read Des O’Neill’s commentary. But also let us think and reflect. How can we, in practical terms, better connect with older people in general, advocate for what we do and how we do it, to help deliver our goal of better health in older age?
You can read the whole 50th Anniversary series here.
Professor Rowan H Harwood is editor in chief Age and Ageing rowan [dot] harwood [at] nottingham [dot] ac [dot] uk