She created the first geriatric unit in the UK. She systematically examined every new patient. Having separated the sick from the healthy, the old from the young, she instituted medical treatment and rehabilitation. Discharges were planned—an innovation at that time. As a result of her work, she reduced her number of chronic beds to 240 with a turnover three times the previous rate, and gave the unwanted beds to chest physicians for treating tuberculosis patients.
Simple measures were used to improve the hospital environment for patients and staff. The wards were repainted. New brightly coloured bed linen and curtains were installed. Lockers for individual patients were acquired, and for the first time patients were encouraged to get out of bed and walk. She attracted the attention of a health minister, who visited her department after her discharge rate reached 25%.
Marjory Warren published 27 scientific papers on her approaches to rehabilitation in the 1940s and 1950s. These included her ideas on rehabilitation of disabled elderly people, especially stroke patients and amputees. In her two most important publications, she described her approach to the management and classification of chronically sick older people (box 1). She strongly believed that elderly people with these conditions should be segregated from chronically sick patients of other ages, and treated in a separate geriatric assessment unit within the general hospital. This model of care would offer sick older people the best chance of diagnosis and treatment. In addition, their chances of discharge would be optimised. Warren echoed Charcot’s call for a specialty of geriatrics. This would “stimulate better work and initiate research”. She also requested a change in the attitude of all medical and nursing staff towards elderly patients.
Warren’s classification of the chronic aged sick
- Chronic up-patients (that is, out of bed).
- Chronic continent bedridden patients.
- Chronic incontinent patients.
- Senile, quietly confused, but not noisy or annoying others.
- Senile dements—requiring segregation from other patients.
As well as being a pioneer of rehabilitation, Marjory Warren was a gifted teacher. She educated junior medical staff and consultant colleagues and she took a keen interest in the education of nursing staff. Many of her ideas remain central to the practice of modern geriatric medicine.
Joseph Sheldon (1893–1972): Sheldon was the father of community geriatric medicine. He was a consultant at the Royal Hospital in Wolverhampton, where his interest in elderly people was prompted by an outbreak of food poisoning.
Sheldon observed many of the problems facing elderly people at home. He realised the importance of good self-care, continence, hearing, and footwear. Of particular importance was his recognition of mobility problems: he documented that 11% of elderly people were housebound. Sheldon recommended home physiotherapy. This would eventually be recognised as standard treatment. He advocated falls prevention strategies, such as adequate lighting at home and the benefits of stair rails.
Norman Exton-Smith (1920–90) and Lord Amulree (1900–83): An exceptional pioneering clinical scientist and researcher, Exton-Smith worked at University College Hospital (UCH) London, under the supervision of Lord Amulree. UCH was for a long time the only London teaching hospital involved with the development of geriatrics. Amulree had previously worked at UCH, but in 1936 had become a civil servant at the Ministry for Health. His influence in the House of Lords proved useful in improving conditions for chronic sick patients for whom he cared deeply. With the inception of the National Health Service he wanted their care transferred from local authority control. This occurred in 1948. Following his consultant appointment, and inspired by the work of Marjory Warren, he set about improving the plight of elderly disabled patients, and also changing the drab wards of St Pancras Hospital (a part of UCH). His work with Exton-Smith was a huge success. Beds were made available as a result of hospital discharges. Elderly services expanded and UCH attracted some of the brightest and keenest junior doctors.
Both Amulree and Exton-Smith were proponents of continuing (that is, long term) care of older people and of home assessment visits (not requested by a general practitioner, undertaken by the geriatrician before hospital admission, and without remuneration). Amulree was present at the inaugural meeting of the British Geriatrics Society and was the first president, a post he held with merit for 25 years.
Exton-Smith also worked with Doreen Norton, who later became the first professor of gerontological nursing. Exton-Smith developed geriatric research and published extensively. He became the first professor of the specialty in London at UCH in 1973. A particular interest was pressure sores (he pioneered pressure mattresses and was involved in the design of the modern Ripple Mattress). Other research interests included temperature regulation, the autonomic nervous system, nutrition, and osteomalacia. His interest in cognitive impairment resulted in the establishment of one of the first memory clinics.
George Adams (1916–2012): Another outstanding academic pioneer, he was the first geriatrician to teach geriatric medicine to undergraduates. He worked as houseman for Professor Thomson in Belfast’s Royal Victoria Hospital and was inspired by his chief’s compassion for patients on the chronic sick wards in the Poor Law infirmaries. He attended the first meeting of the Medical Society for the Care of the Elderly, later renamed the British Geriatrics Society. He met Marjory Warren and attended one of her ward rounds. After returning to Belfast, he wrote, “she gave me a practical illustration of what we might one day hope to achieve with the human wreckage in the overcrowded wards of the City Hospital.”
Adams later opened the first purpose-built elderly rehabilitation unit in the UK, Wakehurst House at Belfast City Hospital. He published widely, his particular research and clinical interests being cerebrovascular disease and disability. He was appointed to the chair of geriatrics in Belfast in 1971, only the second geriatrician at that time to occupy such a position, and served as president of the British Geriatrics Society.
Article authored by: A Barton, G Mulley
Extract courtesy of the Postgrad Med J2003; 79:229-234 doi:10.1136/pmj.79.930.229