Journal of the New Zealand Medical Association, 25-June-2010, Vol 123 No 1317
Geriatric medicine is becoming the core of hospital business
The medical care of the elderly is becoming the core activity of general hospital-based medicine and surgery in New Zealand and this will become increasingly evident over the next 50 years. In my view, younger adult surgery and medicine will become the exception and not the rule, and hospital doctors may consider the care of younger adults with standard single-diagnosis problems to be “practice” for the real job of caring for older people in all their complex, challenging glory.
Is this just a polemic statement? The main drivers for this trend are unarguable and simple: increasing longevity is the main current reason behind this massive population trend, and shows no signs of slowing down; and the slow ageing of the “Baby Boomers” will be the main force behind this dynamic in the near future.1
An audit of admissions to Christchurch Public Hospital, not counting the Canterbury District Health Board’s (CDHB’s) rehab or geriatric wards in other hospitals, revealed that (in 1 week) 62% of general medical admissions were for people over 65 (in fact, 32% were 80 and over) as were 32% of general surgical admissions. Over the whole hospital, including paeds and gynae units, 41% of acute admissions in Christchurch were over the age of 65; 38% of the general hospital outpatient visits that week were also for people over the age of 65.2
These statistics are especially challenging when it is recognised that the portion of the CDHB catchment area made up of over 65s from which these admissions and clinical reviews were generated was only around 13.6%.3 Since it is this ageing segment of the total population that is set to expand significantly, and since the fastest growing age demographic will probably be the over 85s, this is sobering news for health services indeed.1
One response to this is to recognise that it is time for general and sub-specialist medics and surgeons, the nursing and allied health teams with which they work, primary care health services and the health system as a whole to wake up, smell the roses and learn as much as possible from geriatrics and its related disciplines. One of many lessons will be to accord “brain failure” the same level of respect with which heart failure, kidney failure and liver failure are currently imbued. Rodwell and colleagues demonstrate in this issue one of the features of this peculiar neglect.4
Delirium and dementia are very common among hospitalised elders.5,6 These manifestations of acute and chronic brain failure are predictors of mortality.6,7 Patients and their families tell me they are very concerned about the effects of malfunctioning brains, sometimes more so than they are about the other-organ disease that may have been the presenting complaint to hospital.
Standard inpatient care may be compromised if cognitive impairment is not taken into account as may standard outpatient follow-up. Lengths of stay increase, as do costs, something hospital administrators are concerned about, for example, in respect of high ‘hospital sitter’ / special nursing budgets.8
The first step is to improve diagnosis, something that Rodwell and colleague’s paper shows is not currently done well at Christchurch Public Hospital4—and there is no reason to think that other New Zealand hospitals do any better. The days of “STML”, “confusion”, “cognitive impairment” or worse, no entry at all appearing in discharge letters for people with dementia or delirium must surely be over. This is the equivalent of writing “acute abdomen” or “shortness of breath” as a final diagnosis after a surgical or medical admission and reflects an inability or an unwillingness to make a diagnosis of these common manifestations of brain failure.
Perhaps the main reason that this occurs is because there is little sense within our general hospitals of surgical and medical teams being confident that they can manage dementia and delirium themselves, certainly not as confidently as they can manage congestive heart failure. Why diagnose if you cannot recommend an effective treatment plan? Discovering the elements that constitute effective management plans for dementia and delirium are lessons to be learned from psychiatry of old age and related geriatric disciplines.
The challenge for geriatric services will be to become sufficiently integrated into general hospital teams so that this transfer of hard-won lessons and skills can occur smoothly, to the benefit of all.
Competing interests: None known.
Author information: Matthew Croucher, Psychiatrist of Old Age, Canterbury District Health Board—and Clinical Senior Lecturer, University of Otago, Christchurch
Correspondence: Dr Matthew Croucher, The Walshe Centre, PO Box 4345, Christchurch, New Zealand 8140. Email: Matthew.Croucher@cdhb.govt.nz
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