«Children … should be taught respect for the elderly. They should be aware that it is thanks to the elderly that they are here, and that they are the reference of the culture of the family. The elderly should not be forgotten, they should not be humiliated, mistreated or subject to violence. Perhaps the first step is to teach children this once more.»
The Editorial team of the Newsletter interviewed the Coordinator of the newly-created University Geriatrics Unit. He spoke informally about Geriatric Science from an academic, social and assistance providing perspective.
Newsletter: Given that the Portuguese population is ageing, as in the rest of Europe, following a trend contrary to that of other continents, does this mean that more specialists will be needed to meet the needs of an ageing population, particularly in terms of geriatrics? Would you comment on this?
Professor Gorjão Clara: The ageing world population, in civilized countries, has changed the panorama of healthcare. It is not only a social issue (the costs of new pensions, the lower productivity of that age group, etc.) but also a particular problem in medical care. Pathologies, the diseases prevalent in the elderly, are different from those affecting young individuals. Diseases manifest differently in each group. Therapeutic approaches are also distinct. The complementary diagnostic tests and the options for referring the elderly depend on the situation affecting each individual. Not many years ago, when I was a cardiology graduate assistant here in Santa Maria Hospital, I worked at the Emergency Room that now bears the name of its founder, Arsénio Cordeiro. One of the constraints I felt was not to receive patients over 65-70 years of age, because the unit was considered to be aimed at younger groups, which were worth investing in as their life expectancy was longer. These constraints, which have blurred as the population grew older, influence the choice of hospitalization and subsequent hospital discharge, the type of tests to be made, whether or not to use advanced research, the best therapy, when we are talking about an old person. Accordingly, there was a set of very practical and ethical situations that have changed as a result of the ageing of the population. It is necessary to prepare the new doctors for this new situation. This is the reason why the Faculty of Medicine of Lisbon in timely fashion decided that students should not complete their medical degree without having contact with the reality of ageing, with gerontology and geriatrics, actually in compliance with the decisions of the World Health Organization, which has been stating precisely that for some years. The WHO itself was careful to publish what it believes to be essential in terms of knowledge acquisition by any medical student before becoming a doctor. It is like undergraduate training in geriatrics. So, my answer obviously is that new doctors must be prepared to see elderly patients. And this requires lecturers to teach and train them. Hence the need for geriatricians and for geriatrics. Not all doctors need to be geriatricians, but they must know how to take care of the elderly. For this reason, there must be geriatricians to provide training.
Newsletter: The Geriatric Consultation was set up very recently, in March this year. What makes this Consultation different?
Professor Gorjão Clara: To be precise, the Geriatric Consultation began on 3 March. To me, it is a historic day, as it represents the effort of many years, during which time it was necessary to mobilise many people, write a lot, talk to many people, raising their awareness to Portugal’s need to catch up with other countries in Europe. We were, and to some extent still are, at the tail of Europe in terms of geriatrics. Only seven European countries do not have geriatrics and no geriatric consultations organised in accordance with international standards, according to which we set up our consultation.
Our consultation is unique because, like in all geriatric consultations worldwide, it is a multidisciplinary consultation. The elderly are not examined in terms of the disease affecting an organ or system. For instance, when a person goes to the ophthalmologist, he will test the person’s ability to see, looking for possible ocular pathology, and check the eye system. All elderly patients must be examined as a whole, from all angles, regardless of the dominant symptom or complaint. This means they need to be seen from a physical and from a psychological perspective, including in emotional and intellectual terms, from a social perspective, from the perspective of motor autonomy and nutritional status. The consultation team undertakes the nutritional assessment of patients to ascertain if they are well nourished or overweight and if they are eating well. The team assesses their emotional state, to see if they are depressed, as depression is quite frequent in the elderly. There is treatment for it and it should be treated. From a cognitive viewpoint, the team evaluates intelligence and attention span, concentration, memory, and reasoning. The physiotherapist assesses motor autonomy and balance. As you know, one of the major dangers affecting this age group is falls. Every year there are thousands of accidents worldwide, both at home and on the streets, and this is related to motor autonomy, gait speed and autonomy, and balance. All of these aspects are assessed in our consultation. We also conduct evaluation of a social nature. Of course if we see a patient, diagnose his diseases, choose the appropriate therapy and then he has no conditions at home, lives with poor lighting, in minimum health conditions, lacks hygiene and does not have the means to buy drugs or to live in conditions protecting him from risk, such as rain, wind, the cold… Our consultation has another distinctive feature.
One of my concerns is inappropriate medication. It is worrying to know that a study conducted on the population of Lisbon showed that 38% of the elderly who buy medicines in pharmacies purchase at least one they should not take because it is damaging for their health. I mean, they have contra-indications, which can be absolute or relative, but still have side effects. This alerted me to the fact that I must always have an opinion and a warning from the pharmacist at my consultation. In my consultation, I always have a pharmacist working with me when choosing the therapy and drugs to prescribe, who warns me of the interactions and side-effects to prevent me from running the risk of prescribing inappropriate therapy. In summary, in our Geriatric Consultation we use the Comprehensive Geriatric Assessment model. This is what our Geriatric Consultation is like and how it works.
Newsletter: What is the University Geriatrics Unit? ?
Prof. Gorjão Clara: I wanted the University Geriatrics Unit to be organized as a centre capable of establishing partnerships with other entities which, in Portugal and abroad, undertaking research, teaching and assisting the elderly. I have made a partnership with the João Cardiga Equestrian Centre. This may seem laughable, or at least make people smile, and ask: why a partnership with an Equestrian Centre? We are developing a hippotherapy programme for the elderly at that centre. Similarly to what is done to children with disabilities, in elderly people with no disabilities we wish to ascertain the extent to which hippotherapy (horseback riding under surveillance and monitoring) improves, or not, some of the parameters we assess before and after, from a cognitive, emotional, physical (gait and balance) and wellbeing perspective.
This was one of the partnerships we have made. In addition, we have partnered with the Portuguese Association of Psycho-gerontology (APP) and with a group of psychologists from APP, to study various problems affecting our population that have not yet been studied, such as depression, as I mentioned earlier, which is very frequent in the elderly. We don’t have figures for depression among the Portuguese elderly population. There is just one work by Professor Caldas de Almeida on the topic. We have numbers for the elderly population in other countries around the world and in Europe, but not with regard to Portugal, and this is one topic we would like to research.
The quality of life of the elderly has not been studied either. We are also establishing partnerships with the Faculty of Pharmacy of the University of Lisbon to investigate the aforementioned inappropriate medication and the behaviour of the elderly with regard to diseases. We are also trying to partner with the Gulbenkian Ageing Institute. I have had two or three meetings with Professor Villaverde Cabral, with the National Institute of Preventive Cardiology, with Professor Paulo Vitória and Dr. Joana de Ávila, to study smoking and nutritional assessment.
These are all dynamic situations that will gradually materialise. We have created the Geriatric Consultation and the Assistance at Home for the Elderly. We complement the consultation with a mobile team that visits the elderly who have specific characteristics and need to be visited by nurses, the social worker, and, possibly the doctor. Currently the team of the Geriatric Consultation is formed by volunteers, so the consultation does not have anyone who does not want to be there. Those who collaborate do it because they enjoy learning how to optimize care of elderly patients and they participate in the consultation because they choose to do so. The only doctor who must be there is me, the rest are all volunteers. When we have an impatient geriatrics unit with its own group of doctors and nurses, we will be able to make the consultation more effective and the home visit team will always be joined by a doctor. This is, for instance, what happens in Spain, where the home team includes nurses, a social worker and always a geriatrician.
There are many elderly patients who return to hospital shortly after having been discharged, because while at home they stopped complying with what they had been advised to do, or because they did not understand the norms on how to behave at home, or because the disease has worsened. Therefore, rehospitalisation can be reduced if the home team is able to conduct an early assessment of a particular situation, avoiding that patient from being readmitted and helping him to live with his comorbidities as best as he can.
Newsletter: How can this unit assist the elderly?
Professor Gorjão Clara: I believe I have partially answered your question in my previous answer. Basically, the unit can assist the elderly by optimizing the care given to them through the consultation, home support, by avoiding early re-hospitalization, by maximizing assistance when they are readmitted to hospitals, by reducing costs and the average waiting list, by achieving lower mortality rates, lower cognitive deterioration, smaller loss of motor autonomy, and by increasing the number of the elderly who go back to their homes, as many international studies have demonstrated. The unit can also attain this objective by teaching geriatrics to our Faculty students and to students of Nursing Schools who may wish to learn about it.
Newsletter: In that sense, what are the current constraints?
Professor Gorjão Clara: As I mentioned earlier, I do not have a medical team, only a team of volunteers. Like in many countries in the world (this is why I say that we are not on the same level as other countries), I must have an exclusive area for elderly inpatients. It is paramount to create a geriatric unit with inpatient beds. In Spain, it has existed for 27 years. Two years ago, Hospital de San Carlos in Madrid celebrated the 25th anniversary of its Geriatrics Unit. Hospital Ramon Cajal has had a similar unit for twenty something years, and there are many hospitals in Madrid and outside that have geriatric inpatient units. Throughout the world, to go beyond Europe, like in Brazil, there are geriatric hospitals and units, in the US there are geriatric beds and units, they exist in about 60 countries. I think it is important to define which type of patient should be assisted by a geriatrician. I was once asked at a Geriatrics Symposium:” if the average age of patients currently hospitalized in medical units is 76 years, aren’t those units actually true geriatric units?
The answer is no. It is not age that defines which patient should preferably be admitted to a Geriatric Unit. Let me explain: when the first medical specialties were first established, paediatrics was one of the first. It was decided that paediatrics encompassed children up to 10 years of age (subsequently extended until 18 years of age). In those days, when the average age of hospitalized patients was about 50 years and life expectancy was 50-55 years of age, it was decided that geriatric patients (Marjory Warren created geriatrics in 1948 in the United Kingdom) were those aged 65 years or above. Nowadays, it is not age that stipulates which patients should be seen by geriatricians.
In fact, most geriatric patients are old, very old, but not all elderly are geriatric patients. Let me give you an example: If I am 80 years old and suffer from pneumonia, I am not suitable to be admitted to a Geriatrics Unit. This is because I have a single pathology, I don’t have a chronic disease, I am not on any medication, I have no body malfunction, except from acute pneumonia. However, let us suppose I have coronary disease, suffer from heart failure, high blood pressure, hemorrhagic gastritis, osteoarthritis, diabetes, chronic kidney failure, delirium and pneumonia. In those circumstances, I can be admitted to a Geriatrics Unit.
Who decides which patients should be admitted to the geriatric unit or taken to the conventional medicine unit? Common sense decides it, by means of an exchange of information between the internal medicine physician and the geriatrician. It is the meeting between the two that will point to the decision whether it is more or less advantageous for the patient to be looked after by the medical unit or the geriatric unit. With some training, it is not very difficult to understand which patients should be referred to one or the other hospitalization unit. This is how it is done all over the world, where the age boundary is no longer used to define who geriatric patients are. The problem with geriatrics in Portugal can be found elsewhere. One of the last countries in Europe to implement geriatrics, over 10 years ago, was France. They had a problem similar to ours. There was great resistance by internists and general practitioners in recognizing geriatrics. An editorial published in the British Medical Journal about this issue stated that those French doctors were afraid of losing their elderly patients to geriatricians. However, this did not happen, it was nothing but a false problem. Internal medicine is extremely important, plays a major role. Geriatrics does not replace internal medicine. Rather, it complements it and enhances assistance to the elderly. The idea is to optimize the assistance provided to the elderly, not to replace internists or general practitioners. In some aspects, geriatrics can be compared to paediatrics. As an internist, I can diagnose and treat pneumonia in a child, but I am fully aware that in some extremely complex situations, the paediatrician will optimize such assistance, as he trained for years to that effect. Nowadays, France boasts the best equipped geriatrics unit in Europe, at the Hôpital Georges Pompidou, directed by Olivier Saint Jean. I met him through the European Academy for Medicine of Ageing, of which we are both members. Recently I asked him, to receive one of my volunteers, Dr. Lia Marques, on a three-month internship, so that she could learn and bring back that information and later join the geriatrics unit here in Portugal.
Newsletter: We know that a Project of the University Geriatrics Unit won a prize in the competition “A Hospital of the Future». What was this project?
Professor Gorjão Clara: The project has to do with almost everything I have been saying here. In this project, I described the goals of the geriatrics unit, including: establishing partnerships with other entities interested in conducting research, teaching and care giving; optimizing care at a proper consultation and foster home visiting; I also wrote about the need to reform the training of doctors, not allowing any student in any medical school in Portugal to finish the degree without having had training in this area. I wrote that it was necessary to alter our hospitals and I stressed that our hospitals were not suited for our ageing population. New hospitals should not admit patients who are lucid and have motor autonomy and then discharged them in a wheelchair or in a stretcher, often delirious. The muscle atrophy that occurs after staying in bed for 8 days, often longer, leads to loss of autonomy. The environmental conditions that elderly patients find in hospital are very different from those they had at home, and can lead to temporal, spatial, cognitive and acute disturbances, which present risks, and can be the actual cause of morbidity and mortality. The additional costs of recovering these patients and the suffering they and their families experience should be prevented by restructuring hospitals. This is written in the project, and justified with the arguments I mentioned earlier, defending that geriatrics should progress through specialized consultations and the creation of specific units in all hospitals for patients suffering from many complex diseases requiring difficult therapeutic approaches – geriatric patients. I wrote that these measures had to be implemented because it has been demonstrated that those units not only have a scientific foundation, but are also undeniable effective from an economic viewpoint, and also in terms of results. This is how it is done everywhere, with some exceptions where we are included. The mortality rate in patients admitted to geriatric units is lower than in conventional units, the length of their stay is smaller, expenditure on health during and after hospitalization is lower. From an economic perspective, which is a major concern today, and rightly so, to set up geriatric units is a form of making medical services more cost effective and of making assistance to the elderly less expensive. I wrote about the usefulness of geriatric units in university training and research, and about supporting the much needed national geriatric network. This is briefly the project that won the prize you referred to.
Newsletter: How do you see research in geriatrics?
Professor Gorjão Clara: In recent years, research has focused on non-elderly age groups. In fact, research in geriatrics is tricky, because it is difficult to find samples of individuals aged 80. However, that research is beginning to emerge. We need to know better and with increased scientific backing how to treat geriatric patients. Nevertheless, we may say that research in geriatrics is still much incipient and that it is paramount to invest much more in it. Research is one of the objectives of the University Geriatrics Unit which has now been academically recognized by the Scientific Council of the Faculty of Medicine of the University of Lisbon. We want to be involved in advancing knowledge about diseases (physiopathology, treatment, and prevention), the emotional state, and the psychological and social conditions of our elderly. We want to conduct research around the question: Why do we grow old? The answer to that may help us slow down the ageing process or to control it, so that our species may live longer with quality.
Newsletter: The elderly population has been in the news for the worst reasons: abandoned elderly, elderly who die in their homes alone, examples of abuse, social exclusion etc. Our society seems poorly prepared to address these issues. What do you make of this? Do you think there should be measures to prevent such situations?
Professor Gorjão Clara: Surely this is the most difficult question. All we need to do is listen to the news and read the papers to know that the elderly are excluded, live alone, their families often regarding them as a burden. When the elderly are not segregated within the families, often the decision is put them in homes where they lose touch with their families, leaving them practically abandoned, “alone” among so many others. It is a shocking and dramatic reality of our social life which I believe must be changed. It is necessary to recoup values that have been lost, bit by bit, in society.
When I was a kid, an old man who had children was a safe old man. Children represented his support and security in old age. Today, children no longer represent that, and they may even contribute to the elderly being more alone. I think that we should reshape attitudes. We have lost values, notions of ethics and of social behaviour. An effort must be made, starting right at school. In the same way children are taught not to smoke, not to eat sweets, to relate to people without violence, they should be taught respect for the elderly. They should be aware that it is thanks to the elderly that they are here, that the elderly helped their parents raise them and that they are the reference of the culture of the family. The elderly should not be forgotten, they should not be humiliated, mistreated or subject to violence. Perhaps the first step is to teach children this once more.
Newsletter: Dear Professor, we thank you for your kind collaboration. Please feel free to leave a message to the readers of our Newsletter.
Professor Gorjão Clara: I would like to appeal to all those who are interested in geriatrics. I am speaking in particular of doctors and nurses. Do get in touch with me, come and see me, so that together we can advance geriatrics and make it firmly embedded and progressively intervening in our country.
Equipa Editorial
news@fm.ul.pt
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Propriedade e Edição: Faculdade de Medicina da
Universidade de Lisboa NIPC: 502662875 Periodicidade: Mensal Diretor: Prof.
Doutor Fausto J. Pinto Conselho Editorial: