A STATEMENT OF PRINCIPLES: TOWARD IMPROVED CARE OF OLDER PATIENTS IN SURGICAL AND MEDICAL SPECIALTIES

Introduction

The following statement and recommendations resulted from deliberations between geriatricians and surgical and medical specialists from ten disciplines.* These discussions took place in May and September, 1998, and were revisited in June, 1999, at a series of meetings under the auspices of a major project funded by The John A. Hartford Foundation (JAHF) and carried out by the American Geriatrics Society (AGS). The goal of the project is to improve significantly the care of older patients. The organizations represented at these meetings and contributing to this statement are:

• American Society of Anesthesiologists and Foundation for Anesthesia Education and Research
• Society for Academic Emergency Medicine
• Association of Program Directors in Surgery
• American College of Obstetricians & Gynecologists
• American Academy of Ophthalmology
• American Academy of Orthopaedic Surgeons
• American Academy of Otolaryngology
• American Academy of Physical Medicine and Rehabilitation
• Society of Thoracic Surgeons
• American Urological Association

Rationale

The increase in the number of older people in the population in the United States has been striking and will become even more explosive after 2011. Conservative estimates are that the US population aged 65 and older will grow from 35 million in 2000 to 78 million in 2050 (from 13% to 20% of the population), and the number of those aged 85 and over will increase from 4 million to 18.2 million.¹ Moreover, if we assume that life expectancy from age 65 will continue to increase at the rate seen in the 1990s, the projected population of people aged 85 and over would reach an awesome 31.2 million by the year 2050.

Improvements in skill and technology in the various surgical and medical specialties, as well as better physiologic status of older adults, has brought about and will continue a disproportionate increase in the proportion of persons aged 65 and older (and 85 and older) who are candidates for surgery and other surgical and medical interventions.² Meanwhile, geriatricians continue to be in short supply. There are about 9,000 at the present time, whereas the need is estimated to be about 30,000. The shortage of academic geriatricians is particularly pressing.³

In addition to the role they play in primary care, rehabilitation and long-term care of older people, geriatricians offer expertise in "pulling older patients through" traumatic events and avoiding postoperative and other disasters that often befall older patients during hospitalizations. The frequent and at least partially preventable hazards of hospitalization and surgery in the older age group form an impressive list:

• Acute renal failure
• Adverse drug events (incidence 10-15%)^4,5
• Inappropriate bladder catheterization
• Deconditioning and immobility^6,7
• Dehydration (prevalence 7%)⁸
• Delirium (incidence 20% in medical patients, 10-50% in postoperative patients)⁹
• Depression
• Electrolyte disturbances
• Falls (incidence 4-11 per 1000 patient-days)¹⁰
• Functional decline (incidence 32%)^6,7
• Incontinence (prevalence 11% on admission and 23% on discharge)¹¹
• Infection (especially pneumonia and urinary tract infection)
• Malnutrition (prevalence as high as 61%)^12,13
• Pressure ulcers (incidence 5%)¹⁴
• Stress-induced gastrointestinal ulceration
• Thromboembolism
• Untreated or undertreated pain

Given the demography, the expansion in eligibility of even very old patients for surgery, the shortage of geriatricians and the growth of knowledge of how best to manage postoperative and other critically ill older adults,^15,16 we conclude that surgical and medical specialists must carry the responsibility for considerable geriatric care in the future. Therefore, there is now an urgent need for to make available to these specialists opportunities to learn the principles, strategies and tactics of excellent geriatric care and apply them for the benefit of their patients. Only in this way are outcomes likely to improve.

Objectives	Recommendations
The conclusion from analysis of the early years of the Hartford/AGS project is that many specialties are making progress toward enhanced education and faculty development in geriatric care, but there is an urgent need to overcome some important barriers. Accordingly, specialists and geriatricians should set the following mutual objectives:	The following specific recommendations are advanced in order to achieve each objective in the left column. These would be implemented by collaborative efforts on the part of geriatrics and the surgical and medical specialties.
Eliminate historical disinterest in geriatrics and increase awareness among specialists of the progress made in the care of older persons during the Geriatrics Renaissance of the past 25 years	Summarize in specialty-oriented literature the expanding evidence base for excellent geriatric care
Demystify prevalent myths derogatory to older people, which contribute to continuing relative disinterest in the care of elderly Americans	Correct mythology about aging through courses, symposia, and publications for professionals and the general public.
Expand and deepen research on aging and the evidence base for excellent geriatric care for the surgical and medical specialty patient	Encourage basic biogerontological research, define a multispecialty clinical research agenda, and increase funding from foundations, corporations, government agencies and individual philanthropy for controlled clinical trials of interventions to improve health and function of older people
Improve dissemination of new clinical research findings in geriatrics into the surgical and medical specialties	Take steps to assure that specialty residency programs adopt specific learning objectives and curricula in geriatric care as part of a targeted effort to enhance residents' knowledge, skills and attitudes relevant to care of the older patient.
Convince leaders of specialty societies, examining boards and residency review committees of the importance of applying existing evidence regarding methods for improvement of the health of older persons	Increase information dissemination by the major societies, academies and associations, increase mandated emphasis on eldercare in residency programs (not necessarily a defined time commitment), and increase geriatrics content in in-service and board examinations
Improve communication and collaboration between geriatrics and the surgical and medical specialties	Strive locally to strengthen the geriatrics division or department in the institution so that enough people will be available for on-site, day-to-day collaboration with the surgical and medical specialties and, reciprocally, include surgical and medical specialists as affiliates or members of geriatrics programs and centers/institutes on aging
Define the place of in-hospital care on specialty services in the overall care of older persons	Collaborate in developing well organized, continuing, coordinated health care systems for vulnerable older people, characterized by integration of care regardless of settings (office, clinic, home, assisted living, hospital, nursing home, and hospice) and by seamless financing mechanisms
Enhance remuneration for the care of older people, recognizing that the complexity of their illnesses necessitates additional physician time	Campaign, along with organized medicine and the public, for appropriate remuneration for the care of older patients
Overcome widespread deficiencies in knowledge of the principles of good geriatric care among specialists	Encourage medical schools to enhance their educational emphasis on care of the older patient so that all future specialists will have a foundation of basic principles and knowledge
Ameliorate the shortage of academic geriatricians and geriatrically oriented surgical and medical specialists who are needed to accomplish many of the above objectives	Encourage young physicians and surgeons to become interested in the geriatric aspects of their discipline as a career focus, including funding career development awards for junior faculty in surgical and medical specialties

References

1. Statistical Abstract of the United States 1998. The National Data Book. Washington: U.S. Census Bureau, Sept. 16, 1998.

2. Francis J. Perioperative management of the older patient. In Hazzard WR et al. (Eds.) Principles of Geriatric Medicine and Gerontology, 4th Ed, New York, McGraw-Hill, 1999, p 365.

3. Reuben DB, Bradley TB, Zwanziger J et al. The critical shortage of geriatrics faculty. J Am Geriatr Soc 1993;41:560-569.

4. Gray SL, Sanger M, Lestico MR, and Jalauddin M. Adverse drug events in hospitalized elderly. J Gerontology: Medical Sciences 1998;53A:M59-63.

5. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-384.

6. Hansen K, Mahoney J, Palta M. Risk factors for lack of recovery of ADL independence after hospital discharge. J Am Geriatr Soc 1999;47:360-365.

7. Sager MA, Franke T, Inouye SK, et al. Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med 1996;156:645-652.

8. Warren JL, Bacon E, Harris T, McBean AM, Foley DJ, and Phillips C. The burden and outcomes associated with dehydration among US elderly, 1991. Am J Public Health 1994;84:1265-1269.

9. Inouye SK. Delirium in hospitalized elderly patients: recognition, evaluation, and management. Conn Med 1993;57:309-315.

10. Mahoney JE. Immobility and falls. Clinics Geriatr Med 1998;14:699-726.

11. Palmer MH, McCormick KA, Langford A, Langlois J, Alvaran M. Continence outcomes: Documentation on medical records in the nursing home environment. J Nurs Care Qual 1992;6:36-43.

12. Covinsky KE, Martin GE, Beyth RJ, Justice AC, Sehgal AR, Landefeld CS. The relationship between clinical assessment of nutritional status and adverse outcomes in older hospitalized medical patients. J Am Geriatr Soc 1999;47:532-538.

13. Reuben DB, Greendale GA, and Harrison GG. Nutrition screening in older persons. J Am Geriatr Soc 1995;43:415-425.

14. Allman RM. Pressure ulcer prevalence, incidence, risk factors, and impact. Clinics Geriatr Med 1997;13:421-436.

15. Inouye SK, Bogardus ST, Charpentier PA, et al. A. multicomponent intervention to prevent delirium in hospitalized older patients. N Eng J Med 1999;340:669-676.

16. Landefeld CS, Palmer RM, Keresevic DM, et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med 1995;332:1338-1344.

The statement and recommendations resulted from deliberations between the following geriatricians and surgical and medical specialists:

Anesthesiology
Alan D. Sessler, MD	Representing:	Foundation for Anesthesia Education and Research American Society of Anesthesiologists
Emergency Medicine
Gary Strange, MD	Representing:	Society for Academic Emergency Medicine
General Surgery
Walter J. Pories, MD, FACS	Representing:	Association of Program Directors in Surgery
Obstetrics & Gynecology
Gerald Holzman, MD	Representing:	American College of Obstetricians & Gynecologists
Ophthalmology
Thomas J. Liesegang, MD	Representing:	American Academy of Ophthalmology
Orthopaedic Surgery
Kenneth J. Koval, MD	Representing:	American Academy of Orthopaedic Surgeons
Otolaryngology
Steven M. Parnes, MD	Representing:	American Academy of Otolaryngology
Physical Medicine and Rehabilitation
Dale C. Strasser, MD	Representing:	American Academy of Physical Medicine and Rehabilitation
Thoracic Surgery
Reneé S. Hartz, MD Joseph LoCicero, III, MD	Representing:	Society of Thoracic Surgeons Society of Thoracic Surgeons
Urology
George W. Drach, MD	Representing:	American Urological Association
AGS MEMBERS
David H. Solomon, MD	Co-Director	AGS/Hartford Project: Increasing Geriatrics Expertise in Surgical and Medical Specialties
John R. Burton, MD	Co-Director	AGS/Hartford Project: Increasing Geriatrics Expertise in Surgical and Medical Specialties
Joseph G. Ouslander, MD	President	AGS
Paul R. Katz, MD	Editor-in-Chief	Core Curriculum
Myron Miller, MD	Project Advisor	Advisor to Orthopaedic Surgery, PM&R, Representative to AAOS Task Force, Outreach Program
Peter Pompei, MD	Liaison Project Advisor to	AGS Education Committee Anesthesiology, Orthopaedic Surgery, Thoracic Surgery, Outreach Program
Meghan B. Gerety, MD	Treasurer	AGS
William B. Applegate, MD	Member	Board of Directors