Petrovic, Mirko

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Ghent University Academic Bibliography

 1 Professional Standards in Geriatric Training in Europe  Mirko Petrovic1* 1Service of Gerontology and Geriatrics, Ghent University Hospital, Ghent, Belgium                  _________________________________ *Correspondence and requests for reprints should be addressed to Prof. dr. Mirko Petrovic, Service of Geriatrics, University Hospital, De Pintelaan 185, B-9000 Gent, Belgium. Tel: +32-9-332 23 66. Fax: +32-9-240 38 95.  E-mail : mirko.petrovic@ugent.be  2 Demographic evolution  As a result of improved medical care, people in Europe are living progressively longer. In general, life expectancy has increased in the last 40 years, by over 8 years for men (from 67.3 years to 75.6 years today) and for women over the same period by nearly 9 years (from 73 years to 81.8 years today). Further increase of 6 years for men and 5 years for women is estimated by the year 2050. This development has implications for the number of the very old (over 80 years). Their contribution to the total population will nearly triple by the year 2050, from 4.1 percent today to 11.4 percent. This will importantly alter the generational structure. Consequently, the median age in Europe will rise from 39 years today to 49 years.  Due to such evolution the absolute number of frail older persons will increase as well (1). Fast ageing of the society increases the demand for specialists in the healthcare of older people in order to ensure both clinical and research excellence. International Association of Gerontology (IAGG), since its foundation in 1950, has been concerned with demographic evolution and the growing demands for experts in the health care for the elderly. For that reason, IAGG consequently promotes gerontological research in biological, medical, behavioural and social policy, and practice fields. Besides, IAGG promotes the training of highly qualified personnel in the field of ageing, and the interests of gerontological organisations internationally. The IAGG has a close relationship with the United Nations programme on Ageing. The setting up of the European Region in 1967 by the IAGG (ER-IAGG) was the first European organisation dealing with ageing. In 1992 a group of academics in the field of medical gerontology started the European Academy for Medicine of Ageing (EAMA). The European Union of Medical Specialists (UEMS), founded in 1958, inaugurated a Geriatric Medicine Section (GMS) in 1997 and in 2001 the European Union Geriatric Medicine Society (EUGMS) was established (2).   3 History of geriatrics in Europe Geriatric medicine was introduced in the late 1940s in the United Kingdom, specialising mainly on rehabilitation and social reintegration of the older persons into the community. During the last six decades geriatric medicine  has progressed generally in two directions, i.e. either focusing on the management of the elderly in the community or developing a distinct specialty, frequently in close relationship with general internal medicine (3, 4). Due to evolution within general internal medicine towards various subspecialisations and also due to specific needs and demands of the increasingly growing older population, geriatric medicine became recognised as an independent specialty in several European countries (i.e. Belgium, Denmark, Finland, Ireland, Italy, the Netherlands, Spain, Sweden, Switzerland and the United Kingdom).   Geriatric medicine as a distinct speciality Geriatric medicine is a subspeciality of internal medicine concerned with the health and well-being of older adults. Geriatrics addresses not only physical, but also mental, emotional, social and environmental needs of the elderly. Additionally, geriatrics stresses preservation of functional independence even in the presence of multiple chronic diseases. Specific for geriatric medicine is the detection of the unique features of disease presentation in the elderly, the treatment of various co-morbidities, the need for comprehensive geriatric assessment, and the need for tailored and judicious pharmacotherapy in addition to discharge planning and the dealing with ethical issues and terminal care (3, 5).   Specific skills in geriatric medicine Geriatricians posses specific skills in the assessment and treatment of medical, psychological and social problems in the elderly, and particularly of the principle geriatric syndromes, such  4 as mobility disorders, falls, incontinence, pressure ulcers, dementia and delirium. These skills are necessary to achieve high professional standards in the acute and chronic medical care and rehabilitation for the elderly. They include the promotion of good health in later life, the prevention of illness and the reduction of disability. Expertise in geriatric medicine includes comprehensive geriatric assessment, evaluation and management of frail, older patients. Such expertise is effective in improving health, activity and function. It reduces morbidity and mortality, prevents recurrent hospital admission, and delays or postpones institutionalisation (5, 6).  Comprehensive Geriatric Assessment The Comprehensive Geriatric Assessment (CGA) is a multidimensional diagnostic approach within the care for the elderly. It differs from a standard medical evaluation by including non-medical domains such as functional ability and quality of life, and by relying on interdisciplinary teams. CGA  assists in the diagnosis of health-related problems, development of plans for treatment and follow-up, coordination of care, determination of the need for and the site of long-term care, and optimal use of health care resources. CGA has been defined as a multidimensional process intended to assess functional ability, physical health, cognitive and mental health, and socio-environmental situation of an elderly person.  Comprehensive geriatric assessment of frail or chronically ill patients can improve their care and clinical outcomes. The possible benefits include greater diagnostic accuracy, improved functional and mental status, reduced mortality, decreased use of acute care hospitals and nursing homes in addition to greater satisfaction with care. CGA is most successful when conducted by a geriatric interdisciplinary team, which typically includes a geriatrician, a nurse, a psychologist, a physiotherapist, a social worker, and optionally a pharmacist. The geriatrician directs and advises a multidisciplinary team in a patient’s treatment, rehabilitation  5 and long-term care plan where necessary and discusses decisions regarding discharge arrangements with the patient and their carers, respecting at all times the expertise and skills of other professionals. The geriatrician has knowledge of palliative care, of health promotion and preventative health care and of the local social support system (5). The principal domains assessed in all forms of geriatric assessment are functional ability, physical health, cognitive and mental health, and the socio-environmental situation. Standardised instruments make evaluation of these domains more reliable and efficient. They also facilitate the communication of clinical information among health care practitioners and the monitoring of changes in the patient's condition over time. Medical problems that will benefit from preventive, diagnostic, therapeutic or supportive measures, requests and expectations of elderly patients and services offered to the elderly, represent specific aspects of health and social care for old patients (7-11). The elderly need an integrated network of health care and social services to provide the continuity of care.   Multidisciplinary approach in geriatric medicine Key to the provision of health services for older people is a partnership across the whole health and social care framework in a region. Geriatricians continue to have a vital role and duty to provide care for older people in collaboration with general physicians (5, 12). Multidisciplinary working necessitates close liaison with many complementary services such other branches of internal medicine and surgery, physical medicine and rehabilitation and psychiatry of old age. Respect for patient autonomy is at the centre of practice, particularly when dealing with cardiopulmonary resuscitation, assisted ventilation, artificial feeding, and other interventions. Geriatricians recognise the importance of involving informal carers in decisions about complex treatment in old age and consider a patient’s quality of life and disability-free life  6 expectancy as important goals of treatment rather than absolute longevity. Patient and carer support groups have a role in the management of chronic conditions in older life, particularly with conditions such as stroke, Parkinson’s disease and dementia (12).   Undergraduate and postgraduate training in geriatric medicine The European Union Geriatric Medicine Society (EUGMS) is the co-ordinating organisation of the national geriatric medical societies of the European Union member states. Its main goal is to develop geriatric medicine in all member states as an independent specialty, contributing to the care of all older people with age-related diseases. Besides, the EUGMS is aware of the importance of education for all medical students and recommends the inclusion of geriatric medicine in all undergraduate curricula within the European Union. It that line, it has been recommended that training in geriatric medicine should occur throughout Europe starting at undergraduate level and progressing through postgraduate training. However, among the member states there still exist large differences in structure, health care services and training facilities.  Within the EUGMS there is a large consensus on the view that during undergraduate training students need to be aware of aspects of normal ageing: the older patient’s history, interdisciplinarity, ethical and end-of-life issues and the assessment of older patients. It is the responsibility of each medical school to ensure that there is an academic department of geriatric medicine with appropriate educational resources (i.e. staff, facilities, funding). Each medical school should ensure that established competencies and requirements are implemented. These competencies and objectives are conceived as three main domains: knowledge, skills and attitudes. Problem-based questions related to geriatric medicine should be included in the final examinations (2, 3).  7 Enhancement and harmonisation of education is supported by programmes which train the teachers, such as the European Academy for Medicine of Ageing (EAMA). In 1995 the EAMA started a programme for teaching the teachers in geriatric medicine. Each course is divided into four one-week sessions spread over two years. Geriatric medical issues, over a wide range, are covered during the four weeks, and include a large variety of medical problems, ethics and aspects of education and management (13-15). The EUMS recommends the general principle of four years postgraduate training for geriatric medicine in addition to two years of internal medicine. Although in some countries the training is still in addition to the completion of specialist training in internal medicine. In nearly all countries the trainees have to spent at least two years in general or internal medicine (2,3). The curriculum for the training recommended by the EUGMS has been published in the brochure ‘Training in geriatric medicine in the European Union’ (16). Included are the knowledge of basic care and provision of appropriate services in geriatric medicine, assessment and training, rehabilitation services, discharge planning, assessment for long-term care and research. Postgraduate training should comprise aspects of acute and primary care, old age psychiatry, palliative medicine, long-term care and rehabilitation medicine.  Postgraduate training should be a patient-centred learning process, supported by reflective critical evaluation by the trainee. The purpose of the training is to promote the development of a specialist in geriatric medicine, who posses the adequate level of knowledge, skills, attitudes and competence, to work independently and effectively.  The development of such training programmes needs support of national governments, specialist’s societies and universities. The EUGMS advises a combination of clinical and theoretical training as the best method. Most EU countries have this combination.     8 Challenges for the future To ensure its growth and prosperity, geriatric medicine will need to embrace not only the care for the geriatric patient, but also other important challenges such as research on ageing and education in geriatric fields as components of its core mission. The medical and psychological care of the elderly will be more complex also due to ethical aspects of the care. Additionally, the systems of care should be reoriented to providing longitudinal, proactive and coordinated care to complex patients. One of the greatest challenges remains the motivation of young people to accept a job in the care for the old frail people. Geriatric medicine should create a positive image of the frail patient by stimulating the knowledge about this patient population through the development of research (17).             9 References 1. Europe’s demographic future: facts and figures. Commission staff working document.  SEC (237). Brussels: Commission of the European Communities, 2007: p.9. 2. Hastie I, Duursma S. Geriatric Medicine in the European Union: Unification of Diversity. Aging, Clinical and Experimental Research 2003; 15, 4: 347-351. 3. Duursma S, Castleden M, Cherubini A, Cruz-Jentoft A, Pitkälä K, Rainfray M, Sieber C, Sinclair A. Position statement on geriatric medicine and the provision of health care services to older people. J Nutr Health Aging 2004; 8: 190-195. 4. Evans JG. Geriatric medicine: a brief history. BMJ 1997; 315:1075-1077. 5. Van Den Noortgate N, Petrovic M. The importance of a geriatric approach in medicine. Acta Clinica Belgica 2009; 64: 7-10.  6. The Federation of the Royal Colleges of Physicians of the United Kingdom. Census of consultant physicians in the UK, 2002. Data and commentary. London: The Federation of the Royal Colleges of Physicians of the United Kingdom, 2002. 7. Stuck AE, Siu AL, Wieland GD, Adams j, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993; 342: 1032-1036. 8. Vidan M, Serra JA, Moreno C, Riqquelme G, Ortiz J. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. J Am Geriatr Soc 2005; 53: 1476-82. 9. Caplan GA, Williams AJ, Daly B, Abraham K. A randomized controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department – the DEED II study. J Am Geriatr Soc 2004; 52:1417-23.  10 10. Nikolaus T, Specht-Leible N, Bach M, Oster P, Schlierf G. A randomized trial of comprehensive geriatric assessment and home intervention in the care of hospitalized patients. Age Ageing 1999; 28:543-50. 11. Reuben DB, Borok GM, Wolde-Tsadik G, Ershoff DH, Fishman LK, Ambrosini VL, Liu Y, Rubenstein LZ, Beck JC. A randomized trial of comprehensive geriatric assessment in the care of hospitalized patients. N Engl J Med 1995; 18:1345-50. 12. Mold JW, Green LA. General Internists and Family Physicians: Partners in Geriatric Medicine? Ann Intern Med. 2003; 139: 594-596. 13. Stähelin H, Beregi E, Duursma SA, Evans JG, Michel J-P, Ruiz-Torris A, Steen B. Teaching Medical Gerontology in Europe. Group of professors of medical gerontology. Age Ageing 1994; 3:197-8. 14. Verhaar HJJ, Becker C, Lindberg OIJ. European Academy for Medicine of Ageing: a new network for geriatricians in Europe. Age Ageing 1998; 27: 93-4. 15. Michel JP, Stähelin H, Duursma SA, Grimley Evans J, Swine C, Chassagne P, Kressig R, Zuniga C, Van Es MC. Un saignement innovant, une création réussie: l'European Academy for Medicine of Ageing (EAMA). Le point de vue des enseignements et des étudiants. Rev Med Interne 1999;20: 531-5. 16. Training in geriatric medicine in the European Union. Geriatric Medicine Section, European Union of Medical Specialists, Brussels 2000. 17. Research agenda of ageing for the 21st century. At: www.sfu.ca/iag or via: www.eriag.com.   

Professional standards in geriatric training in Europe

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Professional standards in geriatric training in Europe

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Ghent University Academic Bibliography