The importance of the geriatric doctor in the care of the elderly

With the demographic changes that have taken place, the western world has greatly increased life expectancy and reduced the birth rate, which has led to a significant ageing of the population, especially those over 85 years of age, all of which represents a challenge in terms of covering the social and health needs that derive from it.

People over the age of 65 use health resources more, so they attend primary care consultations twice as often, go to the emergency services more often and are admitted more often to hospitals, the stays being longer and more justified. Approximately 10% of GDP is allocated to cover these needs, but the current economic situation has led to cuts in this funding, increasing needs exponentially, so that in the short term this imbalance will become apparent.

The scientific and technical advances in medicine, as well as the hygienic changes in society that have taken place throughout the 20th century, have achieved this milestone in the history of mankind, however they force society to rethink the objectives and adapt the resources to a changing population.

The geriatric doctor must have adequate knowledge of the changes that occur with ageing in the different organs and systems, the modifications of the different chronic pathologies that accumulate over time, detecting early the so-called geriatric syndromes (dementia, delirium, falls, incontinence, malnutrition) and the effects of the medicines in the management of the different pathologies. The form of presentation of the disease is modified by the aforementioned physiological and pathological changes, with the frequent presence of sensory and cognitive changes in the elderly, with the usual form of presentation being atypical and paucisymptomatic. In many cases there is no relationship between the symptom or organ affected and the function, which is why functional deterioration is often due to a multifactorial cause, as there is a decrease in the organic reserve and a homeostatic imbalance that leads to an increase in vulnerability.

The main diagnostic tool is the Comprehensive Geriatric Assessment which dynamically evaluates and quantifies the physical/biological, psychic (cognitive, affective, behavioural) and social state, emphasising knowledge of functional capacity as the main variable for establishing the performance of care plans and care objectives. Once the different needs of the person have been identified and with knowledge of their environment and potential for recovery, the effective participation of an interdisciplinary team (doctor, nurse, social worker, psychologist, occupational therapist, physiotherapist) is required to achieve objectives that are proportional to the classification of the elderly person in a reasonable time frame and monitoring the changes that have taken place. The knowledge and adequate management of the different social and health resources of the community are essential to guarantee continuity of care, requiring multidisciplinary work that facilitates and adapts to the changing needs of vulnerable patients, adapting the necessary transitions between resources.

Another objective of special relevance is the prevention of dependence in order to achieve active and successful ageing, by means of primary prevention measures (reducing the incidence of diseases), secondary prevention (reducing the prevalence of diseases), tertiary prevention (compensating for the consequences of the disease) and quaternary prevention (those measures that prevent damage through the use of diagnostic or therapeutic means). It is advisable to promote healthy lifestyle habits, especially by carrying out physical exercise programmes, in order to maintain an adequate gait, balance and muscular power for as long as possible, an adequate diet that maintains energy needs and is varied, to maintain certain creative concerns and to carry out adapted psycho-stimulation programmes, paying special attention to making adaptations to the disabilities that appear in order to maintain the maximum possible autonomy. The early detection of fragility in the community, as an intermediate step prior to dependency, is fundamental in this preventive strategy of disability, carrying out opportunistic detection in all consultations on loss of weight, strength or energy, slowing down, in order to alert and advance care plans to dynamic needs. It is not necessary to wait passively for the appearance of functional deterioration, or to carry out screening of the same, which although relevant, what is fundamental is an active role in society so that those people with greater risk initiate activities that promote latent capacities, especially those related to basic activities of daily life (hygiene, clothing, walking, food, continence) and psychostimulation.

Aspects that take into consideration the safety of care are increasingly relevant, especially in the most vulnerable population group. It is of interest to have procedures in terms of detection, assessment and intervention in falls and gait disorders, in the appropriate use of medicines and the prevention of adverse reactions to medicines, which is the fourth cause of death in the elderly that is often preventable, and at hospital or institutional level in nosocomial infection control programmes.

The development and implementation of palliative care plans in non-oncological patients with advanced organ failure seeks the maximum comfort of the person, the best possible quality of life, focusing on adequate symptom control, anticipating and planning together with the patient and caregivers for decision-making at the end of life, in order to be able to avoid unnecessary diagnostic or therapeutic measures. Similarly, an assessment of the geriatric oncological or surgical patient must be carried out, so that the benefits and risks of the different diagnostic or therapeutic interventions can be weighed up in the best possible way, in order to avoid unnecessary suffering. As the Hasting Center affirms, the aims of medicine must be more than curing disease and extending life; the human condition is inseparable from disease, pain, suffering and death, so proper medical practice must begin by accepting human finitude and teaching or helping people to live in it.

For all these reasons, the geriatric doctor must disseminate aspects of health promotion, prevent dependency with the help of community resources and in an interdisciplinary way, be a manager of the different care processes seeking real results in health and functionality, accompanying and caring for people and their families by means of the technical tools he or she has available and above all with the ability to communicate, accompany, relieve together with the development of ethical values that respect people's choices and dignity. As the acronym says, "the right old man, in the right place, at the right time" (to which one can add the right diagnostic and therapeutic procedures).

1. King and Guralnik. Maximizing the Potential of an Aging Population. JAMA 2010;304:1944.

2. Abizanda P, Gomez-Pavón J, Martin Lesende I et al. Detection and prevention of fragility: a new perspective of prevention of dependency in the elderly. Med Clin 2010;135:713-9.

3. Strategic Plan for the implementation of the European innovation cooperation on active and healthy ageing. COM (2012) 83, Brussels Available at http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:32011D0940:EN:NOT