While there is still a severe shortage of geriatricians, this has been a decade in which both the public and politicians have become more aware of the need for specialist physicians who focus on the care of older persons. Geriatricians tend to focus on the older person’s ability to function, rather than on specific disease processes. This tends to give them a different perspective on medical advances. Here are my top ten breakthroughs in geriatrics in the last decade:
1. Exercise and sarcopenia. This decade has dramatically increased the awareness of the need for regular exercise (at least three times a week) for older persons. It has become clear that resistance exercise is essential to allow older persons to maintain muscle mass and strength (Stop sarcopenia). Simple exercise has also been shown to prolong life e.g. regular stair climbing; decrease the chance of developing dementia and slowing functional decline and enhancing the mood in depressed people. In the case of persons who are falling, resistance exercise along with balance exercise decreases falls. Physical therapists are now aware that as older persons develop memory problems, they find it difficult to “walk and talk”. Special exercises have been developed to improve the person’s ability to do another task while walking. All older persons who are falling should have six weeks of home exercise therapy from a physical therapist. All persons should increase their Spontaneous Physical Fun (SPF) by parking far away from their destination and climbing stairs.
2.Recognition of FRAILTY: Geriatricians have become very aware that older persons pass through a state of frailty before they become disabled. Frail persons have a combination of weight loss, decreased strength or activity, fatigue and multiple minor illnesses. Emerging evidence suggests that aggressive treatment of frailty may prevent disability from occurring. Treatment includes resistance exercise, increased protein in the diet and perhaps anabolic steroids. Testosterone, together with a protein-calorie drink, decreases hospitalisation. Testosterone improves function in older men and women with heart failure. A new anabolic steroid developed by GTx in Memphis almost looks like “exercise in a pill”.
3. Dabigatran: This drug which works as well as warfarin for older persons who need their blood thining, does not require regular blood sampling to maintain appropriate levels. It may have less side effects as well. The disadvantage is it needs to be taken twice a day. However, for both patients and physicians this drug appears to be likely to greatly improve quality of life.
4. Vitamin D: It is now recognized that the majority of older persons have low blood levels of the sunshine vitamin. Increasing these levels decreases falls, improves function, decreases hip fracture and decreases the chance of dying. Vitamin D is truly the vitamin of the decade.
5. Delirium Intensive Care Units: Older persons with delirium have poor outcomes in hospital. The development of Delirium Units at St Louis University and Des Peres hospitals by my colleague, Dr Joseph Flaherty, has markedly improved outcomes. This along with other system improvements for older persons has lead to more pleasant and happier hospital stays for older people.
6. Stem Cells for the Heart: A number of studies have shown that umbilical stem cells decrease subsequent heart attacks and may reverse hear failure. Fish oil (DHA and EPA) appears to be the miracle drug for heart disease.
7.Alzheimer’s Disease: The recognition that exercise appears to be as effective as available drugs to treat dementia opens the way for the development of new drugs. A number of candidates are being developed including our one (an antisense to Amyloid Precursor Protein developed at the St Louis Veteran’s Administration). The new screening test for dementia and predementia developed at Saint Louis University and the VA represents an important step forward in the early identification of persons at risk for Alzheimer’s disease. This can be coupled with a new skin test being developed for Alzheimer’s disease.
8.Reducing use of therapeutic drugs in older persons: Drugs are over utilized in the United States both by patients and physicians. It is now being recognized that over treatment can be as bad as under treatment. The Cochrane collaboration found that most older people have their blood pressure over treated. Antipsychotic drugs which are often used to treat behavioral problems in older persons have been shown to increase the death rate. One of our medical students actually found that exercise done three times a week was highly effective at reducing the need for drugs for agitation. Geriatricians specialize in reducing drugs.
9. Recognizing the Role of the Caregiver: The wonderful work done by families, certified nurse aides and others, looking after older persons in need of help is being much more recognized. These persons are the true angels of health care and are totally under reimbursed. The importance of high quality support groups such as those run by the Alzheimer’s Association (www.alz.org or 1-800-272 3900) has been recognized.
10. Recognition of Palliative Care: Slowly physicians and patients are recognizing that appropriate palliative and hospice care can allow us to go “gentle into the good night”. The Veterans Administration has been a leader in developing superb end of life care. Studies have shown that withdrawal of care at the right time may not only improve quality of our last days but may even extend life. So I guess I should thank Mr Limbaugh and governor Palin for their ridiculous characterisation of “death panels” as it gave an opportunity for more rational comments on palliative care to appear in the mainstream media.
I invite those of you reading this to comment on what you see as the major advances of the last decade.