Geriatrics is a branch of medicine which is involved with the medical, psychiatric and social problems of late life (Isaacs, 1981). Gerontology, on the other hand, is the science or study of the aging process. It includes the biological, social and psychological aspects of the aging process. As a result of prejudice and disinterest, it has not been until the last century that either geriatrics or gerontology developed as a legitimate area of medicine.
The recognized “graying” of America and the example of model programs, both in the United States and abroad, have stimulated a reawakening of health care educators to the needs of the elderly; educators have come to accept their responsibility to provide educated physicians and systems of health care to meet these needs. Since the 1960s, several medical residency training programs in geriatrics have been established. The National Institute of Aging, a division of the National Institute of Health, has been established to provide medical leadership in research, education and training. At present at least 13 training programs provide some exposure to geriatrics. There is now some interest in integrating gerontology and geriatrics into the curriculum of several medical schools.
Aging involves those changes which occur in any cell of an organ system as a function of time, independent of disease. Disease, on the other hand, is a pathological or abnormal state found in any cell, organ or organ system in a unit of time or extending over many units of time. Unfortunately, many people consider aging to be a pathological state or disease process. Aging is neither a disease process nor the result of multiple disease states. Aging and death, like birth and maturation, are part of the normal life cycle.
Theories of Aging
Many theories have been advanced which purport to explain the aging process on a cellular level. The biological clock theory states that manifestations of senescent changes are the result of the ‘playing out’ of the genetic program which contains specific information that code for senile changes preceding the demise and death of the organism.
The random deterioration theory states that aging results from gene exhaustion. Aging is caused by random events called ‘aging hits,’ which occur with a constant probability per unit of time throughout life. These ‘hits’ alter the chromosomes within the nucleus of the cell and cause aging. Similarly, the theory of auto-antibodies states that aging is a result of the body falsely recognizing part of itself as foreign and producing antibodies against itself. The destruction caused by these antibodies is postulated to result in aging. Another theory of random oxidative reactions and multiple deleterious changes in biologic sytems. Aging is the result of the changes produced by free radicals (Weber, 1990).
Physiological, Psychosocial and Anatomical Concomitants
of Normal Aging
With aging there occurs a decline in organ function. This decline occurs in a fairly predictable fashion and can be hastened by disease or retarded through such preventive means as rest, proper nutrition and exercise. It is important, however, to understand that these age-related decrements in organ function do not significantly impair the lifestyles of most elderly people. They primarily affect the reserve capacity of the organ system and the ability to handle and withstand stress. For example, cardiac function decreases slightly with age, but in spite of this decrease healthy elderly persons lead very comfortable lives. However, stress such as severe pneumonia may tax the cardiac reserve and could precipitate an episode of congestive heart failure.
With advancing age, unfortunately, poor health often accompanies diminished income. Almost all elderly persons report at least one chronic condition or impairment. For many, the chronic disease or illness does not impair either their lifestyle or their daily activities. However, almost one in five with a chronic disease is incapacitated, and one in three is partially limited in his activity level. The most frequently reported debilitating chronic diseases are cardovascular (21.8 percent), arthritis and rheumatism (20.7 percent) and visual problems (9.5 percent). In comparison to the rest of the population, those elderly who are able to secure health care have, per capita, more physician visits per year, consume more medications, are hospitalized more frequently with longer hospital stays and have significantly greater proportions of their income diverted to health care. Approximately 30 percent of the health care cost is now borne by the older person (Weber, 1980).
Medicare, which is only an insurance system, partly succeeded in helping the elderly finance the cost of health care but also inflated the cost of care. Medicare failed by not providing a health care delivery system designed to meet the unique health care needs of the elderly. Medicaid, a second government health financing system, is particularly important to the indigent elderly. Medicaid completely covers the cost of physician, hospital, home and long-term care. However, the 60-70 percent of the elderly who are middle class cannot avail themselves of Medicaid and are the group most hurt by the high cost of medical care.
The true incidence of psychiatric disorders in late life are unknown. It is difficult to determine not only because of the confusing classification systems but also because of the problem of a truly objective criteria in establishing a diagnosis. In 1971, the American Psychological Association estimated that at least 3 million elderly were in need of mental health services. Most would agree that this estimate is conservative. Depression is the most common ‘affective disorder’ found in an aging population (Jooley, 1981; Post, 1981; Arie, 1981).
The depressions of the aged have been divided into three groups: neurotic or situational depressions, endogenous depressions, and the depressions which occur in the course of senile and arteriosclerosis dementia. These categories are not mutually exclusive, nor are they comprehensive. Other terms used to describe depression include psychotic, neurotic, and involution. That depression is a real problem in late life is reflected by the increased rate of suicide, particularly among elderly Caucasian men. White men over 85 have a higher incidence of suicide than other groups by age, sex and race (Post, 1981).
The clinical presentation of depression frequently differs from the classic loss of appetite, weight loss, insomnia and early morning awaking. Most elderly people will deny depression on questioning but will present with apathy, withdrawal, self-depreciation, psychomotor retardation or a host of hypochondriacal complaints. The diagnosis is often missed and the patient labeled either a crock or merely senile. Tragically, the prognosis for treated depression in late life is good and is often smoother than for the younger population. Most elderly persons respond well to relief of environmental stress and antidepressants.
Brain weight declines with age, particularly after the 50s. Many confusing studies have been reported about brain cell or neuron loss during life (Weber, 1980). Several of the chambers located within the brain may enlarge with age. Externally, the coverings of the brain thicken, become fibrotic and may calcify. Another characteristic finding is the presence of senile plaques, composed of degenerated tissue found between brain cells. These lesions are uncommon before ages 50 to 60. There is a significant reduction in cerebral blood flow and metabolism and intellectual impairment (Arie, 1981).
The speed at which impulses are conducted through nerves becomes somewhat reduced after ages 40 to 50. Anatomical, microscopic, metabolic and physiological changes occur within the normal brain. Psychometric testing has also revealed age-related functional changes. Reaction times improve from childhood up to about 19, remain constant until 26 and show a slow decline after 26 on through 84.
With respect to memory, there does seem to be some deterioration of short-term memory. However, much of what has been done depends on what had been asked, by whom and for what purpose. If it is true that short-term memory decreases with age, then writing for older people should be in short sentences and presented in ways easy to understand. Problem solving ability has also been shown to be poorer in older adults. However, the majority of these studies have been in laboratory conditions, and it may well be that older adults solve everyday life problems better than younger people. Most studies on older adults indicate that they are very cautious about their behavior until the new behavior is proven to be better (Bischof, 1978).
Mental confusion is not part of normal aging. It is not a normal concomitant of aging, nor can all individuals who reach advanced age necessarily expect to become mentally impaired. It has been estimated that 15 percent of people 65-75 and 25 percent
of those 75 and older are confused to some degree (Jolley, 1981; Weber, 1980).
With normal aging, the capacity for abstract thinking does not necessarily decrease and in some individuals may actually increase. Likewise, problem solving ability does not necessarily decrease with age. However, the amount of time required to solve problems may increase. In addition, older individuals may be less flexible in their problem solving approaches (Bischof, 1978). On the other hand, senility (or organic brain syndrome) is defined as a decrease in the intellectual and functional ability of individuals to such an extent that they can no longer cope effectively with their environment. Traditionally, the intellectual functions which correlate with effective behavior include judgment, orientation to time, person and place, memory–recent and remote–arithmetic ability, reasoning and emotional stability.
The causes of the organic brain syndrome can be approached by empirically dividing the syndrome or symptom complex into those areas which occur suddenly and those which have a slower, insidious onset or have been evident for a prolonged time. The following are the causes of sudden confusional states: medications, infections, anemia, electrolyte imbalance, elevated or low blood sugar, kidney failure, stroke, cardiac dysfunction, pulmonary insufficiency, liver decompensation, overactive or underactive thyroid gland, malnutrition, psychiatric disorders, loss of vision and loss of hearing. Confusional states resulting from the above causes may be completely or partially reversible. It is important that families, relatives or friends do not automatically accept sudden progressive changes in behavior as senilty; instead, health care from a competent doctor should be sought.
Chronic irreversible confusional states usually have a very insidious onset and frequently are not even recognizable by families. The following are the most common causes of senility: Alzheimer’s disease, multi-infarct dementia, Creutafeldt-Jakob’s disease, post-traumatic dementia, normal pressure hydrocephalus and encephalopathy.
Long Term Care
Long-term care is a loosely organized system of services to assist those in need to reach and maintain their highest level of health and psychosocial functioning. It encompasses such diverse areas as homemaker services, home health aides, hot meal programs, meals-on-wheels, transportation, community mental health programs, social services, nursing, physical therapy, occupational therapy and domicilary care such as adult homes, foster home care and nursing home care.
A nursing home will be thought of as a conglomerate of the previously mentioned services organized within a fixed geographical area to provide services primarily to those elderly who, for various reasons, can no longer be supported in the community. Nursing homes constitute a diverse and heterogeneous group of institutions whose only common denominator is that of being licensed. With the passing of Medicare and Medicaid legislation in the mid-1960s, nursing home stock became a glamour stock in the United States, and there was an increase in the number of nursing homes. Services rendered by nursing homes can be grouped into four categories: hotel services, personal care services, nursing, medical and rehabilitative services, and psychosocial services.
Hotel services include housekeeping, laundry, dietary and maintenance services. Personal care services include assistance with the activities of daily living such as washing, dressing, eating and frequently getting around. These services are usually deliverd by nurse’s aides and nursing assistants. Nursing, medical and rehabilitative services are comprised of such traditional services as those found in most hospitals, including physical therapy, occupational therapy and speech therapy. Psychosocial services include social services, recreational therapy and religious care.
Nursing homes essentially deliver two broad levels of care:
skilled nursing care and intermediate, or health-related, care. These levels of care have been defined and developed by the major third-party reimbursers of care, Medicare and Medicaid. Skilled nursing care, the higher level of care provided by a nursing home, consists of the monitoring of specific disease processes, such as unstable diabetes mellitus, congestive heart failure and chronic obstructive lung disease. It includes the provision of services which must be delivered by or under the supervision of a registered nurse. Rehabilitative services such as physical therapy, occupational therapy and speech therapy are also included.
Individual functional disabilites such as mental confusion, incontinence and the inability to walk or transfer from bed to wheelchair are either not recognized as disabilities in some states or are related to a point-system evaluation which has been shown to have as many drawbacks as advantages. Intermediate, or health-related, care consists of providing such personal care services as assistance with dressing, washing, eating and walking. Few or no skilled nursing services are offered or are readily available except for the distribution of medications and monitoring of vital signs such as blood pressure. Reimbursement determines staffing patterns. Since third-party reimbursement is considerably less for intermediate, or health-related, care, the ratio of staff to residents is considerably less in the intermediate-care nursing homes and in those homes offering more than one level of care.
In time nursing homes will become a more integral part of a more highly organized system of health care for the elderly. Several different models have been suggested (Williamson, 1981; Harrocks, 1981). One model purposes that nursing homes develop a comprehensive system of services which would be available both to institutionalized and community elderly. These institutions would offer multiple levels of care including skilled nursing care, extended care for those recovering from acute illness, intermediate care and minimal supportive services (such as laundry, dietary and housekeeping). Along these levels of care, nursing homes would develop needed medical, nursing, social and restorative resources. These resources would be shared with the community elderly through day hospitals, out-patient geriatric clinics, home care programs and psychogeriatric programs.
An alternative proposal has been that individual nursing homes develop according to a medical model, a social model, a rehabilitative model or a psychiatric model. The medical model would be similar to the chronic disease hospital found in Britain and some other countries. Its purpose would be to care for those individuals who have serious and irreversible heart disease and other malignancies. The rehabilitative model would be fairly close to an acute care hospital. Its purpose would be to make available extensive rehabilitative medicine and restorative nursing to those elderly persons who have incurred such acute but reversible problems as hip fracture, stroke, congestive heart failure and pneumonia. The psychiatric model would be developed to manage the long-term psychiatric patient and also to diagnose and treat reversible psychiatric problems in late life.
The social model is conceptually similar to present adult homes and domiciliary care facilities. These facilities would offer a structured environment and essentially ‘hotel-like’ services to those elderly who could no longer provide these services for themselves in the community. Both the proposed comprehensive model and the fractionated model have inherent problems. The comprehensive models would result in a large institution which would become impersonal and nonresponsive to both the instutionalized elderly and the community elderly. In addition, health care, supportive services and institutional care, rather than occuring in the community, may be far removed from the community. The fractional model could split up health care, social services and support services to a greater extent than at present.
Alternatives to Instutionalized Care
During the past several years, there has been increasing interest in alternatives to institutionalized care (Wilson, 1981). This interest is a result of increasing costs of institutionalized care, rapid expansion of the population over 65, and realization that many of the services provided by the nursing home can be provided in the community at far less cost and with greater comfort and safety to the person in need. Alternatives to institutionalized care can be considered to include day hospitals, day care centers, home care programs and out-reach programs.
Day hospitals were first used in Britain. Patients are picked up at their residences by a vehicle designed for the handicapped and brought to the day hospital for however long their particular therapy requires. While there, they are served a warm meal and attention is given to their multiple problems. Day hospitals have allowed for earlier discharge from acute care and convalescent centers and prevented regression of functional ability after discharge.
Day care, similar in concept, delivers more supervision in terms of recreational therapy and socialization than actual restorative techniques such as physical therapy or occupational therapy. Day care permits families caring for a mentally or physically handicapped parent to continue their normal eight-hour working day and yet still be able to care for their parent evenings, nights and weekends.
Many home-bound elderly persons who are unable to leave their apartments or homes are in need of medical nursing, restorative or social services. Home care can fill this void by providing these needed services in the home. In several cities, out-reach programs have been developed which seek out those in need of care before an acute crisis precipitates the need for institutionalized care (Ginevan & Hadeka, 1986).
Since most of the programs described are funded by grants, they are limited in scope and duration. Little is available in permanent funding or existing reimbursement to support these needed programs. It could be that providing alternative services may not actually decrease the absolute number of institutionalized elderly persons as much as increase the number who actually receive appropriate services.