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Brand New Medicine for an Older Society
JAMDA xxx (2016) 1e2
JAMDA journal homepage: www.jamda.com
Letter to the Editor
Brand New Medicine for an Older Society To the Editor: The prolongation of life expectancy has been a major endeavor throughout human history. Economic development, technological and medical advancements, and the establishment of solid public health systems have been instrumental to the fast-paced increase in longevity witnessed over the past century. Yet, global aging poses serious threats to the sustainability of health and social care systems and urges a thoughtful reshaping of current models of care.1 The traditional medical paradigm of (young) patients suffering from a single acute illness is unsuitable for the efficient take-incharge of older, multimorbid, and functionally impaired persons, who represent a growing and increasingly demanding share of modern societies.2 Not surprisingly, the concepts of “comprehensive assessment,” “frailty,” “biological age,” “functional capacity,” and so forth, once confined within the boundaries of geriatric medicine, have begun to “permeate” other medical disciplines. So, can we confidently withstand the “gray tsunami” that looms over contemporary medicine? Not quite yet. The notion of age per se being a chief factor in medical decisions is still deeply rooted in clinical practice. The tendency of various medical specialists to consider one health condition at a time without appreciating the whole picture is difficult to eradicate and rather resembles “the blind men and the elephant” attitude. As a matter of fact, chronological age and individual diseases are commonly the sole factors considered when estimating the risk of incurring adverse health-related events. Although advanced age and specific diseases undoubtedly contribute to increasing the risk of unfavorable endpoints, the heterogeneity of the older population cannot simply be captured by the “number of years a person has been living.”3 Furthermore, multimorbidity has a greater impact on an older person’s functional capacities and health care utilization than might be expected from the “arithmetical” sum of single conditions.4 Finally, exogenous factors (eg, socioeconomic status, access to health care services, caregivers’ network) are very often neglected in clinical decision algorithms, whereas they are crucial for the formulation of wise medical decisions in the elderly. There is indeed a striking dissociation between what should be discussed in the medical literature because it is demanded by daily practice and what is actually found. For example, a recent article published in a major medical journal brilliantly reviewed the cardiac complications occurring in patients undergoing major noncardiac surgery.5 Although the work is surely commendable, all the aforementioned considerations were not adequately taken into account for judging the perioperative risk in older patients. http://dx.doi.org/10.1016/j.jamda.2016.02.024 1525-8610/Ó 2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
On the other hand, risk assessment in surgical geriatric patients is not necessarily as complicated and time-consuming as one might assume. A measure as simple as usual gait speed, often indicated as a true vital sign in advanced age,6 is already sufficient to improve the predictive capacity of traditional risk models (eg, the Society of Thoracic Surgeons [STS] score) for negative outcomes in older patients undergoing cardiac surgery.7 The fact that the STS score and gait speed were found not to be correlated with each other suggests that the 2 tools indeed capture distinct aspects of an older person’s health status.7 From a different perspective, applying tools that were originally developed for younger patients to geriatric medicine may expose to the risk of failure in correctly judging the risk profile of older adults. Indeed, the lack of appreciation of the peculiar clinical characteristics of complex elderly patients very often results in 2 extreme, equally detrimental consequences: (1) the exclusion of older multimorbid persons from effective treatments, or (2) disease-specific, guideline-driven prescription of numerous and potentially harmful drugs and procedures.8,9 Obviously, the improvement of care and maximization of benefits from interventions in older patients cannot be solely obtained by adding the measurement of gait speed to traditional assessment tools. To solve the duality between “reductionism” and the medical complexity of our aging societies, a substantial modification of current paradigms is required, shifting from traditional, disease-centered models of care to more comprehensive and person-tailored approaches.2 An unavoidable, yet desirable step in such a transition would entail the widespread implementation of integrated models of care in which a geriatrician (or an internist versed in geriatric medicine) may support clinical decisions for complex older patients. In other words, health care models should promote the implementation of multidisciplinarity and comprehensive evaluations by privileging the integration of specialties around the common denominator of the “aging phenomenon.” Notable examples of such an approach already exist. The orthogeriatric comanagement is a long-standing success combining the expertise of 2 “disparate” disciplines. Other collaborative programs, including oncogeriatrics,10 geriatric surgery (both cardiac and noncardiac),11 and geriatric palliative care,12 are receiving increasing attention. The brand new medicine that will flourish from the synthesis of geriatric care with other specialties will be better equipped to confront the multifaceted medical needs of an aging society and ensure the sustainability of public health care systems in the years to come. However, an integrated system of care will be successful only if the individual disciplines that compose it receive equal attention and respect in the development of intervention models. Should this not be granted, suboptimal and antagonistic forms of apparent collaboration will continue to be generated with single specialists working in “parallel” rather than collegially interacting with one another.
2
Letter to the Editor / JAMDA xxx (2016) 1e2
Acknowledgment The authors thank Alex Sisto (Catholic University of the Sacred Heart, Rome) for his thoughtful comments during the preparation of the manuscript. References 1. Christensen K, Doblhammer G, Rau R, Vaupel JW. Ageing populations: The challenges ahead. Lancet 2009;374:1196e1208. 2. Banerjee S. Multimorbiditydolder adults need health care that can count past one. Lancet 2015;385:587e589. 3. Cesari M, Vellas B, Gambassi G. The stress of aging. Exp Gerontol 2013;48: 451e456. 4. WHO. World report on ageing and health. Geneva, Switzerland: WHO. Available at: http://apps.who.int/iris/bitstream/10665/186463/1/9789240694811_ eng.pdf; 2015. Accessed February 19, 2016. 5. Devereaux PJ, Sessler DI. Cardiac complications in patients undergoing major noncardiac surgery. N Engl J Med 2015;373:2258e2269. 6. Afilalo J, Eisenberg MJ, Morin JF, et al. Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery. J Am Coll Cardiol 2010;56:1668e1676. 7. Cesari M. Role of gait speed in the assessment of older patients. JAMA 2011; 305:93e94.
8. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA 2005;294:716e724. 9. Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med 2004;351: 2870e2874. 10. Wildiers H, Heeren P, Puts M, et al. International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer. J Clin Oncol 2014;32:2595e2603. 11. Zenilman ME, Katlic MR, Rosenthal RA. Geriatric surgerydevolution of a clinical community. Am J Surg 2015;209:943e949. 12. Just JM, Schulz C, Bongartz M, Schnell MW. Palliative care for the elderlyddeveloping a curriculum for nursing and medical students. BMC Geriatr 2010;10:66.
Emanuele Marzetti, MD, PhD, Tommaso Sanna, MD, Riccardo Calvani, PhD, Roberto Bernabei, MD, Francesco Landi, MD, PhD Catholic University of the Sacred Heart, Rome, Italy Matteo Cesari, MD, PhD Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
JAMDA journal homepage: www.jamda.com
Letter to the Editor
Brand New Medicine for an Older Society To the Editor: The prolongation of life expectancy has been a major endeavor throughout human history. Economic development, technological and medical advancements, and the establishment of solid public health systems have been instrumental to the fast-paced increase in longevity witnessed over the past century. Yet, global aging poses serious threats to the sustainability of health and social care systems and urges a thoughtful reshaping of current models of care.1 The traditional medical paradigm of (young) patients suffering from a single acute illness is unsuitable for the efficient take-incharge of older, multimorbid, and functionally impaired persons, who represent a growing and increasingly demanding share of modern societies.2 Not surprisingly, the concepts of “comprehensive assessment,” “frailty,” “biological age,” “functional capacity,” and so forth, once confined within the boundaries of geriatric medicine, have begun to “permeate” other medical disciplines. So, can we confidently withstand the “gray tsunami” that looms over contemporary medicine? Not quite yet. The notion of age per se being a chief factor in medical decisions is still deeply rooted in clinical practice. The tendency of various medical specialists to consider one health condition at a time without appreciating the whole picture is difficult to eradicate and rather resembles “the blind men and the elephant” attitude. As a matter of fact, chronological age and individual diseases are commonly the sole factors considered when estimating the risk of incurring adverse health-related events. Although advanced age and specific diseases undoubtedly contribute to increasing the risk of unfavorable endpoints, the heterogeneity of the older population cannot simply be captured by the “number of years a person has been living.”3 Furthermore, multimorbidity has a greater impact on an older person’s functional capacities and health care utilization than might be expected from the “arithmetical” sum of single conditions.4 Finally, exogenous factors (eg, socioeconomic status, access to health care services, caregivers’ network) are very often neglected in clinical decision algorithms, whereas they are crucial for the formulation of wise medical decisions in the elderly. There is indeed a striking dissociation between what should be discussed in the medical literature because it is demanded by daily practice and what is actually found. For example, a recent article published in a major medical journal brilliantly reviewed the cardiac complications occurring in patients undergoing major noncardiac surgery.5 Although the work is surely commendable, all the aforementioned considerations were not adequately taken into account for judging the perioperative risk in older patients. http://dx.doi.org/10.1016/j.jamda.2016.02.024 1525-8610/Ó 2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
On the other hand, risk assessment in surgical geriatric patients is not necessarily as complicated and time-consuming as one might assume. A measure as simple as usual gait speed, often indicated as a true vital sign in advanced age,6 is already sufficient to improve the predictive capacity of traditional risk models (eg, the Society of Thoracic Surgeons [STS] score) for negative outcomes in older patients undergoing cardiac surgery.7 The fact that the STS score and gait speed were found not to be correlated with each other suggests that the 2 tools indeed capture distinct aspects of an older person’s health status.7 From a different perspective, applying tools that were originally developed for younger patients to geriatric medicine may expose to the risk of failure in correctly judging the risk profile of older adults. Indeed, the lack of appreciation of the peculiar clinical characteristics of complex elderly patients very often results in 2 extreme, equally detrimental consequences: (1) the exclusion of older multimorbid persons from effective treatments, or (2) disease-specific, guideline-driven prescription of numerous and potentially harmful drugs and procedures.8,9 Obviously, the improvement of care and maximization of benefits from interventions in older patients cannot be solely obtained by adding the measurement of gait speed to traditional assessment tools. To solve the duality between “reductionism” and the medical complexity of our aging societies, a substantial modification of current paradigms is required, shifting from traditional, disease-centered models of care to more comprehensive and person-tailored approaches.2 An unavoidable, yet desirable step in such a transition would entail the widespread implementation of integrated models of care in which a geriatrician (or an internist versed in geriatric medicine) may support clinical decisions for complex older patients. In other words, health care models should promote the implementation of multidisciplinarity and comprehensive evaluations by privileging the integration of specialties around the common denominator of the “aging phenomenon.” Notable examples of such an approach already exist. The orthogeriatric comanagement is a long-standing success combining the expertise of 2 “disparate” disciplines. Other collaborative programs, including oncogeriatrics,10 geriatric surgery (both cardiac and noncardiac),11 and geriatric palliative care,12 are receiving increasing attention. The brand new medicine that will flourish from the synthesis of geriatric care with other specialties will be better equipped to confront the multifaceted medical needs of an aging society and ensure the sustainability of public health care systems in the years to come. However, an integrated system of care will be successful only if the individual disciplines that compose it receive equal attention and respect in the development of intervention models. Should this not be granted, suboptimal and antagonistic forms of apparent collaboration will continue to be generated with single specialists working in “parallel” rather than collegially interacting with one another.
2
Letter to the Editor / JAMDA xxx (2016) 1e2
Acknowledgment The authors thank Alex Sisto (Catholic University of the Sacred Heart, Rome) for his thoughtful comments during the preparation of the manuscript. References 1. Christensen K, Doblhammer G, Rau R, Vaupel JW. Ageing populations: The challenges ahead. Lancet 2009;374:1196e1208. 2. Banerjee S. Multimorbiditydolder adults need health care that can count past one. Lancet 2015;385:587e589. 3. Cesari M, Vellas B, Gambassi G. The stress of aging. Exp Gerontol 2013;48: 451e456. 4. WHO. World report on ageing and health. Geneva, Switzerland: WHO. Available at: http://apps.who.int/iris/bitstream/10665/186463/1/9789240694811_ eng.pdf; 2015. Accessed February 19, 2016. 5. Devereaux PJ, Sessler DI. Cardiac complications in patients undergoing major noncardiac surgery. N Engl J Med 2015;373:2258e2269. 6. Afilalo J, Eisenberg MJ, Morin JF, et al. Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery. J Am Coll Cardiol 2010;56:1668e1676. 7. Cesari M. Role of gait speed in the assessment of older patients. JAMA 2011; 305:93e94.
8. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA 2005;294:716e724. 9. Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med 2004;351: 2870e2874. 10. Wildiers H, Heeren P, Puts M, et al. International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer. J Clin Oncol 2014;32:2595e2603. 11. Zenilman ME, Katlic MR, Rosenthal RA. Geriatric surgerydevolution of a clinical community. Am J Surg 2015;209:943e949. 12. Just JM, Schulz C, Bongartz M, Schnell MW. Palliative care for the elderlyddeveloping a curriculum for nursing and medical students. BMC Geriatr 2010;10:66.
Emanuele Marzetti, MD, PhD, Tommaso Sanna, MD, Riccardo Calvani, PhD, Roberto Bernabei, MD, Francesco Landi, MD, PhD Catholic University of the Sacred Heart, Rome, Italy Matteo Cesari, MD, PhD Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France