- Email: [email protected]
The future of geriatric medicine
European Geriatric Medicine 3 (2012) 233–237
Available online at
www.sciencedirect.com
Hot topic in geriatric medicine
The future of geriatric medicine J.-P. Michel Geneva University, Geneva, Switzerland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 June 2012 Accepted 10 June 2012 Available online 12 July 2012
The old adults of today have benefited during their lifetime from tremendous public health successes, including the control of communicable diseases as well as outstanding progress in acute medicine, leading to a rise in chronic and disabled diseases. These important paradigm changes will be reinforced in future generations of elders by the introduction of informatics, biological innovations, high technology, DNA sequencing, nanotechnology, advances in cognitive sciences and artificial intelligence. Today, natural ageing with all its social inequities and insecure surroundings (war, natural catastrophes and climatic changes) constitutes an enormous challenge for the world countries. These widely varying conditions will be further exacerbated by the possible access to more sophisticated prosthetic devices and medical technology for the richest compared to the poorest countries. ‘‘Modified’’ ageing already exist but will benefit more of high technology, which will leads to ‘‘improved’’ and perhaps ‘‘immortal’’ humans. Radical changes in society will deeply influence the practice of medicine. Undoubtedly, the practice of tomorrow’s medicine will be wireless, from home to the hospitals and institutions. Miniature epidermal captures or ‘‘electronic skin’’ will transmit all the recorded health information to your mobile phone and your exhaustive and constantly updated medical chart will be sent to a ‘‘cloud computer’’. Whatever all of these discoveries and their applications in daily life it is impossible to imagine the individual ageing process without considering the affective surroundings of the person. This ‘‘informal network of care’’ will be increasingly important in the context and will not be replaced soon by ‘‘companion’’ robots. ß 2012 Published by Elsevier Masson SAS.
Keywords: Ageing Care networks High technology Nanotechnology Wireless medicine
Geriatric medicine only is understood by taking a global approach that includes the life course perspective, from conception to death, in which age itself is less important than the ability to function in daily life [1]. The old adults of today have benefited during their lifetime from tremendous public health successes, including the control of communicable diseases as well as outstanding progress in acute medicine, leading to a rise in chronic and disabled diseases. These important paradigm changes will be reinforced in future generations of elders by the introduction of informatics, biological innovations, high technology, DNA sequencing, nanotechnology, advances in cognitive sciences and artificial intelligence. All of these discoveries and their applications in daily life will completely transform how future generations of elderly people think, act and age. However, although the technical environment in which we live our life may be completely transformed, the ageing process will continue to be analysed taking into account three major components, which we will discuss in this paper:
E-mail address: [email protected]. 1878-7649/$ – see front matter ß 2012 Published by Elsevier Masson SAS. http://dx.doi.org/10.1016/j.eurger.2012.06.004
firstly, the individual and specific ageing process of each human being. Indeed, human longevity will continue to progress naturally or with the help, support, and/or intervention of all imaginable scientific innovations; secondly, up to now, it would have been impossible to imagine this individual ageing process (whatever its course) without considering the affective surroundings of the person (spouse, partner, family members and friends). The members of this close circle of affective support who intervene when necessary as natural, non-professional caregivers, will constitute the ‘‘informal network of care’’, and will be increasingly important in the context of probable future financial constraints; when this informal network is unable to provide an adequate response to the need for care, it is generally, and will continue to be helped and supported by another network composed of health care professionals. This formal or professional care network is based in the community, in hospitals, and in intermediate or long term care facilities. This three-level approach will form the structure for this paper, where we will focus firstly on the future of ageing, before anticipating the future of medicine and then more generally, the future of geriatric medicine.
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J.-P. Michel / European Geriatric Medicine 3 (2012) 233–237
1. The future of ageing Over the next 50 years, today’s new-borns will live in a world mainly constituted by an old population. Between 2008 and 2060, it is estimated that the global world population will only increase by 2%, while the population of over-65 s will grow by 86% and the population of over-80 s by 177% [2]. Behind these disturbing data, health inequities will also completely change the face of the world. The life expectancy in Switzerland today is 82 years (the 15th longest in the world, compared to 38.8 years in Angola, ranked 222nd in the world) [3–5]. Continuing the comparison between these two countries by including the GDP and health care costs, it emerges that each Swiss person spent 11.5% of the GDP on health care costs and Angola, 4%. In other words, each Swiss person spends the same amount of money in health care per year (8090 USD) as each Angolan citizen has to live on for a year (GDP = 8200 USD) [3–5]. Such social and health inequities appear even more disturbing when we compare life expectancy at birth: 17 years of a difference between the life expectancy at birth of US citizens living in downtown Washington DC as compared to suburban Maryland; 28 years of a difference in life expectancy at birth between the richest and the poorest neighbourhoods of Glasgow [6]! Therefore, today, natural ageing with all its social inequities and insecure surroundings (war, natural catastrophes and climatic changes) constitutes an enormous challenge for the countries of the world. These widely varying conditions will be further exacerbated by the possible access to more sophisticated prosthetic devices and medical technology for the richest compared to the poorest countries. ‘‘Modified’’ humans have already appeared, with the emergence of pacemakers, prosthetic joints, and coronary stents (. . .). Progress in these different domains is evolving towards very sophisticated solutions, such as implantable cardiac defibrillators, hip or knee prosthesis with ceramic heads [7,8], cochlear implants [9], artificial retinas [10], or bionic eyes [11]. All these new technologies applied in humans will completely modify not only life expectancy, but also the quality of life of new generations of old people that live in the richest countries. In parallel to natural vs. modified ageing, it is necessary to underline that regardless of the era in which we live the world has always produced supra-natural individuals. The natural survival of Mrs. Jeanne Calment to the age of 122 years, 5 months and 11 days raises the still unresolved problem of the limits of longevity. Kim Peek, with his eidetic memory, was the fastest world reader and calculator, able to memorize about 98% of the 12,000 books he read during his lifetime. He was also able to recall music and play on the piano pieces of music that he had heard decades before. However, it is now established that he in fact suffered from FG syndrome, also known as Opitz-Kaveggia syndrome [12]. Nowadays, the term ‘‘improved humans’’ appears more and more often in the medical literature. It is linked to the fantastic developments of genomics, digital and nano-medicines, progress in cognitive science and robotics, all of which are connected within health networks. The development of exoskeletons, which represent a true integration of the machine and the body confers supranatural abilities on humans, namely extra strength, increased walking speed, better balance, as well as the ability to stand up and walk again for paraplegic patients, for example [13]. Improving human strength is laudable, but improving or restoring cognitive abilities now seems likely to become a reality: genetic modification of the brain, cybernetic implants, and brain chips are just some examples of what humans might evolve towards in the distant future [14,15].
Moreover, currently ‘‘Technosens’’, a think-tank, speaks of possibility that humans could be immortal, by combining all the newest technologies from genomic modifications to cell stem transplants and updated nano- and high technology. Aubrey DeGrey, a British researcher on ageing, even goes so far as to suggest that we can avoid ageing [16]. Therefore, we can clearly affirm that the ageing experienced by new generations will be completely different from ours. New generations will be healthier, more engaged, more productive and, at the same time will benefit from greater health literacy, and will be better at self-care and management.
2. The future of medicine Radical changes in society will deeply influence the practice of medicine. Undoubtedly, the practice of tomorrow’s medicine will be wireless, from home to the hospitals and institutions. Miniature epidermal captures [17] composed of electronic tissue [18] will make it possible to instantly measure heart rate and blood pressure, and to record ECG, caloric intake and expenditure, quality of sleep or pain control, and even to assess mood and eventually biological parameters. This ‘‘electronic skin’’ [17]or ‘‘smart band aid’’ will transmit all the information collected to your mobile phone, which will record all data over a period of at least one week or send them to a ‘‘cloud computer’’, where they will be available for all the health care professionals in charge of your health to consult [19]. In parallel, clinical investigations or any medical events would also be collected on the same electronic ‘‘cloud’’ chart, accessible from everywhere by authorized health care professionals caring for you. It should be noted that this exhaustive and constantly updated medical chart will include information collected by new high tech investigations. For example, endoscopy of the whole gastrointestinal tube would be possible at home by using the ‘‘iPill’’, also known as ‘‘endo-capsule’’ for diagnostic radiology [20]. Portable ultrasound scanners will also allow home investigations [21] and if needed, total body magnetic resonance imaging (MRI) could be performed to complete the investigations and identify the underlying pathology without losing any time. The images thus captured will make it possible to analyse the damaged organ with increased precision, such as virtual colonoscopy, brain angiography or exploration of cardiac valves. Currently, in the presence of aortic stenosis, Transcatheter Aortic Valve Implantation (TAVI) using prosthetic valves (such as the Sapien valve by Edwards, or Medtronic’s CoreValve) is already being performed in many centres in the oldest, frailest and co-morbid patients. This procedure boasts an impressive success rate, with few post-implantation complications and increased quality of life for patients [22–24]. If surgical intervention is needed, future medicine will include the possibility of undergoing robotic surgery. The highly technological procedures, the precision of new operating tools for complex surgery, as well as the fantastic progression of anaesthesia procedures are contributing to increasing success in prostate, micro-gynaecology and complex abdominal surgery [25]. To help identify malignant tissue, the injection of a specific marker could make it possible to delimit normal from tumor tissue, which represents another outstanding aid to robotic surgery. In contrast with these exciting advances in medical technology, it is important to underline that not all drugs on the market are tested in old, frail, co-morbid populations. We need to combat this age-related discrimination in clinical trials of drugs, by focussing the drug assessment on the most lethal diseases, and by evaluating their impact on survival in the population for which they are intended [26]. Drug trials in the future will have to focus on the most disabling diseases from which elderly, poly-morbid
J.-P. Michel / European Geriatric Medicine 3 (2012) 233–237
patients suffer, and evaluate their impact on the daily functioning and quality of life. Fortunately, the different US and European drug agencies (FDA and EMA) are beginning to demand that new drugs be tested in the ‘‘true’’ older populations as a pre-requisite to obtaining market authorisation, i.e. they must be tested in the populations that are the greatest consumers of health care and drugs. This approach is encouraging, bearing in mind that two major processes are likely to transform the future of medical therapy: the first revolution is linked to DNA sequencing and the development of pharmacogenetics. While the first DNA sequence performed in 2000 cost 3 billion US Dollars, it is expected that in 2025, the same technique will only cost around 1000 US Dollars to perform [27]. This implies that DNA sequencing will be a widespread practice, and will allow the development of individualized and safer treatments, e.g. nutrigenomics, pharmacogenetics and perhaps control of genomic mutation [27]. Already in today’s market, at least two such drugs exist. The first targets breast cancer with metastasis and HER2 overexpression, namely trastuzumab (Herceptin1, Hoffman La Roche, Basel, Switzerland [28]). The second is used to treat metastatic colorectal cancer with KRAS oncogene (negative predictive biomarker); this new drug is named cetuximab (Erbitux1, ImClone LLC, New York, USA [29]); the second therapeutic revolution will concern anti-cancer drugs that will target only malignant cells, without destroying neighbouring normal cells [20]. Ingestible electronic devices that kill cancer cells while sparing healthy tissue are already under development [30].
All these advances in the practice of medicine, including genomics, proteomics, new biomarkers, microbial scans, and imaging data banks, will produce a data explosion stock. Yesterday, body imaging comprised only 100 slices, corresponding to 5122 pixels or 50 MB, which is the equivalent of 50 books or 2 linear meters. In the future, body imaging will represent 10243 voxels or 100 Hz, i.e. one terabyte or 800,000 books, whose data could be contained in 3.2 linear kilometers of books [20]. As previously mentioned, the practice of medicine in tomorrow’s world will be wireless, and technology will make it possible to collect and share the data of all patients from the community to the hospital and institutions of care [20]. 3. The future of geriatric medicine How is geriatric medicine likely to progress in the context of an ever-changing concept of ageing, and the increasing technical complexity of medicine? The geriatric medicine of tomorrow will have to be simultaneously predictive, preventive, personalized and participatory [20,31]. 3.1. Geriatric medicine will have to be predictive Because the ageing is a life-long process, from conception to death: anthropometrics and diet before and during pregnancy, family and personal medical history, socio-economic status, chosen lifestyle and life habits will greatly influence children’s growth but will also determine risk factors in later life [32]. In addition, it has also been proven that midlife risk factors are essential for determining not only the ageing of the musculoskeletal system [33,34] but also the risk of dementia in old age [35–39]. All these competing and complementary factors explain why ageing life cycles are so different from one individual to the other. Prevention of frailty and disability includes an adequate, well-balanced diet as well as moderate and regular physical
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exercise [40]. Until now, it has been difficult to include genetics in this predictive geriatric medicine equation, because knowing that you are apolipoprotein E4 homozygote, for example, may transform your life, but will not in any way enable you to benefit from prevention of cure of a disease that may only develop when you reach the age of 90 years old. This is a topic that may change rapidly, but this futuristic prospect is currently difficult to predict. In any case, if a cure for genetic diseases was possible, early diagnosis and radical intervention would be the best approach. Increasingly, researchers are looking for ‘‘High-tech guardian angels’’, which will be inconspicuous, intelligent and self-sufficient devices designed to help people in their daily life. For example, sensors on and in the body measure different bodily functions, process the data and transfer them to mobile devices via corresponding communication channels [41]. These bio-molecular machines might someday make you well, without you ever knowing that you were even sick. 3.2. Geriatric medicine for the 21st century has to be preventive [42] As mentioned, prevention starts from the earliest stages of life. The peak bone mass determined both by genetics, childhood nutrition and physical exercise is reached at around 15 years of age in females [43]. The higher the peak bonemass at this young age, the lower the risk that this person will suffer hip fracture in old age. A balanced diet and regular physical exercise are key in protecting against osteoporosis, and also sarcopenia, and all the related consequences in terms of frailty and disability. It has been shown that even in very old age, it is possible to regain musculo-skeletal muscles by strength exercises in association with vitamin D and amino acid intake [44]. 3.3. Future geriatric medicine has to be personalized Wireless sensors and bio-sensing devices can be embedded into garments to record the wearer’s temperature, heart rate, galvanic skin response (moisture) and respiratory rate. These intelligent materials may also be able to identify external or internal causes of repeated falls [45]. It has also been postulated that wearing electronic soles to increase proprioception may decrease the incidence of falls [19]. Another major geriatric topic is Alzheimer’s disease and other types of dementia. To date, only four symptomatic drugs are available on the market; their main positive effects are to facilitate patients’ ‘daily life, decrease caregiver burden and delay admission to institutions. One surprising issue concerning these drugs is the very poor compliance, which can probably be explained by the poor cognitive status of the patients and/or the non-respect of drug prescriptions by the caregivers. Alarm devices to serve as reminders to take multiple pills are available on the market [46–48]. Although their efficacy has not yet been demonstrated, we cannot doubt their effectiveness. More innovative advances include the advent of intelligent medicines, based on ingestible microchips, such as the ingestible event marker (IEM) (Proteus, Redwood, CA, USA) [48]. IEMs are tiny, digestible sensors made from food ingredients, which are activated by stomach fluids after swallowing. Once activated, the IEM generates an ultra-low-power digital signal detected by a microelectronic recorder configured as a small skin-patch or on a cell phone [48]. Drug activity and adherence are crucial issues, but the major challenge is to discover a drug able to cure Alzheimer’s disease. Multiple drug trials are ongoing, but since the pathophysiology of Alzheimer’s disease remains unknown, a new curative treatment for this disease is not expected before at least a decade [49]. For this reason, some researchers are now investigating biomimetic models of hippocampus as neural prostheses for lost cognitive functions [50].
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While we wait for these promising, but long term therapeutic issues to come to fruition, several devices and systems can be proposed to favour safer surroundings for Alzheimer’s disease patients, particularly for demented patients prone to wandering. Simple voice identification devices [51] or jewellery incorporating contact information for the police or people who encounter wandering patients can be proposed [52]. In parallel, task organisers [53] or cell phones designed for seniors [54] can also be proposed depending on the severity of the disease. The most interesting tools to have appeared recently are GPS shoes that are immediately able to locate any wandering demented patient wearing this quite nicely designed innovative footwear [55]. With the same goal, but for more severely cognitively impaired patients, there also exist locator devices for walking frames that integrate a computer system designed to help demented patients find their way around a pre-determined space filled with sensors [56]. 3.4. Geriatric medicine for the 21st century will be participatory The home surroundings of elderly patients with cognitive disturbances have to be safe. Multiple devices are now on the market to ensure safety precautions, such as detect gas leaks, check the temperature of food kept in the fridge or freezer, check the bath temperature or detect water overflow. There are many further examples, all of which contribute to ‘‘universal design’’, i.e. a userfriendly approach to design in the living environment [57]. This approach is now linked to easier access to social networks for older computer users [57]. More imminent technical advances could include the integration of humanoid robots able to help old or disabled people in their daily life. For example, the ECCE Robot developed by the Lausanne and Zurich Polytechnic Schools is an excellent example of what robots could contribute to the life and care of persons in need [58]. A fully-programmable, adult-sized, personal robot will be made available in the home for any precisely programmed mission [58], even detection of mood disturbances in the related person and possible psychological support for the current situation [59]. These ‘‘companion’’ robots for older citizens maybe a part of life for the next generation of elderly people.
4. Conclusion As another author previously said, ‘‘Prediction is difficult, particularly about the future’’ [60]. However, a few issues will remain constant: ageing is an inevitable process in human being and whatever its course, one of the most important factors is the affective surroundings constituted by the spouse, partners, family members and close friends who ensure quality of life, love and also permanence and daily care when needed. It is unnecessary to repeat that greater health literacy, better self-care, and an adequate and balanced diet will favour a longer, healthier ageing process. Technology will be implicated in every aspect of daily life, from DNA sequencing and cognitive enhancement, to personalized and safer medicines. However, the most important aspect is probably the fact that each individual will have a unique medical chart, accessible from everywhere to specific health care professionals working from home, hospitals or institutions. The worldwide scientific data bank will make it possible to share knowledge and experience, to avoid repeated mistakes and wasted time. In particular, it has recently been shown that comprehensive geriatric assessment and the presence of geriatricians in the emergency rooms led to improved survival, functioning and quality of life. These findings are of paramount importance for patient outcomes, quality of care and cost reductions [61,62]. Geriatric medicine is the medicine of tomorrow, and the new adult
doctors and specialists will have to cope with the growing population of elderly people in need of holistic, human and ethical care, whatever the new technical revolution currently under way.
Disclosure of interest The author declares that he has no conflicts of interest concerning this article.
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Available online at
www.sciencedirect.com
Hot topic in geriatric medicine
The future of geriatric medicine J.-P. Michel Geneva University, Geneva, Switzerland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 June 2012 Accepted 10 June 2012 Available online 12 July 2012
The old adults of today have benefited during their lifetime from tremendous public health successes, including the control of communicable diseases as well as outstanding progress in acute medicine, leading to a rise in chronic and disabled diseases. These important paradigm changes will be reinforced in future generations of elders by the introduction of informatics, biological innovations, high technology, DNA sequencing, nanotechnology, advances in cognitive sciences and artificial intelligence. Today, natural ageing with all its social inequities and insecure surroundings (war, natural catastrophes and climatic changes) constitutes an enormous challenge for the world countries. These widely varying conditions will be further exacerbated by the possible access to more sophisticated prosthetic devices and medical technology for the richest compared to the poorest countries. ‘‘Modified’’ ageing already exist but will benefit more of high technology, which will leads to ‘‘improved’’ and perhaps ‘‘immortal’’ humans. Radical changes in society will deeply influence the practice of medicine. Undoubtedly, the practice of tomorrow’s medicine will be wireless, from home to the hospitals and institutions. Miniature epidermal captures or ‘‘electronic skin’’ will transmit all the recorded health information to your mobile phone and your exhaustive and constantly updated medical chart will be sent to a ‘‘cloud computer’’. Whatever all of these discoveries and their applications in daily life it is impossible to imagine the individual ageing process without considering the affective surroundings of the person. This ‘‘informal network of care’’ will be increasingly important in the context and will not be replaced soon by ‘‘companion’’ robots. ß 2012 Published by Elsevier Masson SAS.
Keywords: Ageing Care networks High technology Nanotechnology Wireless medicine
Geriatric medicine only is understood by taking a global approach that includes the life course perspective, from conception to death, in which age itself is less important than the ability to function in daily life [1]. The old adults of today have benefited during their lifetime from tremendous public health successes, including the control of communicable diseases as well as outstanding progress in acute medicine, leading to a rise in chronic and disabled diseases. These important paradigm changes will be reinforced in future generations of elders by the introduction of informatics, biological innovations, high technology, DNA sequencing, nanotechnology, advances in cognitive sciences and artificial intelligence. All of these discoveries and their applications in daily life will completely transform how future generations of elderly people think, act and age. However, although the technical environment in which we live our life may be completely transformed, the ageing process will continue to be analysed taking into account three major components, which we will discuss in this paper:
E-mail address: [email protected]. 1878-7649/$ – see front matter ß 2012 Published by Elsevier Masson SAS. http://dx.doi.org/10.1016/j.eurger.2012.06.004
firstly, the individual and specific ageing process of each human being. Indeed, human longevity will continue to progress naturally or with the help, support, and/or intervention of all imaginable scientific innovations; secondly, up to now, it would have been impossible to imagine this individual ageing process (whatever its course) without considering the affective surroundings of the person (spouse, partner, family members and friends). The members of this close circle of affective support who intervene when necessary as natural, non-professional caregivers, will constitute the ‘‘informal network of care’’, and will be increasingly important in the context of probable future financial constraints; when this informal network is unable to provide an adequate response to the need for care, it is generally, and will continue to be helped and supported by another network composed of health care professionals. This formal or professional care network is based in the community, in hospitals, and in intermediate or long term care facilities. This three-level approach will form the structure for this paper, where we will focus firstly on the future of ageing, before anticipating the future of medicine and then more generally, the future of geriatric medicine.
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1. The future of ageing Over the next 50 years, today’s new-borns will live in a world mainly constituted by an old population. Between 2008 and 2060, it is estimated that the global world population will only increase by 2%, while the population of over-65 s will grow by 86% and the population of over-80 s by 177% [2]. Behind these disturbing data, health inequities will also completely change the face of the world. The life expectancy in Switzerland today is 82 years (the 15th longest in the world, compared to 38.8 years in Angola, ranked 222nd in the world) [3–5]. Continuing the comparison between these two countries by including the GDP and health care costs, it emerges that each Swiss person spent 11.5% of the GDP on health care costs and Angola, 4%. In other words, each Swiss person spends the same amount of money in health care per year (8090 USD) as each Angolan citizen has to live on for a year (GDP = 8200 USD) [3–5]. Such social and health inequities appear even more disturbing when we compare life expectancy at birth: 17 years of a difference between the life expectancy at birth of US citizens living in downtown Washington DC as compared to suburban Maryland; 28 years of a difference in life expectancy at birth between the richest and the poorest neighbourhoods of Glasgow [6]! Therefore, today, natural ageing with all its social inequities and insecure surroundings (war, natural catastrophes and climatic changes) constitutes an enormous challenge for the countries of the world. These widely varying conditions will be further exacerbated by the possible access to more sophisticated prosthetic devices and medical technology for the richest compared to the poorest countries. ‘‘Modified’’ humans have already appeared, with the emergence of pacemakers, prosthetic joints, and coronary stents (. . .). Progress in these different domains is evolving towards very sophisticated solutions, such as implantable cardiac defibrillators, hip or knee prosthesis with ceramic heads [7,8], cochlear implants [9], artificial retinas [10], or bionic eyes [11]. All these new technologies applied in humans will completely modify not only life expectancy, but also the quality of life of new generations of old people that live in the richest countries. In parallel to natural vs. modified ageing, it is necessary to underline that regardless of the era in which we live the world has always produced supra-natural individuals. The natural survival of Mrs. Jeanne Calment to the age of 122 years, 5 months and 11 days raises the still unresolved problem of the limits of longevity. Kim Peek, with his eidetic memory, was the fastest world reader and calculator, able to memorize about 98% of the 12,000 books he read during his lifetime. He was also able to recall music and play on the piano pieces of music that he had heard decades before. However, it is now established that he in fact suffered from FG syndrome, also known as Opitz-Kaveggia syndrome [12]. Nowadays, the term ‘‘improved humans’’ appears more and more often in the medical literature. It is linked to the fantastic developments of genomics, digital and nano-medicines, progress in cognitive science and robotics, all of which are connected within health networks. The development of exoskeletons, which represent a true integration of the machine and the body confers supranatural abilities on humans, namely extra strength, increased walking speed, better balance, as well as the ability to stand up and walk again for paraplegic patients, for example [13]. Improving human strength is laudable, but improving or restoring cognitive abilities now seems likely to become a reality: genetic modification of the brain, cybernetic implants, and brain chips are just some examples of what humans might evolve towards in the distant future [14,15].
Moreover, currently ‘‘Technosens’’, a think-tank, speaks of possibility that humans could be immortal, by combining all the newest technologies from genomic modifications to cell stem transplants and updated nano- and high technology. Aubrey DeGrey, a British researcher on ageing, even goes so far as to suggest that we can avoid ageing [16]. Therefore, we can clearly affirm that the ageing experienced by new generations will be completely different from ours. New generations will be healthier, more engaged, more productive and, at the same time will benefit from greater health literacy, and will be better at self-care and management.
2. The future of medicine Radical changes in society will deeply influence the practice of medicine. Undoubtedly, the practice of tomorrow’s medicine will be wireless, from home to the hospitals and institutions. Miniature epidermal captures [17] composed of electronic tissue [18] will make it possible to instantly measure heart rate and blood pressure, and to record ECG, caloric intake and expenditure, quality of sleep or pain control, and even to assess mood and eventually biological parameters. This ‘‘electronic skin’’ [17]or ‘‘smart band aid’’ will transmit all the information collected to your mobile phone, which will record all data over a period of at least one week or send them to a ‘‘cloud computer’’, where they will be available for all the health care professionals in charge of your health to consult [19]. In parallel, clinical investigations or any medical events would also be collected on the same electronic ‘‘cloud’’ chart, accessible from everywhere by authorized health care professionals caring for you. It should be noted that this exhaustive and constantly updated medical chart will include information collected by new high tech investigations. For example, endoscopy of the whole gastrointestinal tube would be possible at home by using the ‘‘iPill’’, also known as ‘‘endo-capsule’’ for diagnostic radiology [20]. Portable ultrasound scanners will also allow home investigations [21] and if needed, total body magnetic resonance imaging (MRI) could be performed to complete the investigations and identify the underlying pathology without losing any time. The images thus captured will make it possible to analyse the damaged organ with increased precision, such as virtual colonoscopy, brain angiography or exploration of cardiac valves. Currently, in the presence of aortic stenosis, Transcatheter Aortic Valve Implantation (TAVI) using prosthetic valves (such as the Sapien valve by Edwards, or Medtronic’s CoreValve) is already being performed in many centres in the oldest, frailest and co-morbid patients. This procedure boasts an impressive success rate, with few post-implantation complications and increased quality of life for patients [22–24]. If surgical intervention is needed, future medicine will include the possibility of undergoing robotic surgery. The highly technological procedures, the precision of new operating tools for complex surgery, as well as the fantastic progression of anaesthesia procedures are contributing to increasing success in prostate, micro-gynaecology and complex abdominal surgery [25]. To help identify malignant tissue, the injection of a specific marker could make it possible to delimit normal from tumor tissue, which represents another outstanding aid to robotic surgery. In contrast with these exciting advances in medical technology, it is important to underline that not all drugs on the market are tested in old, frail, co-morbid populations. We need to combat this age-related discrimination in clinical trials of drugs, by focussing the drug assessment on the most lethal diseases, and by evaluating their impact on survival in the population for which they are intended [26]. Drug trials in the future will have to focus on the most disabling diseases from which elderly, poly-morbid
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patients suffer, and evaluate their impact on the daily functioning and quality of life. Fortunately, the different US and European drug agencies (FDA and EMA) are beginning to demand that new drugs be tested in the ‘‘true’’ older populations as a pre-requisite to obtaining market authorisation, i.e. they must be tested in the populations that are the greatest consumers of health care and drugs. This approach is encouraging, bearing in mind that two major processes are likely to transform the future of medical therapy: the first revolution is linked to DNA sequencing and the development of pharmacogenetics. While the first DNA sequence performed in 2000 cost 3 billion US Dollars, it is expected that in 2025, the same technique will only cost around 1000 US Dollars to perform [27]. This implies that DNA sequencing will be a widespread practice, and will allow the development of individualized and safer treatments, e.g. nutrigenomics, pharmacogenetics and perhaps control of genomic mutation [27]. Already in today’s market, at least two such drugs exist. The first targets breast cancer with metastasis and HER2 overexpression, namely trastuzumab (Herceptin1, Hoffman La Roche, Basel, Switzerland [28]). The second is used to treat metastatic colorectal cancer with KRAS oncogene (negative predictive biomarker); this new drug is named cetuximab (Erbitux1, ImClone LLC, New York, USA [29]); the second therapeutic revolution will concern anti-cancer drugs that will target only malignant cells, without destroying neighbouring normal cells [20]. Ingestible electronic devices that kill cancer cells while sparing healthy tissue are already under development [30].
All these advances in the practice of medicine, including genomics, proteomics, new biomarkers, microbial scans, and imaging data banks, will produce a data explosion stock. Yesterday, body imaging comprised only 100 slices, corresponding to 5122 pixels or 50 MB, which is the equivalent of 50 books or 2 linear meters. In the future, body imaging will represent 10243 voxels or 100 Hz, i.e. one terabyte or 800,000 books, whose data could be contained in 3.2 linear kilometers of books [20]. As previously mentioned, the practice of medicine in tomorrow’s world will be wireless, and technology will make it possible to collect and share the data of all patients from the community to the hospital and institutions of care [20]. 3. The future of geriatric medicine How is geriatric medicine likely to progress in the context of an ever-changing concept of ageing, and the increasing technical complexity of medicine? The geriatric medicine of tomorrow will have to be simultaneously predictive, preventive, personalized and participatory [20,31]. 3.1. Geriatric medicine will have to be predictive Because the ageing is a life-long process, from conception to death: anthropometrics and diet before and during pregnancy, family and personal medical history, socio-economic status, chosen lifestyle and life habits will greatly influence children’s growth but will also determine risk factors in later life [32]. In addition, it has also been proven that midlife risk factors are essential for determining not only the ageing of the musculoskeletal system [33,34] but also the risk of dementia in old age [35–39]. All these competing and complementary factors explain why ageing life cycles are so different from one individual to the other. Prevention of frailty and disability includes an adequate, well-balanced diet as well as moderate and regular physical
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exercise [40]. Until now, it has been difficult to include genetics in this predictive geriatric medicine equation, because knowing that you are apolipoprotein E4 homozygote, for example, may transform your life, but will not in any way enable you to benefit from prevention of cure of a disease that may only develop when you reach the age of 90 years old. This is a topic that may change rapidly, but this futuristic prospect is currently difficult to predict. In any case, if a cure for genetic diseases was possible, early diagnosis and radical intervention would be the best approach. Increasingly, researchers are looking for ‘‘High-tech guardian angels’’, which will be inconspicuous, intelligent and self-sufficient devices designed to help people in their daily life. For example, sensors on and in the body measure different bodily functions, process the data and transfer them to mobile devices via corresponding communication channels [41]. These bio-molecular machines might someday make you well, without you ever knowing that you were even sick. 3.2. Geriatric medicine for the 21st century has to be preventive [42] As mentioned, prevention starts from the earliest stages of life. The peak bone mass determined both by genetics, childhood nutrition and physical exercise is reached at around 15 years of age in females [43]. The higher the peak bonemass at this young age, the lower the risk that this person will suffer hip fracture in old age. A balanced diet and regular physical exercise are key in protecting against osteoporosis, and also sarcopenia, and all the related consequences in terms of frailty and disability. It has been shown that even in very old age, it is possible to regain musculo-skeletal muscles by strength exercises in association with vitamin D and amino acid intake [44]. 3.3. Future geriatric medicine has to be personalized Wireless sensors and bio-sensing devices can be embedded into garments to record the wearer’s temperature, heart rate, galvanic skin response (moisture) and respiratory rate. These intelligent materials may also be able to identify external or internal causes of repeated falls [45]. It has also been postulated that wearing electronic soles to increase proprioception may decrease the incidence of falls [19]. Another major geriatric topic is Alzheimer’s disease and other types of dementia. To date, only four symptomatic drugs are available on the market; their main positive effects are to facilitate patients’ ‘daily life, decrease caregiver burden and delay admission to institutions. One surprising issue concerning these drugs is the very poor compliance, which can probably be explained by the poor cognitive status of the patients and/or the non-respect of drug prescriptions by the caregivers. Alarm devices to serve as reminders to take multiple pills are available on the market [46–48]. Although their efficacy has not yet been demonstrated, we cannot doubt their effectiveness. More innovative advances include the advent of intelligent medicines, based on ingestible microchips, such as the ingestible event marker (IEM) (Proteus, Redwood, CA, USA) [48]. IEMs are tiny, digestible sensors made from food ingredients, which are activated by stomach fluids after swallowing. Once activated, the IEM generates an ultra-low-power digital signal detected by a microelectronic recorder configured as a small skin-patch or on a cell phone [48]. Drug activity and adherence are crucial issues, but the major challenge is to discover a drug able to cure Alzheimer’s disease. Multiple drug trials are ongoing, but since the pathophysiology of Alzheimer’s disease remains unknown, a new curative treatment for this disease is not expected before at least a decade [49]. For this reason, some researchers are now investigating biomimetic models of hippocampus as neural prostheses for lost cognitive functions [50].
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While we wait for these promising, but long term therapeutic issues to come to fruition, several devices and systems can be proposed to favour safer surroundings for Alzheimer’s disease patients, particularly for demented patients prone to wandering. Simple voice identification devices [51] or jewellery incorporating contact information for the police or people who encounter wandering patients can be proposed [52]. In parallel, task organisers [53] or cell phones designed for seniors [54] can also be proposed depending on the severity of the disease. The most interesting tools to have appeared recently are GPS shoes that are immediately able to locate any wandering demented patient wearing this quite nicely designed innovative footwear [55]. With the same goal, but for more severely cognitively impaired patients, there also exist locator devices for walking frames that integrate a computer system designed to help demented patients find their way around a pre-determined space filled with sensors [56]. 3.4. Geriatric medicine for the 21st century will be participatory The home surroundings of elderly patients with cognitive disturbances have to be safe. Multiple devices are now on the market to ensure safety precautions, such as detect gas leaks, check the temperature of food kept in the fridge or freezer, check the bath temperature or detect water overflow. There are many further examples, all of which contribute to ‘‘universal design’’, i.e. a userfriendly approach to design in the living environment [57]. This approach is now linked to easier access to social networks for older computer users [57]. More imminent technical advances could include the integration of humanoid robots able to help old or disabled people in their daily life. For example, the ECCE Robot developed by the Lausanne and Zurich Polytechnic Schools is an excellent example of what robots could contribute to the life and care of persons in need [58]. A fully-programmable, adult-sized, personal robot will be made available in the home for any precisely programmed mission [58], even detection of mood disturbances in the related person and possible psychological support for the current situation [59]. These ‘‘companion’’ robots for older citizens maybe a part of life for the next generation of elderly people.
4. Conclusion As another author previously said, ‘‘Prediction is difficult, particularly about the future’’ [60]. However, a few issues will remain constant: ageing is an inevitable process in human being and whatever its course, one of the most important factors is the affective surroundings constituted by the spouse, partners, family members and close friends who ensure quality of life, love and also permanence and daily care when needed. It is unnecessary to repeat that greater health literacy, better self-care, and an adequate and balanced diet will favour a longer, healthier ageing process. Technology will be implicated in every aspect of daily life, from DNA sequencing and cognitive enhancement, to personalized and safer medicines. However, the most important aspect is probably the fact that each individual will have a unique medical chart, accessible from everywhere to specific health care professionals working from home, hospitals or institutions. The worldwide scientific data bank will make it possible to share knowledge and experience, to avoid repeated mistakes and wasted time. In particular, it has recently been shown that comprehensive geriatric assessment and the presence of geriatricians in the emergency rooms led to improved survival, functioning and quality of life. These findings are of paramount importance for patient outcomes, quality of care and cost reductions [61,62]. Geriatric medicine is the medicine of tomorrow, and the new adult
doctors and specialists will have to cope with the growing population of elderly people in need of holistic, human and ethical care, whatever the new technical revolution currently under way.
Disclosure of interest The author declares that he has no conflicts of interest concerning this article.
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