“Every clinician, apart from paediatricians, should know geriatrics”

“Every clinician, apart from paediatricians, should know geriatrics”

Dr Alka Ganesh is a geriatrician currently practising at G Kuppuswamy Naidu Memorial Hospital, Coimbatore.

A former professor and HOD of medicine at CMC Vellore, she received a training fellowship in Geriatric Medicine at Newcastle-upon-Tyne, UK. Dr Alka is also a recipient of Distinguished Teacher Award from National Board of Examination in the year 2014.

As a pioneer in geriatric medicine, she was instrumental in setting up a Family Medicine Department at CMC. In a free-wheeling conversation with
Divya Choyikutty of Future Medicine, Dr Alka discusses what makes geriatric medicine different from other medical disciplines and the crucial role to be played by the specialty in India to address widening gaps in caring for the ever-growing elderly population who are outnumbering children and have multiple comorbidities. Edited excerpts:

 What is the age when a person should start visiting a geriatrician? What enables a person to visit a geriatrician?

It is something which people are confused about. In actual practice, it is not a chronological age. But anyone from 60-65 years of age may visit a geriatrician. However, in India, since we do not have many geriatricians, one will benefit from visiting such a physician if they have multiple comorbidities, or when they require a multidisciplinary care involving a physiotherapist and or a nurse, besides the physician. 

You may have an 80-year-old patient who is very fit and has got only one disease, say, hypertension. Such a person can be easily managed by any ordinary physician, but you may have a 65-year-old patient who may have dementia, arthritis and a leaky bladder. Such a person will benefit
from going to a geriatrician who can provide all necessary care for the patient. So, comorbidity is the basic factor that decides whether a person needs to be treated by a geriatrician. 

 How common is the practice of geriatrics in India?

 We have very few geriatricians in our country, and hence, visiting a geriatrician is not something you usually do via self-referral. Further, nobody you see regularly declares himself a geriatrician, because geriatrics is at a very young age in our country. If we take a western country, when an elderly person with unknown or multiple comorbidities visits a physician, and if the patient is not somebody whom the doctor can treat, he will immediately be referred to a geriatrician. Therefore, the referral to a geriatrician depends on how the health service is organised in that country. Similarly, overseas, there would often be a geriatric team that may include four or five, or even up to ten, allied healthcare persons, including a pharmacist, physiotherapist and a nurse, along with a speech therapist and so on.  

 How significant is the need of geriatrics in our country now and how can care be offered?

 The population over the age of 60 years has tripled in the last 50 years in India and will relentlessly increase in the near future. By 2021, about 21% of our total population is expected to be composed of people 60 years and above.

The elderly pose a unique challenge due to their complex health problems. The majority have multiple diseases like diabetes, high blood pressure, heart problems, kidney failure, asthma, etc., at the same time, requiring them to take up multiple medicines at a time. Many conditions are present atypically or have different presentations in the elderly age group compared to the young, which calls for specialised care. Since geriatrics is at a nascent stage in our country, and we require more of these doctors, it will be helpful if more doctors take up geriatrics in our country.

Further, we need more geriatricians as trainers to train other people as well.

Thus, every clinician, whether he is a cardiologist or a general physician, should know geriatrics. He should be able to take care of the elderly patients before their condition becomes very severe, and that is something which can be done best by a physician who has a lot of experience and knowledge about geriatric syndromes and issues.

Every physician should know how an older person behaves, how he responds to medications, how he gets toxic effects from the current kind of treatment. That is why there is a need to conduct geriatric focused conferences and workshops to create awareness in our country. Furthermore, the availability of geriatric care and research centres at a hospital-level would be of great importance to our ageing population.

 What makes geriatricians different from other physicians?

 Geriatricians care for the full spectrum of diseases seen in general/internal medicine; imparting special focus on elderly individuals. We care for the elderly by recognising the importance of maintaining their functional independence, and focus on providing preventive interventions, thereby improving their quality of life. We are specifically trained in the normal and abnormal physiologic and psychological changes associated with ageing, and to recognise the differences in presentation of diseases relative to normal ageing.

Ageing is a complex process altered by genetics, environment and social factors, and is inevitable. However, the misery and dependence that accompany ageing can be prevented to a great extent through care. The knowledge of individual age-related organ changes enables geriatricians to understand deeply about geriatric giants such as urinary incontinence and frailty. Anticipating geriatric syndromes and practicing comprehensive geriatric assessment helps us to provide holistic therapy to every patient. This is what we, as geriatricians, can do differently from other physicians. Whether it is a balance problem or Parkinson’s disease or dementia or hypertension, we can provide comprehensive medical care. 

A geriatrician can help patients by identifying the underlying issue and then refer him to a specialist. They are experts in optimising/decreasing the number of medications taken by the elderly and thereby helping prevent side effects.

 In what ways do geriatricians manage patients with multiple comorbidities?

 Suppose an elderly patient has chronic problems like arthritis, cardiac issues and lung problems, he would have to go to each of these specialists who would specifically attend to his knee, heart or lung separately, and that is when it gets complicated. 

It is because often a cardiologist is giving his own medicines, an orthopaedist is giving some other medicines, and those medicines might cause some gastrointestinal problem for which the patient will now be going to a gastroenterologist. Diseases are already there, but then, the doctors are also knowingly or unknowingly producing new diseases because of their medications, which is known as iatrogenic diseases. This becomes very complex and is quite common in our country. This is where either a general physician, who is well-versed with geriatrics, or a geriatrician should step in and that person can take care of all the problems. That doctor can decide when the patient needs to be sent back to the orthopaedist, not as a routine, but only when he or she cannot take care of it. So you see, a geriatrician is both a referral person as well as a primary person who deals patients. 

 How often is specialist care required for geriatric patients?

 In terms of the goal of the treatment, a specialist orthopaedic person is primarily interested in the bones, a cardiologist is interested in the heart as an organ, but a geriatrician or any primary care physician is interested in the whole person. Instead of trying to make that bone problem perfect or the heart problem perfect, what the geriatrician is trying to do is to help make a little improvement in each of these conditions. Those improvements will not only just add up, they will multiply each other and improve the quality of life of the patients. 

However, the patient’s heart failure may still need some treatment. But if you push drugs for heart failure, much of it is going to affect his kidneys, and if the kidney gets affected, then there is something else that is going to happen to him. Therefore, a geriatrician knows the limit of how far to push certain cases and also to decide when a patient requires surgery etc..

 How can an aspiring doctor become a geriatrician in India?

 In India, we started MD in geriatrics separately a few years ago. So, an MBBS person can directly do MD Geriatrics. But there are only a few institutions in our country that offer this, including CMC Vellore and Madras Medical College. So, you can imagine the number of geriatricians getting trained. At the moment, we can still get geriatric care without needing geriatricians. What we need is every clinician, specifically the internal medicine people, to have an awareness about how an ageing person requires modifications in his treatment. 

 How dire is the need for geriatric care centres in India?

 There are many elderly people who are still mobile, who can come to the hospitals as outpatients. But many of them do not come because it takes so long to see a doctor, and, as they are old, they cannot sit so long. So, at an administrative level, if we can have designated geriatric care centre units in hospitals, it could make the visit of an older person much simpler. There can also be facilities which should be available easily to treat some of the conditions that older people have. This would further reduce clogging up of the beds in the hospital and enables patients to access better care. 

The Madras Medical College has a geriatric ward in which they have purpose-built one part as a physiotherapy centre so that an in-patient who just has come with a stroke does not have to be wheeled off to the physiotherapy department. The physiotherapist is in the ward itself and they can give that care. Sometimes, a patient who comes in with breathlessness or lung disease is doing well and suddenly takes a turn for the worse. He can go to the ICU which is designated for older people. They know how much care to give, when it is not feasible to continue, and so on.. 

At every stage in life, it is more desirable if you can keep a person at home instead of admitting him in a hospital. Putting a person in a hospital should be done only if the treatment cannot be given at home. Home care services are now being done by many people, which may involve multiple allied health services. It is practiced in our country in various models. It can be a part of the government service, which is not there in India at the moment. It can also be a part of the private service or an individual doctor’s practice as well. We are very backward in offering such services. It is the need of the hour that we have to form such teams, both in the public and in the private sector, and in NGOs.

 Any advice to aspiring doctors?

 Everybody is in a rat race to take up a speciality. We need specialists, and what is happening now is everybody is specialising. There is a perception that if you become a specialist, you are smart. Doctors, who belong to the so-called noble profession, have to be noble. My advice is that if you want to impact a large section of people, remain a generalist. Once you become a super-specialist, the care of the person gets fragmented. It is fragmented into his heart or his lung or his liver, depending on the specialisation. If you remain a generalist and learn better geriatrics, you learn a primary care approach which lets you know how to look after a person with certain illnesses at the first point of contact, how to detect certain illnesses earlier so that they do not increase the risk, and how to continue the chronic management of a case after a specialist has given an advice. These are all things which can be done by a person who opts to not super specialise.

If you remain as a generalist, you will be doing service to more and more number of people. 

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