The future history of geriatrics: geriatrics at the crossroads.

Abstract

C ONTEXT Geriatrics has had a hard time deciding just what it wants to be when it grows up. An early concept of geriatrics equated it primarily with caring for persons in long-term care (1). A major effort to predict the need for geriatrically trained personnel envisioned geriatrics as primarily consisting of specialists who would handle complex cases on referral and provide oversight and advice otherwise (2). A decade later, as managed care was gaining strength and the demand for primary care seemed insatiable, geriatrics redefined itself as a primary care specialty (3). Today one hears geriatricians describe themselves as those who deal with end-of-life care. During the era of managed care, geriatrics did not enhance its credibility when it often appeared to be making contradictory promises. To managed care organizations, it promised to decrease the need for other specialists by employing improved primary care methods, while it also promised its parent medical centers, which were anxious to build their patient base for technologically intensive (and expensive) services, increased referrals of older patients who needed just such care. In many ways, geriatrics might be defined as the synthesis of gerontology and chronic care. The core of geriatric practice consists of addressing geriatric syndromes such as falls, dementia, and incontinence; emphasizing the resultant functional changes that accompany chronic illness; recognizing atypical presentations of common diseases; and managing multiple, simultaneous interaction problems, which require medical attention and coordination of the work of various other disciplines. The basic principles of chronic illness care (i.e., using interdisciplinary team care, recognizing the need for care investments that will bear fruit later, promoting active involvement of patients in their own care, distinguishing care episodes from events, and being sensitive to the context of care as well as the immediate problems presenting) are the hallmarks of geriatric care. Essentially, geriatrics is the epitome of good chronic care. S UPPLY