Silver paper: the future of health promotion and preventive actions, basic research, and clinical aspects of age-related disease--a report of the European Summit on Age-Related Disease

A scoping review of the changing landscape of geriatric medicine in undergraduate medical education: curricula, topics and teaching methods

PURPOSE

The world's population is ageing. Therefore, every doctor should receive geriatric medicine training during their undergraduate education. This review aims to summarise recent developments in geriatric medicine that will potentially inform developments and updating of undergraduate medical curricula for geriatric content.

METHODS

We systematically searched the electronic databases Ovid Medline, Ovid Embase and Pubmed, from 1st January 2009 to 18th May 2021. We included studies related to (1) undergraduate medical students and (2) geriatric medicine or ageing or older adults and (3) curriculum or curriculum topics or learning objectives or competencies or teaching methods or students' attitudes and (4) published in a scientific journal. No language restrictions were applied.

RESULTS

We identified 2503 records and assessed the full texts of 393 records for eligibility with 367 records included in the thematic analysis. Six major themes emerged: curriculum, topics, teaching methods, teaching settings, medical students' skills and medical students' attitudes. New curricula focussed on minimum Geriatrics Competencies, Geriatric Psychiatry and Comprehensive Geriatric Assessment; vertical integration of Geriatric Medicine into the curriculum has been advocated. Emerging or evolving topics included delirium, pharmacotherapeutics, healthy ageing and health promotion, and Telemedicine. Teaching methods emphasised interprofessional education, senior mentor programmes and intergenerational contact, student journaling and reflective writing, simulation, clinical placements and e-learning. Nursing homes featured among new teaching settings. Communication skills, empathy and professionalism were highlighted as essential skills for interacting with older adults.

CONCLUSION

We recommend that future undergraduate medical curricula in Geriatric Medicine should take into account recent developments described in this paper. In addition to including newly emerged topics and advances in existing topics, different teaching settings and methods should also be considered. Employing vertical integration throughout the undergraduate course can usefully supplement learning achieved in a dedicated Geriatric Medicine undergraduate course. Interprofessional education can improve understanding of the roles of other professionals and improve team-working skills. A focus on improving communication skills and empathy should particularly enable better interaction with older patients. Embedding expected levels of Geriatric competencies should ensure that medical students have acquired the skills necessary to effectively treat older patients.

[Survey on innovation in the teaching of Geriatrics at the Spanish Medical Schools]

OBJECTIVE

To identify the innovations in teaching of Geriatrics at the Spanish Medical Schools.

METHODOLOGY

Interviews with those responsible for Geriatrics teaching at the Spanish Medical Schools through a short online survey. Existing Geriatrics curricula and responsible professors were identified by reviewing the curricula of the different Medical Schools.

RESULTS

35 of the 42 Medical Schools incorporated teaching in Geriatrics in 2019 with an answer rate of 94.3%. Regarding Geriatrics training it stand out classic methods (master classes, clinical rotations, and theoretical seminars), followed by innovation of teaching programs (clinical simulation and use of new technologies). While OSCE and portfolio stand out among the innovative evaluation tools of Geriatrics teaching. Of the 33 Medical Schools with Geriatrics teaching surveyed, 60.6% of them included the use of at least one innovative teaching or evaluation methodology.

CONCLUSIONS

Although the classical model predominates as a teaching methodology in Geriatrics, different innovations are also used in the undergraduate teaching in Spain. It is necessary to continue working in this area that may help a better level of skills in Geriatrics for our students.

[Ten recommendations to improve undergraduate training in Geriatric Medicine]

INTRODUCTION

Population ageing and scientific progress have made specific training in Geriatrics essential for any medical students. There are different international recommendations on the teaching of Geriatric Medicine at undergraduate level, but they are still far from being offered systematically. The aim of this work was to develop a National list of recommendations in order to improve training in Geriatric Medicine at the undergraduate level.

MATERIAL AND METHODS

A list of 10 recommendations was produced by reflecting on the Geriatric training situation in Spain in 2016/2017 and international recommendations. Consensus was reached among the members of the Spanish Society of Geriatrics and Gerontology (SEGG) working group on «Geriatric training at undergraduate level» through 2meetings and online discussions.

RESULTS

A list of 10 of recommendations on Geriatric training in Spanish Medical Schools is proposed, including areas such as, the status of the discipline in the curriculum, length, contents, practical training, lecturers, teaching methods, and innovation.

CONCLUSIONS

These recommendations are intended to improve Geriatrics training. They can be used by different Medical Schools either to adapt their programs or to start training in Geriatric Medicine.

Status of Geriatrics in 22 Countries

OBJECTIVES

The aim of this article is to describe the current status of geriatrics and position of geriatricians in 22 countries of three continents, and to portray their attitudes towards and resources allocated to geriatrics.

METHODS

An electronic survey was delivered to a convenience sample of 22 geriatricians in leading positions of their countries.

RESULTS

The time required in post graduation specialist training to become a geriatrician varied from one year (subspecialty in the USA) to six years (independent specialty in Belgium). The number in the population aged 80+ per geriatrician varied from 450 (Austria) to 25,000 (Turkey). Of respondents, 55% reported that geriatrics is not a popular specialty in their country. Acute geriatric wards, rehabilitation and outpatient clinics were the most common working places for geriatricians. Nearly half of the respondents had an opinion that older patients who were acutely ill, were receiving subacute rehabilitation or had dementia should be cared for by geriatricians whereas half of the respondents would place geriatricians also in charge of nursing home and orthogeriatric patients. The biggest problems affecting older people's clinical care in their countries were: lack of geriatric knowledge, lack of geriatricians, and attitudes towards older people. Half of respondents thought that older people's health promotion and comprehensive geriatric assessment were not well implemented in their countries, although a majority felt that they could promote good geriatric care in their present position as a geriatrician.

CONCLUSION

The position of geriatric, geriatricians' training and contents of work has wide international variety.

European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome

This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization's classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.

European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome

This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization's classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.

[University studies plan in geriatric medicine developed using a modified Delphi technique]

INTRODUCTION

The increase in the number of frail elderly people has led to the necessity that all doctors of the future acquire sufficient knowledge on human ageing and the skills in the management of the patient of advanced age, as well as the diseases associated with ageing. Few countries offer geriatric medicine within undergraduate training. The purpose of the present project was to obtain a consensus between European geriatricians on the minimum requirements that medical students must achieve at the end of their university degree course.

MATERIAL AND METHODS

A modified Delphi process was used. Firstly, experts in education and geriatrics proposed a set of learning objectives based on a review of the literature. Three Delphi rounds were then performed, in which a panel of 49 experts representing 29 countries affiliated to the European Union of Medical Specialists took part. This enabled them to reach a consensus on a definitive study plan.

RESULTS

The number of disagreements after the Delphi rounds 1 and 2 were 81 and 53, respectively. Full agreement was reached after the third round. The definitive study plan consisted of detailed objectives grouped under 10 general training objectives.

CONCLUSIONS

A consensus has been reached between European geriatricians that sets specific training objectives for medical students. Great efforts will be required for the introduction of these requirements, given the variability there is in the quality of teaching in geriatrics. This study plan is a first step in helping to improve geriatrics teaching in faculties of medicine, and will also serve as a basis to make advances in the training in post-graduate geriatrics throughout Europe.

[Geriatric teaching at undergraduate level: are Spanish Medical Schools following European recommendations?]

OBJECTIVES

To compare the learning objectives proposed by the European Union of Medical Specialists Geriatric section (UEMS-GS) with those approved in Spain for undergraduate teaching.

MATERIAL AND METHODS

Learning objectives included in the European Undergraduate Curriculum in Geriatric Medicine developed by the UEMS-GS in 2013 were compared with those listed in different Spanish official documents: Boletín Oficial del Estado (BOE, Spanish State Gazette), white book on Medicine of the Spanish Accreditation Agency (ANECA), and list of learning objectives of Spanish Medical Schools.

RESULTS

the European curriculum recommends to teach 42 competencies divided in 10 sections, while the BOE mentions 37 general competencies and some other specific competencies, and the ANECA mentions 23 generic and 34 specific competencies (similar to the 37 of the BOE), and a list of common contents in which Geriatrics is included. The BOE includes 38% of the European competencies (range 17-100% of competencies in different sections), while the ANECA includes 52% of them (range 17-100%).

CONCLUSIONS

Spanish regulations include from one third to half of the European recommendations for Geriatrics teaching at undergraduate level. In the future, it seems advisable that official requirements in Spain should converge with European recommendations. This task should also be performed by Spanish Medical Schools.

European undergraduate curriculum in geriatric medicine developed using an international modified Delphi technique

Introduction: the rise in the number of older, frail adults necessitates that future doctors are adequately trained in the skills of geriatric medicine. Few countries have dedicated curricula in geriatric medicine at the undergraduate level. The aim of this project was to develop a consensus among geriatricians on a curriculum with the minimal requirements that a medical student should achieve by the end of medical school.

Methods: a modified Delphi process was used. First, educational experts and geriatricians proposed a set of learning objectives based on a literature review. Second, three Delphi rounds involving a panel with 49 experts representing 29 countries affiliated to the European Union of Medical Specialists (UEMS) was used to gain consensus for a final curriculum.

Results: the number of disagreements following Delphi Rounds 1 and 2 were 81 and 53, respectively. Complete agreement was reached following the third round. The final curriculum consisted of detailed objectives grouped under 10 overarching learning outcomes.

Discussion: a consensus on the minimum requirements of geriatric learning objectives for medical students has been agreed by European geriatricians. Major efforts will be needed to implement these requirements, given the large variation in the quality of geriatric teaching in medical schools. This curriculum is a first step to help improve teaching of geriatrics in medical schools, and will also serve as a basis for advancing postgraduate training in geriatrics across Europe.

Malignancy as a risk factor in single-stage combined approach for simultaneous elective surgical diseases

OBJECTIVE

To identify morbidity and mortality risk factors in patients with synchronous diseases who underwent single-stage combined (SSC) surgery.

METHODS

We considered data of 328 patients, each with multiple, elective, synchronous surgical problems treated by a SSC operation. By univariate and multivariate analysis we evaluated many patient-, disease - or treatment-related variables with respect to post-operative mortality, morbidity, and hospital stay.

RESULTS

Two combined procedures were synchronously performed in 283 patients (86%), 3 combined procedures in 45 patients (14%). Post-operative mortality and morbidity rates were 3% and 24%, respectively, and median duration of hospital stay was 9 days. The occurrence of a surgical oncology procedure emerged as the most important independent risk factor for post-operative mortality and morbidity.

CONCLUSIONS

The safety of SSC surgery for the treatment of synchronous problems appears similar to that of multi-stage procedures. The understanding of risk factors for this surgical approach could be useful in order to improve patient selection.

Designing assisted living technologies 'in the wild': preliminary experiences with cultural probe methodology

BACKGROUND

There is growing interest in assisted living technologies to support independence at home. Such technologies should ideally be designed 'in the wild' i.e. taking account of how real people live in real homes and communities. The ATHENE (Assistive Technologies for Healthy Living in Elders: Needs Assessment by Ethnography) project seeks to illuminate the living needs of older people and facilitate the co-production with older people of technologies and services. This paper describes the development of a cultural probe tool produced as part of the ATHENE project and how it was used to support home visit interviews with elders with a range of ethnic and social backgrounds, family circumstances, health conditions and assisted living needs.

METHOD

Thirty one people aged 60 to 98 were visited in their homes on three occasions. Following an initial interview, participants were given a set of cultural probe materials, including a digital camera and the 'Home and Life Scrapbook' to complete in their own time for one week. Activities within the Home and Life Scrapbook included maps (indicating their relationships to people, places and objects), lists (e.g. likes, dislikes, things they were concerned about, things they were comfortable with), wishes (things they wanted to change or improve), body outline (indicating symptoms or impairments), home plan (room layouts of their homes to indicate spaces and objects used) and a diary. After one week, the researcher and participant reviewed any digital photos taken and the content of the Home and Life Scrapbook as part of the home visit interview.

FINDINGS

The cultural probe facilitated collection of visual, narrative and material data by older people, and appeared to generate high levels of engagement from some participants. However, others used the probe minimally or not at all for various reasons including limited literacy, physical problems (e.g. holding a pen), lack of time or energy, limited emotional or psychological resources, life events, and acute illness. Discussions between researchers and participants about the materials collected (and sometimes about what had prevented them completing the tasks) helped elicit further information relevant to assisted living technology design. The probe materials were particularly helpful when having conversations with non-English speaking participants through an interpreter.

CONCLUSIONS

Cultural probe methods can help build a rich picture of the lives and experiences of older people to facilitate the co-production of assisted living technologies. But their application may be constrained by the participant's physical, mental and emotional capacity. They are most effective when used as a tool to facilitate communication and development of a deeper understanding of older people's needs.

The match between institutional elderly care management research and management challenges - a systematic literature review

BACKGROUND

Elderly care practice and its management together with policy and research play a crucial role in responding to increasing challenges in institutional care for elderly people. Successful dialogue between these is necessary. The purpose of this systematic literature review is to compare how institutional elderly care management research meets the care challenges currently emphasized in international long-term care policy documents.

METHODS

This paper was based on a systematic literature review. After screening 1971 abstracts using inclusion/exclusion criteria, 58 refereed articles published between 2000 and 2010 remained for analysis. The articles were analyzed using theory-based content analysis by comparing the results to the framework based on analysis of international long-term care management policy documents.

RESULTS

The current challenges of long-term care management identified from policy documents were Integrated Care Management, Productivity Management, Quality Management, Workforce Management and ICT Management. The research on institutional elderly care management responded somewhat to the challenges mentioned in policy documents. However, some of the challenges were studied broadly and some were paid only minor attention. Further, only few studies focused on the core items of challenges addressed in policy documents.

CONCLUSIONS

Institutional care management research needs to focus more on challenges in integrated care, productivity, ICT and division of labor. Managers, researchers and policy-makers should assume more active collaborative roles in processes of research, policymaking and policy implementation. In addition managers' and policymakers' scientific literacy needs to be enhanced.

Effects of comprehensive geriatric intervention on physical performance among people aged 75 years and over

BACKGROUND AND AIMS

We studied the effects of comprehensive geriatric assessment and multifactorial intervention on physical performance among older people.

METHODS

In a 3-year geriatric development project with an experimental design, 668 participants aged 75-98 were assigned to intervention (n=348) or control (n=320) groups. The intervention group received comprehensive geriatric assessment with an individually targeted intervention for 2 years. The outcome measures - performance in the Timed Up-and-Go (TUG), 10-meter walking and Berg Balance Scale tests - were gathered annually during the intervention and the 1-year follow-up after it.

RESULTS

With linear mixed models, over the 2-year intervention period, the intervention group was found to be improved in the balance (p<0.001) and walking speed (p<0.001) tests, and maintained performance in the TUG test (p<0.001), compared with the control group. The results remained significant 1 year post-intervention.

CONCLUSIONS

Comprehensive geriatric assessment and individually targeted multifactorial intervention had positive effects on physical performance, potentially helping to maintain mobility and prevent disability in old age.

A pilot trial to predict frailty syndrome: the Japanese Health Research Volunteer Study

Most definitions of frailty utilize US populations in their development. The concept of frailty has not been well studied in Japan, which has the largest percentage of older patients (per capita) in the world. We created a 5-year prospective cohort study of community-dwelling older Japanese adults. Participants were not frail at baseline, based on our definition adapted from the Canadian Study for Health and Aging Clinical Frailty Scale. Participants underwent a comprehensive geriatric assessment (CGA) at baseline, and final assessments were either in person or via mailed survey. We enrolled 407 individuals (184 men, mean age 78 ± 4 years; 223 women, mean age 77 ± 4 years). Sixty-five participants met criteria for frailty by the end of the study. In univariate analyses, eighteen separate parameters were associated with frailty, some of which included: age, gender, handgrip, timed walk, systolic blood pressure, pulse pressure, cognitive status, living alone, and hearing deficits. In multivariate analyses, the following elements remained associated with frailty: timed walk, pulse pressure, cognition deficits and hearing deficits. We established cut-off points for timed walk (5m/3s) and pulse pressure (60 mmHg). We then created a simple additive score for these four factors (present = 1; absent = 0). A score of 0 had a 93% negative predictive value for frailty while a score of 4 had a 70% positive predictive value. While further study is needed, this work creates an easy-to-administer tool that may be generalizable to other populations.

Biogerontology in Finland

This paper describes current biogerontology research in Finland especially in the universities with professorships in gerontology/geriatrics. If biogerontology is broadly taken to include all research in basic mechanisms of normal ageing as well as age-related diseases, the most prevalent current topics include basic research in genetics, mitochondrial function, musculoskeletal physiology, neurodegenerative and vascular diseases. The research activity of each institute and their international collaboration is briefly described with examples focused on recent publications in the field of biogerontology.