Paediatric medicine is now so well established that we would think it strange for a child to be looked after in an adult hospital service. Yet up until the middle of the 19th century children were seen as small adults and treated as such.
It took a considerable effort from early pioneers to establish the then radical concepts that children differ from adults, requiring different doses and types of medications, responding differently to some treatments, possessing conditions unique to their age group and having additional developmental, social, and family needs that have a significant impact on their care and outcomes.
Indeed, there was initial resistance from the established medical and nursing professions on the basis that “we all look after these patients”, and formal recognition of paediatrics came late in some countries.
The evolution of thought on the challenge of communication with babies was interesting, with earlier clinicians leaning on parallels with veterinary medicine, progressing to the concept of exploring the language of signs and a more engaged approach requiring active learning of a new culture and language.
The early 21st century faces a parallel challenge in its response to a new complexity associated with the very fortunate increase in our longevity. Just as with children, older people differ significantly from younger adults, with not only more marked inter-individual variation and more likely to have multiple diseases but also different presentations, responses to treatments and complex syndromes such as frailty and dementia.
Our engagement with the significant minority of those with dementia equally requires new skill sets and imaginative engagement with the person affected and those who support them.
Fortunately, new and effective techniques and principles of care, largely through geriatric medicine, old-age psychiatry and gerontological nursing, have developed which tackle this complexity head on as an integral part of care rather than as something to be dealt with later.
For example, acute medical care for older people in hospital delivered through geriatric medicine rather than traditional pathways reduces death and discharge to nursing home by 25 per cent.
For this benefit to happen, the care must be delivered in a geriatric medicine ward, indicative of the key role of gerontological nurses, and points to a major concern that many Irish hospitals do not yet have dedicated wards for geriatric medicine.
So why is this not delivered more widely? There is a wide range of reasons, some of which is related to the mindset of “we all look after older people”, or “treat first and deal with the complexity later” among some planners and senior professionals. Indeed, the 2009 guidance from the Nursing and Midwifery Board about nursing older people spectacularly omits any reference to “gerontological nursing” or “specialist nursing of older people”.
In addition, older people themselves may harbour ageist attitudes towards the concept of specialist services for older people, as evidenced in a number of studies asking whether they would rather be treated in a general or geriatric medicine ward: this may in turn mute the political impetus to develop specialist care.
Two pieces of good news should change attitudes and practice. The first arises from the most important research paper of 2015 for older people, published in the Lancet. It showed that early involvement of geriatric medicine and gerontological nursing in the care and assessment of those with fractured hips not only improved their function, cognitive function, and abilities, but reduced the need for – and duration of – formal rehabilitation, with significantly lower overall healthcare costs over the following year despite extra investment during the hospital stay.
This form of combined care – known as orthogeriatrics – will need to become the new standard of care, and although requiring investment in personnel will pay for itself in a very short period. The progress of this initiative can be tracked through the Irish Hip Fracture Database, an excellent example of geriatric medicine and orthopaedic surgery working together at a national level.
The second element is a survey proposed by the Health Service Executive for next year to monitor how many frail older people admitted to Irish hospitals will be treated in dedicated geriatric medicine wards. This will provide a benchmark for the development of gerontologically- attuned services and hopefully will mark a turning point where Ireland wholeheartedly embraces specialised approaches to healthcare at both extremes of the lifespan.
Prof Desmond O’Neill is a consultant physician in geriatric and stroke medicine and professor of medical gerontology at Tallaght hospital and Trinity College Dublin. He blogs at blogs.bmj.com/bmj/category/desmond-oneill. Twitter: @Age_Matters