Old age, its care and treatment in health and disease (1914)

Geriatrics: The Diseases of Old Age and Their Treatment the modern era with the publication in of Ignatz Leo Nascher's seminal text.
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Old age is frequently accompanied by many long-term conditions that affect health. Many old people will have multiple long-term conditions e. Dysphagia, difficulty in swallowing, will accompany many long term conditions and may be latent in many frail older people, and is associated with increasing dependency and death.

This short paper will outline the reasons why it should be considered thus. The essential function of the swallowing process is to transfer food from the mouth to the stomach via the oesophagus, a simple, but complex process. The process of swallowing is separated into three phases, oral, pharyngeal and oesophageal [ 2 , 3 ]. The oral phase, to be efficient, requires adequate lip closure, a functioning tongue and the presence of saliva; the pharyngeal phase is a transfer phase between the mouth and the oesophagus, but it is a shared space with respiration.

Therefore the airway needs to be protected during this phase. Then to enter the oesophagus the upper oesophageal sphincter or cricopharyngeus needs to relax. The pharyngeal phase of the swallow is a complex reflex, coordinated by the swallowing centres within the medullary pontine area of the brainstem [ 4 ] This reflex is modified via the feedback loop between the pharynx, hyoid muscles and tongue to the cortex regarding bolus characteristics volume and consistency , which then regulates the timing of events during the pharyngeal swallow, but not the sequence of events [ 5 , 6 ].

Protection of the airway is a complex process that involves the closure of the larynx by the false and true vocal folds, elevation and rotation forward of the larynx and backward pressure from the base of the tongue. The Naso-pharynx is protected by elevation of the soft palate and the forward movement of the posterior pharyngeal wall.

As the larynx closes off, respiration ceases to be followed by expiration when the swallow has been completed. The neurological innervation of swallowing Figure 1 comprises 6 cranial nerves as well as the pharyngeal plexus. Cortical representation is diffuse, but work by Hamdy and colleagues have shown that although cortical representation is bilateral, one hemisphere is dominant.

This dominance has importance when the brain is injured stroke, TBI , and if the injury has affected the dominant side, the response of the non-dominant hemisphere is important to recovery [ 4 , 7 - 9 ]. Food recognition requires more than taste alone. The recognition of a particular food relies on vision, smell, proprioception and memory.

Unfortunately age brings changes to these systems. Memory may be reduced due to dementia resulting in the inability to recall previous experiences with food. Not least to cope with the joys of having dentures and eating. Saliva is crucial for a swallow and although volumes are reduced, adequate volumes are still present, until there is a perturbation on the system due to illness or medication Table 2 [ 14 , 15 ]. With age there are changes in the ability to swallow, though, not infrequently the older person may not recognise that any changes to their swallow has occurred.

Within the peripheral neurological system, there is a reduction in nerve conduction and increased conduction times due to myelin degeneration [ 11 , 16 ], which reduces the effectiveness of the feedback loop. There is a reduction in proprioception both in the tongue and lips reducing the ability to identify texture and viscosity [ 17 ]. The sequence of events during swallowing does not change, but the timing of events and the degree of change is different. The oro-pharyngeal phase is prolonged [ 18 ] with a prolonged transit time [ 19 ] and there are more cortical areas activating during swallow suggesting a more concentrated effort [ 20 ].

The changes in the oral phase will include prolonged oral bolus transit [ 21 ]; there is an increase in the dippers as opposed to tippers of tongue position [ 22 ] prior to the propulsion of the bolus towards the pharynx.

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Changes in the swallowing process may be affected due to frailty and sarcopenia rather than an overt disease process [ 23 ]. As a consequence of both of these processes, skeletal muscle is weak poor quality muscle fibres and reduction in number which may result in reduced tongue function and pharyngeal contraction.

Isometric tongue pressures although reduced, have no clinical effect as the tongue is working at submaximal pressures [ 24 ], Calve et al. However Logemann did note that women exhibit reduction in tongue base movement [ 25 ]. Smaller volumes are swallowed but a larger bolus is required to trigger a reflex swallow [ 26 , 27 ]. Laryngeal elevation, rotation and forward movement are reduced. Laryngeal vestibule closure is delayed and maximal hyolaryngeal excursion is delayed [ 24 ].

The final defence of the airway during swallowing is the cough reflex. A weak cough reflex increases the risk of aspiration and pneumonia [ 28 ], with normal ageing there is no change in the cough reflex,however the threshold concentration for citric acid does increase in the presence of dementia 2. This is evident with the need to undertake recurrent hyoid gestures [ 25 ] table.

Pharyngeal transit times increase. The larynx has a tendency to have a lower resting height and does not elevate as much in younger people. Many older people will have swallowing problems. The prevalence of dysphagia increases with the degree of frailty present and the degree of dependence irrespective of ethnicity [ 13 , 16 , 33 - 37 ]. Problems may present with fatigability whilst eating, coughing on certain consistencies and at times with behavioural issues such as food refusal, spitting and the hiding of food. The consequences of swallowing problems Table 4 may be very little for some, but in others it will result in poor nutrition, reduced muscle strength, immobility, poor wound healing, aspiration and pneumonia [ 63 , 64 ].

The consequence for society is a greater use of health resources at time when there are already pressures on health systems. Mortality at 30 days from pneumonia has been found to be The relative risk of pneumonia is 6 fold for those greater than 75 years compared to those under Those living in care homes are 33 times as likely to be admitted to hospital with a pneumonia compared to those living in the community [ 37 ]. Oral health is an important factor in the occurrence of pneumonia. There he built a particularly strong geriatric psychiatry program.

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This program was responsible for the training of luminaries such as Murray Raskind and Burton Reifler. Around the same time, the Boston Society for Gerontologic Psychiatry was established, and, in , began to publish the Journal of Geriatric Psychiatry. The International Psychogeriatric Association was formed out of the Nottingham club, which had been created as part of a 2-week course on psychogeriatrics developed by Tom Arie.

It publishes International Psychogeriatrics. The Alzheimer's Disease and Related Disorders Association is a consumer organization, formed in , which has played a major role in improving care, research, and political lobbying for patients with dementia. Two books written for the public have had a major influence on increasing awareness of the needs of patients with dementia. The development of geriatrics in Europe has been somewhat helter skelter with programs developing and then regressing, depending on the leadership. At the start of the 20th century, Austria was a powerhouse of the emerging field of geriatric care.

Arnold Lorund in his book, Old Age Deferred, which was published in He felt that the causes of aging were arteriosclerosis, problems with immunity leading to increased infections, and abnormalities of the secretions of the ductless glands. He felt that being married and having a religious belief were important components in prolonging life. In Sweden, the first chair and department of long-term care medicine was established at Uppsala University in the s and the second at Goteborg University in the s Geriatric specialty training takes 5 years, and a voluntary examination for specialization was first offered in The longitudinal population study of persons 70 years of age was established in Gothenburg in — — The success of this project was largely due to Alvar Svanborg and Bertil Steen.

The Geriatric Society in Italy was founded in under the chairmanship of M. Most medical schools in Italy have a chair of gerontology. In Geneva, psychogeriatric consultation was developed by Dr. Junod, in , who later became the first Swiss professor of geriatrics , This was followed by the opening of the Hospital de Geriatric beds in In , the University Geriatric Institutions of Geneva was formally instituted, and this metamorphosed into the Department of Geriatrics in under the leadership of Jean-Pierre Michel.

The Spanish Society of Geriatry and Gerontology was founded in In Spain, a limited number of persons receive high-quality care from geriatric hospitals, geriatric units, inpatient geriatric consultation services, and geriatric home care teams Geriatrics was recognized as a medical specialty in The training program is of 4 years' duration. Geriatrics has not played a major role in France, although the first geriatric society was formed in under the chairmanship of A.

The exception has been the development of geriatrics and gerontology in Toulouse Subsequently, under the leadership of Professor Albarede and the younger Bruno Vellas, geriatric care focusing on nutrition and Alzheimer's disease was developed in the department of internal medicine and the gerontology clinic at CHU Purpon-Casselardit.

Bruno Vellas has played a major role in increasing geriatric awareness throughout Europe. His work led to the establishment of a medical specialty in long-term care. The Danish Society of Geriatric Medicine was established in Geriatric medicine was recognized as a subspecialty of internal medicine in Denmark in General practitioners have historically carried out home visits for older persons. Denmark has been a leader in home visit research , Japan has been slow to recognize the specialty of geriatrics, despite the fact that it has the world's longest mean life span and over , centenarians.

Most older persons are accommodated in acute hospitals where the length of stay has traditionally been very long. Many hospitals have lacked adequate rehabilitation facilities. Tokuyo special homes for the care of the elderly are run at public expense. The Tokyo Metropolitan Institute of Gerontology was founded in This Institute focuses on interdisciplinary research on aging, with two thirds being in the biomedical area and the rest in social science and nursing. In , the National Institute of Longevity Science was established. The development of the senescence-accelerated mouse SAM models by Professor Takeda at Kyoto University has been a major contribution to aging research These models have been particularly useful for exploring memory deficits — These mice are particularly good models of mitochondrial dysfunction and free radical damage — The SAMP8 mouse appears to produce its memory deficit due to an excess production of amyloid precursor protein — Korenchevsky had played a major role in stimulating its development.

There were attendees from 14 nations. This first Congress focused on the definition of aging, the dichotomy between aging and disease, and the social aspects of aging. The second International Congress was held in St. Louis, Missouri, in under the presidency of Dr. There were attendees from 51 countries. These included six from Argentina, who had formed their formal geriatrics society in Geriatrics is also strongly developed in other parts of the world such as Canada, Australia, and Hong Kong. There is also an increasing need for geriatrics in the developing countries of the world The first major advance in modern geriatrics has been the codifying of the geriatric assessment into a number of widely used screening tools Table 7.

The first of these was developed by Dorothea Barthel, a physical therapist at Montebello State Hospital in Baltimore, in Tables 8 and 9 list the articles in the Journal of the American Geriatrics Society and the Journal of Gerontology that have been cited or more times. These give a broad view of the areas that have had the most impact from the gerontological literature. It should be noted that few of the papers on Alzheimer's disease or depression have been published in these journals. The evidence that geriatric assessment and management units are effective — , and that geriatric assessment in the home also can improve outcomes — , perhaps represents the major component of the success of geriatrics in the last half of the 20th century.

Within hospitals, the development of units for Acute Care of the Elderly and innovative approaches to the management of delirium appear to be the sentinel geriatric events From the therapeutic viewpoint, the importance of exercise therapy, especially resistance exercise, would appear to be the major impact area , The role of hormone replacement, both positive and negative, has occupied a large amount of the geriatrician's time , Of the seminal theoretical underpinnings of modern geriatrics, I believe we should identify Fries' theory of compression of morbidity — , Rowe and Kahn's successful aging hypothesis , and the controversial emergence of frailty as a syndrome — Finally, the enormous advances of medicine in general in the treatment of diseases from cardiovascular diseases — to neuropsychiatry conditions — has had a tremendous impact on the care of the older person.

In this century, we will hopefully obtain the evidence-based medicine necessary to allow us to make appropriate treatment choices for 70, 80, and even 90 year olds. The increasing studies on the factors genetic and environmental that allow centenarians to age successfully will certainly be one of the major scientific successes in the next 50 years — It is hoped that this brief review of the history of geriatrics, together with the commentaries that follow, will provide a foundation for geriatricians of the 21st century to view their origins.

Like all histories, this one is somewhat epochcentric, focusing on the last 50 years. However, in the case of geriatrics, this is less of a problem, as the flourishing of geriatrics has been a relatively recent phenomenon. For those wishing more detail of more distant history, I recommend Roots of Modern Gerontology and Geriatrics: This history focuses on the physician history, and geriatrics is clearly par excellence an interdisciplinary endeavor.

As such, there is a need for a future history that provides a less physician-centered viewpoint. Finally, this history is somewhat geocentric, focusing on the Anglo-American development of geriatrics and, to some extent, a Californian-Midwestern perspective. It is hoped that the commentaries will help to offset some of these shortcomings. Cicero together with the first quotation recognizing a physiological anorexia of aging. Address correspondence to John E. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.

Sign In or Create an Account. Close mobile search navigation Article navigation. P rehistory of G eriatrics. T he B irth of G eriatrics. T he H istory of N ursing H omes.

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P hysician -D irected H ome C are and H ospice. C ontinuous Q uality I mprovement and G eriatrics. T he D evelopment of G eriatric P sychiatry. G eriatrics in the R est of the W orld.


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M odern A dvances in G eriatrics. The Journals of Gerontology: Chesterton In the end, each of our endeavors is only a product of those who went before us trailblazing the path to the present. T he D evelopment of M odern G eriatrics —T he U nited K ingdom Marjory Warren — is given much credit for the development of modern geriatrics. T he D evelopment of M odern G eriatrics —T he U nited S tates of A merica Before reviewing the development of modern geriatrics in the United States, it is of use to review a number of key early events in the social condition of elderly people.

T he D evelopment of G eriatric P sychiatry As mentioned, geriatric psychiatry had its birth in with the articles written by Benjamin Rush. G eriatrics in the R est of the W orld The development of geriatrics in Europe has been somewhat helter skelter with programs developing and then regressing, depending on the leadership. M odern A dvances in G eriatrics The first major advance in modern geriatrics has been the codifying of the geriatric assessment into a number of widely used screening tools Table 7.

C onclusion It is hoped that this brief review of the history of geriatrics, together with the commentaries that follow, will provide a foundation for geriatricians of the 21st century to view their origins. View large Download slide. Brown-Sequard and a quotation from his article on the effects of testicular injections.

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    Geriatrics: The Diseases of Old Age and Their Treatment

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    Memories are made of this: Depression in late life: Discovering the secrets of successful longevity [Editorial]. Cardiovascular advantages among the offspring of centenarians.