Geriatrics as - Associazione Geriatri Extraospedalieri

Università degli Studi di Palermo. Scuola di Medicina e Chirurgia
U.O.C. di Geriatria e Lungodegenza
Direttore prof. M. Barbagallo
Competenze geriatriche e training geriatrico in Europa:
dove siamo nel 2016?
Bari, Congresso Nazionale AGE, 3 Marzo 2016
Prof. Mario Barbagallo
Professore Ordinario di Geriatria
Presidente della Clinical Section della IAGG-ER
Segretario Generale SIGG
Esperto Consiglio Superiore della Sanità
Direttore U.O.C. di Geriatria e Lungodegenza
Direttore Scuola di Specializzazione in Geriatria,
Università degli Studi di Palermo
PROBLEMS WITH GERIATRICS
IDENTITY IN EUROPE
• Difficulties in many countries in establishing
the independent specialty of geriatrics
• Difficulties with its academic recognition
• Need of more clinical scientific production and
clinical evidence
• Difficulties in incorporating it into health care
system
HISTORY OF GERIATRIC MEDICINE
MARJORY WARREN – THE MOTHER OF GERIATRICS
1935: from 714 old “incurable” patients to 200.
Most of them had:
Poor diagnosis
Insufficient treatment
Lack of medical supervision
Lack of multidisciplinary teamwork
Absence of rehabilitation
Argued for the opening of special wards for geriatric
patients
«Many of the so-called old, incurable cases only need the
tact and quiet energy of a staff trained to work with this type
of patients to show considerable measure of improvement»
Rete dei Servizi Geriatrici Ospedale-Territorio
MD Med Generale
• Ass. volontariato
• Assistenza sociale
Ospedale (Subacuto)
Lungodegenza
Post-acuto
RSA
Centri diurni
Ospedale (Acuto)
Day Hospital
UVGM
ADI
VGM: Valutazione Geriatrica Multidimensionale
Università
Studi
di Palermo.Facoltà
Scuola didi
Medicina
e Chirurgia
Università
deglidegli
Studi
di Palermo.
Medicina
e Chirurgia
U.O.C. di Geriatria e Lungodegenza
U.O. di Medicina Interna e Geriatria.
Direttore prof. M. Barbagallo
Direttore prof. M. Barbagallo
The First Geriatric Society in Europe
British Geriatrics Society (BGS )
The British Geriatrics Society (BGS)
was founded in 1947
for “the relief of suffering and distress
amongst the aged and infirm
by the improvement of standards of
medical care for such persons”
Università
Studi
di Palermo.Facoltà
Scuola didi
Medicina
e Chirurgia
Università
deglidegli
Studi
di Palermo.
Medicina
e Chirurgia
U.O.C. di Geriatria e Lungodegenza
U.O. di Medicina Interna e Geriatria.
Direttore prof. M. Barbagallo
Direttore prof. M. Barbagallo
Alcune date della Geriatria Italiana
1950 - Su iniziativa del Prof. ENRICO GREPPI (Clinico Medico dell´Universitá di
Firenze), la Societá Italiana di Gerontologia e Geriatria (SIGG), fu fondata a
Firenze il 28 aprile 1950, con lo scopo di "promuovere e coordinare gli studi sulla
fisiopatologia della vecchiaia, nonché quello di affrontare anche nei suoi aspetti di
ordine sociale il grave e complesso problema della vecchiaia".
A reggere la presidenza della SIGG viene chiamato il Prof. Enrico Greppi, che
manterrá tale carica fino alla sua morte avvenuta nel febbraio 1969.
1955 - Il Ministero dell´Insegnamento in Pubblica Istruzione concede alla Facoltá di
Medicina dell´Universitá di Firenze l´istituzione di un incarico di insegnamento in
Gerontologia e Geriatria, affidato al Direttore della Clinica Medica e Presidente SIGG,
Prof. E. Greppi. Si tratta del primo incarico nell´ordinamento degli studi medici in
Italia.
1961- La Gazzetta Ufficiale n° 275 del 7/11/1961 riporta il decreto di istituzione della
prima Scuola di Specializzazione in Gerontologia e Geriatria, che inizierá la
propria attivitá nell´anno accademico 1961/62. La direzione e coordinazione
della Scuola é affidata al Direttore della Clinica Medica di Firenze, Prof. E. Greppi.
1962 - Presso l´Ateneo fiorentino viene istituita la prima Cattedra in Gerontologia e
Geriatria, affidata al Prof. Francesco Maria Antonini.
Università
Studi
di Palermo.Facoltà
Scuola didi
Medicina
e Chirurgia
Università
deglidegli
Studi
di Palermo.
Medicina
e Chirurgia
U.O.C. di Geriatria e Lungodegenza
U.O. di Medicina Interna e Geriatria.
Direttore prof. M. Barbagallo
Direttore prof. M. Barbagallo
Geriatric Medicine Training in Europe
• Geriatric Medicine has been
clearly defined and accepted
only in 2008 in a consensus document
performed by the
EUMS (European Union of
Medical Specialists)
-Geriatric Section -
Definition of Geriatric Medicine
(EUMS-Malta 03-05-2008)
• Geriatric Medicine is a specialty of medicine
concerned with physical, mental, functional
and social conditions occurring in the acute
care, chronic disease, rehabilitation,
prevention, social and end of life situations in
older patients.
• This group of patients are considered to have a
high degree of frailty and active multiple
pathology, requiring a holistic approach.
Diseases may present differently in old age,
are often very difficult to diagnose, the
response to treatment is often delayed and
there is frequently a need for social support.
Definition of Geriatric Medicine
(UEMS-Malta 03-05-2008)
• Geriatric Medicine exceeds organ orientated
medicine offering additional therapy in a
multidisciplinary team setting, the main aim of
which is to optimise the functional status of
the older person and improve the quality of life
and autonomy.
• Geriatric Medicine is not specifically age
defined but deal with the typical morbidity
found in older patients.
• Most patients will be over 65 years of age but
the problems best dealt with by the speciality
of Geriatric Medicine become much more
common in the 80+ age group.
• It is recognised that for historic and structural reasons
the organisation of geriatric medicine may vary
between European Member Countries.
MODEL STRUCTURE OF HEALTH AND
SOCIAL SERVICES FOR THE ELDERLY
• Each country has specific
cultural/historical context and level of
development
• Each country has most of the geriatric
services but they are
- not universally available
- not accessible
- with low awareness of public and
professionals
- not financially sustainable
Geriatric Medicine Training in Europe
Open Questions
•
•
•
•
WHAT KIND OF MEDICAL SPECIALTY?
THERE ARE SEVERAL MODELS
Geriatrics as primary specialty (4-6 yrs training program)
Geriatrics as a narrow «super-specialty»
(internal medicine or general medicine or common trunk
in training, than 2/3 years of geriatric fellowship)
Geriatrics as «supra-specialty» (above all disciplines, in
any medical field)
What about «Added competence in geriatrics»?
Implications for
- General acceptance of the field and discipline
- Financing as health care service
- Legislation and job finding in EU
Geriatric Medicine Training in Europe
Open Questions
• Geriatrics as medical specialty should be
identified by
- Age specific population (elderly but which age
65+,75+, 80+ ?)
- Conditions (frailty, multimorbidity, geriatric
giants,?)
- Geriatric approach?
- Specific methods (CGA-geriatric assessment?)
- General geriatrization of medicine (all doctors
become geriatricians ?)
• Since 1930 a hospital-based specialty (UK)
• Only since 1970s other settings opened up for
the field (ambulatory services, home care)
Geriatric Medicine Training in Europe
Open Questions
• Geriatrics is a Specific Clinical Medical
Specialty
• Geriatrics is NOT only long-term care (but what
should be the relationship ?)
• Geriatrics is NOT general «elderly care» (social
care and programs, pension system ect.)
Geriatric Medicine Training in Europe
Open Questions
HOWEVER, THE PROBLEM STILL PERSISTS
GERIATRICS IS PERCIEVED AS A FIELD OF
•
•
•
•
low technology (vs high touch)
low scientific input
low prestige
and low income field …
What are the solutions for change?
Università
Studi
di Palermo.Facoltà
Scuola didi
Medicina
e Chirurgia
Università
deglidegli
Studi
di Palermo.
Medicina
e Chirurgia
U.O.C. di Geriatria e Lungodegenza
U.O. di Medicina Interna e Geriatria.
Direttore prof. M. Barbagallo
Direttore prof. M. Barbagallo
Geriatric Medicine Training in Europe
Open Questions
• The change from the Hippocratic
paradigm to the functional one in
which the functional consequences
of the diagnosis of the illness should
be taken into account in the training
of the future physicians.
Università
Studi
di Palermo.Facoltà
Scuola didi
Medicina
e Chirurgia
Università
deglidegli
Studi
di Palermo.
Medicina
e Chirurgia
U.O.C. di Geriatria e Lungodegenza
U.O. di Medicina Interna e Geriatria.
Direttore prof. M. Barbagallo
Direttore prof. M. Barbagallo
Geriatric Medicine Training in Europe
Open Questions
Under-graduate and
post-graduate geriatric
training is not uniform in
the different European
countries.
TRAINING IN GERIATRICS
• Under-graduate
medicine studies (voluntary/obligatory, extent and
content)
other paramedical staff (occupational and physiotherapist, nursing)
• Post-graduate
specialists training/fellowships and Continuing
Medical Education
• Post-graduate doctoral studies (PhD)
EAMA, Doctoral studies, Research in
Gerontology/Geraitrics
Geriatric facilities (university-based?) as training
centers
Under-graduate
Training in
Geriatrics
Differences in undergraduate teaching
in Geriatrics in Europe
France
Hungary
Poland
Austria
Finland
Iceland
Estonia
Italy
Slovakia
Slovenia
Spain
Serbia
Sweden
NORWAY
Belgium
Czech Rep
Lithuania Denmark
Malta
Germany
Inexistent
N=6
Ireland
Turkey
Luxembourg
Mean number of hours of the undergraduate geriatric teaching
0
15
30
45
60
//
100
Chairs of geriatrics per
medical schools in each country
100%
• Belgium
• Denmark
• Finland
• France
• Hungary
• Iceland
• Malta
• Norway
• Slovakia
• Sweden
The Netherlands 85%
Poland 65%
Slovakia 65%
Italy 60%
Switzerland 60%
Serbia 50%
Lithuania 50%
United Kingdom 50%
Czech Rep 40%
Bulgaria 40%
Spain 30%
Germany 20%
Ireland 20%
Ukraine 20%
Serbia 15%
Turkey 15%
0
Greece
Portugal
Cyprus
Luxembourg
0%
• Albania
• Austria
• Estonia
• Macedonia
• Slovenia
A.Cruz-Jentoft, 2006
Chairs of geriatrics
in European Medical Schools
Medical
schools
286
Chairs of
Biology of
Ageing
Geriatrics
Psycho
12
130
15
4.2%
45.5 %
5.2%
geriatrics
A.Cruz-Jentoft, 2006
Frenk, Lancet, 2013, 376, 1923
Post-graduate
Training in
Geriatrics
Geriatrics recognized as medical
speciality or sub speciality in 2006
(31 countries)
Speciality
Belgium
Czech Rep
Denmark
Finland
France
( N = 15 )
Hungary
Italy
Lithuania
Luxembourg
Macedonia
Malta
The Netherlands
Spain
Sweden
United Kingdom
Sub-speciality (N = 11)
Bulgaria
Iceland
Ireland
Germany*
Norway
Poland
Serbia
Slovakia
Switzerland
Turkey
Ukraine
Not a Speciality (N = 5)
Cyprus, Greece, Estonia, Portugal, Slovenia
A.Cruz-Jentoft, 2006
Geriatrics Medicine as medical speciality or sub
speciality in 2015
)
(31 countries
Geriatric Medicine as Independent Speciality ( N = 18 )
Belgium
Bulgaria
Czech Rep
Denmark
Finland
France (*)
Hungary
Ireland
Italy
Lithuania
Luxembourg
Malta
Netherlands
Poland
Romania
Spain
Sweden
United Kingdom
Geriatric Medicine as Sub-speciality (N = 9)
Austria
Iceland,
Serbia,
France (*)
Norway,
Switzerland
Germany (13/16 states),
Poland,
Turkey
Geriatric Medicine so far not recognized as independent
specialty of Sub-speciality (N = 5)
Cyprus, Greece, Estonia, Portugal, Slovenia
UEMS 2015
Specialty of Geriatric Medicine
Duration of training in different countries with geriatrics as a primary specialty
Country
Title
Current status
Belgium
Gériatrie/Geriatrie
Гериатрична
медицина
Geriatrie
Γηριατρική
Internal medicine:
geriatric
Geriatria / Geriatri
Geriátria
Öldrunarlækningar
Primary specialty
Primary specialty
Geriatric medicine
Geriatria
Geriatrija
Ġerjatrija
Klinische geriatrie
Geriatri
Geriatria
Geriatria
Geriatrie şi
gerontologie
Geriatrik
Geriatría
Geriatrik
Geriatric medicine
Bulgaria
Czech Republic
Cyprus
Denmark
Finland
Hungary
Iceland
Ireland
Italy
Lithuania
Malta
Netherlands
Norway
Poland
Portugal
Romania
Slovakia
Spain
Sweden
United Kingdom
Primary specialty
Duration of training
(number of years)
6
4
Primary specialty
4
n.a.
7
Primary specialty
Primary specialty
Sub specialty
5
5
8
Primary specialty
Primary specialty
Primary specialty
Primary specialty
Primary specialty
Sub specialty
Primary specialty
Primary specialty
8
4
4
8
5
7
5
n.a.
4
Primary specialty
Primary specialty
Primary specialty
Primary specialty
5
4
7
9
n.a.: not available
List based on survey UEMS-IAGG-EUGMS July 1, 2015
Training in Internal Medicine
Specific Domains of Expertise
In conclusion, we … have emphasized the need for all doctors to have core skills in this arena, for some specialists, including those
in G(I)M to have higher levels skills and we have also emphasized the case for a specific discipline of geriatric medicine which has
higher-level competencies still.
Geriatric Medicine and General (Internal) Medicine need to be recognized as complementary disciplines if healthcare
professionals and health services are to provide care fit for the 21st century. We thus hope that you will agree with us on the
importance of internal medicine doctors working closely with geriatricians for the benefit for older patients and will consider
adjusting your proposed paper accordingly.
Kind Regards
Yours Sincerely
Specialty of Geriatric Medicine
Duration of training in countries with geriatrics as
a primary specialty
UEMS Geriatrics Medicine Section agrees that
the minimum training period for Geriatric
Medicine should be 5 years, and not 4 years as
listed in the current European directive.
UEMS Geriatrics Medicine Section is in favour
of a prolonging the minimum postgraduate
training period from 4 to 5 years for Geriatric
Medicine, provided the minimum training period
is also prolonged for other disciplines.
UEMS 2015
Geriatrics in Europe
Positive Aspects
• Development of geriatrics is in line with EU
recommendations and responds to increasing needs
for specialist treatment of European citizens
• In EU there are currently about 15 000 specialists in
geriatric medicine
• There is increasing scientific evidence about
efficacy and effectiveness of specific geriatric
interventions
• Education and training of Geriatric Medicine
specialists are promoted as well as the role of
academic institutions.
Geriatrics in Europe
UNRESOLVED QUESTIONS
• What are the relations of geriatrics and
- internal medicine (general medicine)
- primary care
- old age psychiatry
- nursing (nursing home medicine)
- rehabilitation
- palliative care
• What are the competencies of a geriatrician
versus the above mentioned disciplines
(e.g. dementia – tx by psychiatrist, neurologist,
geriatrician)
Consequences in limitation of procedures
performed and reimbursed, drug prescription ect.
Unresolved Questions
The role of the Geriatrician
Primary Doctor o Super Specialist?
• The geriatrician should be a primary Doctor or
specialist that may be in fact compared to the
role of the cardiologist or the surgeon?
• Or we can suggest a network of super-primary
Doctors that when there is a problem that
cannot be solved at home by the GP, the help of
the specialist Geriatrician can be asked for by
the GP.
Care of the Elderly
Best model (Cost/benefit)?
• Most of European Countries have preferred the model
with a General Practitioner (GP) as gate keeper for
meeting the needs of older geriatric patients.
• The diseases are more and more concentrated in the
older (oldest) group.
• The medical activity will so be more and more
concentrated on the very old population.
• The greatest part of the job of the GP’s will be more and
more the care for the very old persons.
• The GP’s have thus to be experts in Geriatric Medicine.
Out-patient clinics for older adults: a
difficult exercise
• In many countries it is very difficult to organise outpatient clinics for older patients
– Most GP do recognize now very well a heart failure, a
COPD, the early signs of diabetes, etc
Many GP don’t recognize the typical geriatric syndromes
(never learned during their physician training). They go
on to look to organs, not to the functionality status.
– This disabled people are no so easy to mobilise to the
classical out-patient clinic, staying in waiting rooms, etc
– Importance of the training of all medical students (future
GP) in geriatrics
We are living in a period of great
contradictions
Hospitals full with geriatric patients:
↨
Treated NOT by geriatricians, but by organ
specialist, NOT competent in Geriatric
medicine.
Università
Studi
di Palermo.Facoltà
Scuola didi
Medicina
e Chirurgia
Università
deglidegli
Studi
di Palermo.
Medicina
e Chirurgia
U.O.C. di Geriatria e Lungodegenza
U.O. di Medicina Interna e Geriatria.
Direttore prof. M. Barbagallo
Direttore prof. M. Barbagallo
Long Term Care in Europe
The role of Geriatricians
• Progressive increase of Elderly subjects in need of
sanitary and social assistance
• Countries and regional differences in sanitary and social
policies
• Differences
in providers of care;
• Differences in quality of the assistance and lodging
costs
• Nursing Homes in different countries have different
standards in the quality of care, personnel, sanitary and
social assistance, public coverage, co-payment.
• Urgent necessity of more shared and common
standards!!!
Who is in charge of Nursing Home
Care/Long Term Care?
In few countries (Sweden) and in some Italian
Regions is the geriatrician in charge
In most countries is the GP (not the
geriatrician) in charge.
• Role of Geriatrician (with multidisciplinary
team): make before admission in NH/LTC, first
a good CGA, to avoid a useless admission in
Nursing Home/Long Term Care
Future GOALS TO PROMOTE GERIATRICS
and incorporate it into clinical practice,
research and health care system
• As a full speciality in every General Hospital
in all EU countries
• in the curriculum of each student in Medicine
• In the curriculum of each student nursing,
Physiotherapist, Occupational Therapist,
Social Worker, psychologist.
Future Goals to Promote Geriatric
Competences and Geriatric Training in
Europe
• Harmonization of undergratuate and
postgraduate and Continuous Medical Education
in EU
• Accreditation of training centers for specialists
training
• European training manual in Geriatrics
• European Exam (European Speciality Board) –
Board Certification
How to Promote Geriatric Competences and
Geriatric Training in Europe:
Need of a Common approach in all European
Union countries
– UEMS- Geriatric Medicine Section -EAMA–
working on the harmonization of specialty
education and geriatric training in Europe
– IAGG-ER Clinical section and EUGMS- (European
professional societies) with the essential support
of all the National Societies- working on the
harmonization of Geriatric Services and to
increase the visibility of the Geriatrician work in
Europe
Università
degli
Studi
Palermo. Facoltà
Scuola didi
Medicina
e Chirurgia
Università
degli
Studi
di di
Palermo.
Medicina
e Chirurgia
U.O.C.
di
Geriatria
e
Lungodegenza
U.O. di Medicina Interna e Geriatria.
Direttore prof. M. Barbagallo
Direttore prof. M. Barbagallo
GRAZIE PER LA CORTESE
ATTENZIONE