One Thing Leads to Another…
Well, like the Nescafe ad goes- ‘One thing
leads to another’. The social backdrop of America in the 20th
century had a huge role in the development of Modern Geriatrics. The Great
Depression led to huge numbers of elderly poor in the United States- nearly 30%
in 1930 and 66% by 1940. To rectify this situation President Roosevelt passed
the Social Security Act in 1935. 1950 saw the first National Conference of
Aging which was called by President Truman, which was followed in 1961 by the
1st White House Conference on Aging. At this time, the Senate Special Committee
on Aging was established. However, it only obtained permanent status in 1977.
Edmund Cowdry & The
Gerontological Society of America..
Edmund Vincent Cowdry (1888–1975) was born
in MacLeod, Alberta, Canada. He graduated with an MD from the University of
Chicago in 1913. He was appointed a Professor of Cytology at the Washington
University in St. Louis in 1939. Cowdry was active in ageing research,
particularly as it related to atherosclerosis. He went onto edit ‘The Problems of Ageing: Biological and
Medical Aspects’ in 1939. He produced two other books, viz., ‘The Case of
the Geriatric Patient’ in 1958 and ‘Aging
Better’ in 1972. He championed the special medical needs of elderly persons
and opposed the American Medical Association by advocating special care needed
for geriatric patients (I believe opposing the status quo is the only way for
bringing about effective change, sounds a bit clichéd!!) . In 1939 with support
from the Josiah Macy Jr. Foundation, the Club for Research in Aging was
established. Its leadership included V. Korenchevsky and Cowdry. Korenchevsky
who was born
in Russia in 1880, also played a major role in the development of Geriatrics on
the other side of the Atlantic by convincing Lord Nuffield and his foundation
to fund geriatric research units at Oxford, Cambridge, and Leeds. Out of the Club for Research in Aging sprouted
The Gerontological Society of America, which was founded in 1945 with 80
members. William MacNider was the first President.
Journals…
The
Journal of Gerontology which was first
published in 1946, was split into four separate sections under one cover,
representing the diverse interests of the membership in 1988. It was split into two separate covers in
1995, with biological and medical sciences coexisting as one volume and
psychological and social sciences as the other. The Gerontologist,
another reputed journal was first published in 1961. The American Geriatrics
Society was organized on June 11, 1942, at the Hotel Brighton in Atlantic City
by Malford W. Thewlis. Its first annual meeting was held in 1943 with Lucien
Stark of Norfolk, Nebraska, as president. In 1953, the Journal of the American
Geriatrics Society was published with Willard O. Thompson as its editor.
Geriatrics had been first published in 1946 with an association with the
American Geriatrics Society, but the publisher held title to the name and the
journal continues to be published today1.
BLSA…
Edward J. Stieglitz was appointed the first
head of the Unit on Aging with the Division of Chemotherapy at the National
Institutes of Health in 1940. This unit was initially funded by a $10,000 grant
from the Josiah Macy Jr. Foundation. In 1941, the unit moved to Baltimore City
Hospital under the leadership of Nathan Shock. This led to the establishment of
the Baltimore Longitudinal Study on Aging in 1958. For many years, this program
was successfully led by Reuben Andres, who created a generation of geriatric
researchers. It is one of the
world’s longest running studies of aging. Sounds interesting, right? Let’s dive
in to see how it works…
Since
1958, the BLSA enrolls healthy volunteers ages 20 years and older and follows
them longitudinally—for life—even performing an autopsy in those who consented. During a 3-day visit, BLSA participants receive a battery
of tests assessing many biomarkers and physiological parameters. These
measures include, but are not limited to mobility, cognition, brain and nerve
structure and function, body composition, muscle strength, bone and joints, multiple
sensory functions, & glucose metabolism. Follow-up
visits occur every 4 years for participants age 60 and younger, every 2 years
for participants between ages 60 and 79 years, and yearly when they are age 80
and older. Some measures have been collected in the same participants for more
than 40 years and often mark the transition between their health and disease
development2.
National Institute on Aging & the
GRECCs..
The National Advisory Committee on
Gerontology was formed in 1941 by Surgeon General, Thomas Parran. In 1948, the gerontology branch was moved
under the National Heart Institute. Dr. Henry Simms tried hard to have an
Institute of Aging established with Heart as a subsidiary, but his efforts
failed. James E. Birren was
appointed the first head of the Section on Aging of the National Institute of
Mental Health in 1959. The
Research on Aging Act passed on May 31st 1974 established the
National Institute on Aging (NIA) with Robert Butler becoming the first
director. The true giant of
medical geriatrics in the United States was Les Libow who worked in New York at the Jewish Home and Hospital
for the Aged. He went on to create the first fellowship in geriatric medicine
at City Hospital Center (a Mount Sinai School of Medicine affiliate) in 1966. He introduced resident rotations in
geriatrics and even founded a teaching nursing home in 1967. The single most
important institution in the development of geriatrics in the United States has
to be the Veterans Administration (VA). This
association recognized a marked increase in aging veterans and its potential
effects on the veteran’s health care system. The first Geriatric Research,
Education and Clinical Centers (GRECCs) were opened in 1976. The Congress authorized
the creation of the GRECCs, thanks to the efforts of Paul Haber. These institutions played a pivotal role
in developing geriatric faculty, science, and education at major universities
throughout the United States. They also supported the first geriatric
fellowships in 1976 and were later responsible for geriatric psychiatry
fellowships. Interdisciplinary team training programs in geriatrics were
developed by GRECCs. They went on to introduce geriatric evaluation and
management units throughout most VAs in the United States. They played a leading
role in the development of palliative care as well. They also developed numerous
teaching nursing homes1. In spite of Geriatric organisations &
fellowships between 1940 & 1970, the first professorship in geriatrics was
created at Cornell University in 19771,3. The first Department of
Geriatrics was created at Mount Sinai Medical School with Robert Butler as its
first chairperson in 1982. 1988
saw the first certifying examination in geriatric medicine being offered and,
at the same time, the Accreditation Council for Graduate Medical Education
accredited 62 internal medicine and 16 family practice programs to offer
geriatric fellowship programs. The initial geriatric fellowship programs had a
two year requirement, but in 1995 this was reduced to one year3.
The Nascher/Manning Award..
The Nascher/Manning Award for Lifetime
Achievement in Geriatrics, was given by the American Geriatrics Society since 1987. Through the generosity of
the Manning family, the intent of the award is to honor Dr. Nascher’s
pioneering work in the field by recognizing an individual with distinguished,
life-long achievement in clinical geriatrics, including medicine, psychiatry,
& all other relevant disciplines. The awardee may have achieved distinction
in clinical geriatrics through activities such as innovative program
development or administration of outstanding clinical programs4.
Big Leaps
Modern
geriatrics advanced greatly by the codifying of the geriatric assessment into a
number of widely used screening tools. The Barthel Index devised by Dorothea
Barthel, the Physical Therapist at Montebello State
Hospital in Baltimore in 1955 was the first of these. Eventually more such
assessment tools were developed & approved, most notably- FIM Score, MMSE,
Geriatric Depression Scale & Mini Nutritional Assessment.
The importance of exercise therapy,
especially resistance exercise is an area of huge impact. The coining of the
term sarcopenia & the understanding of its pathophysiology are important
developments in this field. The emergence of Obese Sarcopenic Syndrome is a key
area of interest where much research could be directed1.
Theories
of interest:-
Many theories are likely to kick up research in the field of geraitrics,
let’s look at a few of them…
Fries’
hypothesis:- Known
as “compression of morbidity,” Fries’ hypothesis holds that if the age at the
onset of the first chronic infirmity can be postponed more rapidly than the age
of death, then the lifetime illness burden may be compressed into a shorter
period of time nearer to the age of death5.
Successful
Aging:-Rowe
and Kahn's model of successful aging has three components: (a) minimizing risk
and disability, (b) engaging in active life, and (c) maximizing physical and
mental activities. Rowe and Kahn 1998 model has been criticized for not
emphasizing biological research and for not including social structure and
self-efficacy. One interesting article supports the view that adding positive
spirituality as the fourth component helps in successful aging6.
Frailty (a syndrome):-
Fried et al. described frailty as the phenotype of a clinical syndrome in
which three or more of the following are present: (1) unintentional weight loss
of at least 10 lb over the past year, (2) self-reported exhaustion, (3)
weakness (grip strength), (4) slow walking speed, and (5) low physical
activity—all being understood as distinct from comorbid medical conditions and
disability7.
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.
This is the last blog post on how
Geriatrics evolved over time. I hope you all enjoyed reading about the quirky
beliefs, the weird norms & rapid developments that helped shape this
field..
References
- Journal of Gerontology:
MEDICAL SCIENCES 2004, Vol. 59A, No. 11, 1132–1152
- https://www.nia.nih.gov/research/blog/2014/04/valuable-data-resource-baltimore-longitudinal-study-aging
- The Journal of Lancaster General Hospital • Fall 2008 • Vol. 3 – No.
3
- https://meeting.americangeriatrics.org/submissions/naschermanning-award
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2424092/#:~:text=The%20idea%20behind%20compression%20of,in%20which%20a%20person%20dies.
- https://academic.oup.com/gerontologist/article/42/5/613/653590?login=false
- Braddom’s
Physical Medicine and Rehabilitation, 6th Edition, David C.Xifu MD
