In the context of the very welcome increase in longevity of Europeans over the last 50 years, geriatric medicine has evolved as a speciality to meet the challenges of the increased complexities of healthcare in later life. Blending the principles of gerontology (the science of ageing), internal medicine, rehabilitation and palliative care, geriatric medicine is now recognized as an effective instrument to deliver high-quality, humane, interdisciplinary, appropriate and cost-effective care to older people, proportionately the most significant group of healthcare users in all European populations. Through a wide range of services, including acute geriatric medicine (reducing death and disability by more than 25% compared to internal medicine), falls clinics, ambulatory assessment, dementia services, support for nursing home residents, the specialty has made a major impact in those countries where it is well established.1
In the 1990’s it became increasingly clear that there was a need for a European focus to support and promote the concept of specialist healthcare for older people in the European Union. In particular, a focus was needed for specific research into how the presentation of illness in later life differed from that of younger adults, and what methods might be most effective in terms of patient-focused services, both in for the patient and for health services regarding costs and personnel.
Part of the aim of geriatric medicine is to not only to engage in research in older people, but to also generate the parameters and terminology by which research and service development might be usefully directed. A number of European societies – including the European Union Geriatric Medicine Society2 and the International Association of Gerontology and Geriatrics, European Region – have developed a common platform for the promotion of research into health in ageing, together with a representative of the European Commission’s DG V SANCO. This ‘Silver Paper’ is a position statement agreed in conjunction with other European bodies interested in ageing, and published in national and international journals.3 This has been a useful roadmap for a complex area, and in effect provides an agenda for the priority areas for development in healthcare for older people. The Silver Paper emphasises the need for research that is both interdisciplinary and translational, and divides the areas of priority into basic research, health promotion and preventive action, and clinical care. The basic research elements prioritised include a better understanding of how ageing is modulated and a focus on epigenetic modulation of the ageing process. At a health promotion and preventive level, the elements covered include training of health professionals, vaccines, nutrition, exercise, injury prevention, mental stimulation, social activity and informal care giving.
The focus in the clinical area lies with the development of geriatric medicine and specialist training, appropriate regulation of medicines, comprehensive assessment protocols, age-attuned palliative care, old age psychiatry, long-term care and quality assurance.
The role of universities in assuring age-friendly training and research is emphasised. In particular, it is noted that health services research rarely includes frail older individuals. Research outcomes that are relevant for younger populations (ie. mortality) may lose importance at advanced age.
Health services research is limited, and the impact of changes in organisation and delivery of health services on function and health of older people is rarely considered. It is therefore proposed that research in the prevention and treatment of disabling and chronic disorders should:
- Include the full spectrum of people who are likely to benefit from it (including frail older people and taking into account gender differences in ageing);
- Use relevant outcomes, which include not only mortality, but also disability, use of healthcare and community services, quality of care, and quality of life;
- Be informed by evidence and the principles of clinical gerontology and geriatric medicine;
- Include public health issues.
The EUGMS recognises that research in old age health and disease is fragmented, with limited interactions between basic, epidemiological, preventive, clinical, and health service research. Translational research is particularly sparse, despite evidence of the difficulties to translate projects into routine healthcare delivery. Ineffective treatment strategies are wasteful of ever-scarcer resources. A European Institute of Ageing would be an excellent answer, able to improve basic, translational and applied research in the ageing process, and in the prevention, treatment and rehabilitation of related diseases. It would bring awareness, funds, leadership and coordination. In view of our, as yet, limited understanding of the benefits and challenges of an ageing Europe, it would also contribute to the Lisbon declaration vision that Europe would have the most competitive knowledge-based economy in the world by 2010.
An important example of this need for a common, age-relevant health research agenda is the imperative to separate out the twin concepts of ‘ageing’ and ‘frailty’. In layman’s terms, the two may seem synonymous, but in fact frailty is a hugely important concept, because it is increasingly clear that is a potentially reversible condition, unlike ageing. Clinicians and researchers need better definitions of, and insights into, frailty – a key element is the propensity to ‘sarcopaenia’, the wasting of muscle and connective tissue. The European Union Geriatric Medicine Society has taken a lead in defining and outlining scientific progress in sarcopaenia by producing a consensus paper in partnership with other European organisations involved in ageing and nutrition research4. This work ought to facilitate further development of strategies to ensure that later life is not invariably accompanied by frailty.
Other areas of research and advocacy include the developing strategies for appropriate research in medication development. It is a cause of concern that despite recognition that older people are not only the largest group of users of medication, but also show significantly altered handling of medication – i.e., are more prone to side effects and toxicity – they are insufficiently included in clinical trials of medication and licensing processes for medications. EUGMS has been acting as a strong advocate in this important field since 2004, and some important progress has been made, such as a joint symposium with the AGS (2008)5, meeting with Health Commissioner John Dalli (2010), and a dedicated conference with the European Parliament Intergroup on Ageing (2011). Following publication of a Geriatric medicines Strategy by the European Medicines Agency, a dialogue on the development of a ‘Geriatric Medicines Committee’’, similar to the ‘Paediatric Medicine Committee’ is on the way. In addition, many of our academics take part in European research consortia, such as PREDICT, which provide research and evidence platforms for clinical trials on prescribing in older people.
It is encouraging to see increasing momentum for the elements captured by the Silver Paper; for example, important movement has been made in promoting a common agenda for lifespan approaches to adult vaccines. Vaccination represents an important form of prevention of age related disease and disability, and as outlined in a new position paper, it is clear that there are significant deficits in both the schedules and uptakes of relevant vaccines in the Europe Union, representing an important area of potential gain of disability-free life expectancy.6 In conjunction with other partners, the EU Geriatric Medicine Society is undertaking research and advocacy on optimal methods of developing programmes for maximising the benefit of this important but underutilised technology. Equally, WHO Europe has engaged with European geriatricians to develop a guide for palliative care for older people, ‘Palliative Care for Older People: Better Practice published in 2010. This synthesises the best of research and clinical practice, and ensures that older people near death will have their palliative care needs met in a way informed by the insights of geriatric medicine, which makes allowances for the increased complexity that comes with later life.7
Although much has been achieved, much still remains to be done; but the encouragement of the response to its impact can only mean that it will continue to flourish, and help to provide a European healthcare system where the increased inter-individual variability and needs of older people will find an appropriate response from an age-attuned system. For, in the words of the eminent pioneer of geriatric medicine, Bernard Isaacs: ‘If you design for the old, you include the young – if you design for the young, you exclude the old.’
- O’Neill D, Knight P. Getting used to growing old, Public Service Review: European Union 18, 2009, 180-3
- Baeyens J P, Cruz Jentoft A J, Cherubini A. The success story of the European Union Geriatric Medicine Society (EUGMS). ‘European Geriatric Medicine’ 2010; 1: 137-140
- Cruz-Jentoft A J, Franco A, Sommer P, Baeyens J P, Jankowska E, Maggi A, Ponikowski P, Rys A, Szczerbinska K, Milewicz A. European silver paper on the future of health promotion and preventive actions, basic research, and clinical aspects of age-related disease. ‘European Journal of Ageing’ 2009; 6: 51-57
- Cruz-Jentoft A J, Baeyens J P, Bauer J M, Boirie Y, Cederholm T, Landi F, Martin F C, Michel J P, Rolland Y, Schneider S M, Topinková E, Vandewoude M, Zamboni M. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing 2010; 39:412-23
- Cherubini A., Del Signore S., Ouslander J., Semla T., Michel JP. Fighting against age discrimination in clinical trials. J Am Geriatr Soc 2010; 58: 1791-1796.
- Michel J P, Gusmano M, Blank P R, Philp I. Vaccination and healthy ageing: How to make life-course vaccination a successful public health strategy. ‘European Geriatric Medicine’ 2010, epublication June 2010
- Blain H. Palliative medicine and end of life issues in older adults. The main messages from the European Union Geriatric Medicine Society Glasgow symposium. ‘European Geriatric Medicine’ 2010; 1: 66-68