Summary

The holistic approach of family medicine and the multidisciplinary approach of geriatric medicine are complimentary to each other. Both disciplines together provide a solid foundation for the practice of good community geriatric medicine. In time, family physicians with formal geriatric medicine training can help to improve the hospital bed situation, save hospital costs, minimize inappropriate use of the facilities and hence better use of the resources of the community as a whole.

摘要

家庭醫學的整體論方法和老年病學的多學科方法互相補充，兩者結合為社區老年病學的良好服務提供了堅固的基礎。在一定時間之後，經過老年病學正式訓練的家庭醫生能有助改善醫院床位的狀況，節約醫院的成本，減少設備使用不當，從而在總體上更好地利用社區資源。

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Introduction

Since the outbreak of severe acute respiratory syndrome (SARS), the elders from old age homes (OAHs) are identified as a potential source of infection. The risk of cross infection is increased among sick elders who have been transferred back and forth between hospitals and OAHs for treatment of recurrent illnesses. Treating sick elders within the OAHs, as far as possible, is an effective way to halt infections spreading to and from these elders. Visiting medical officers (VMOs) who regularly visit the elders in OAHs can undertake such duty. However, only few VMOs have had formal geriatric training. Also, VMOs may not have the knowledge and skill in assessing the needs and arranging care for elderly patients.¹ In order to increase their contribution to the OAHs, they have to pursue further education to improve their skill. Since undergraduate teaching in various subspecialties is minimal, many of us take courses to upgrade our knowledge in different areas of medicine, partly because we know our shortfalls and partly because our practice demands a broadened scope of knowledge. Most would agree that the past curriculum provided inadequate knowledge and skills in elderly care.² Family physicians, albeit knowledgeable, still are working hard, through various means, to improve their professional skills. The discipline of family medicine is making it possible to play a pivotal role in connecting us with other specialties and geriatric medicine is one of them. Family physicians equipped with geriatric knowledge can then meet the challenge of increasingly important role of VMO.

Important concepts of geriatric medicine

Geriatric medicine adopts a multidisciplinary and comprehensive approach towards the care of elderly patients. When performing a physical examination for the elders, family physicians with geriatric medicine training will not only look into the biopsychosocial but also the functional, cognitive and even environmental aspects. Various screening instruments such as the Geriatric Depression Scale, Mini Mental State Examination, Barthel Index of Activities of Daily Living, are needed in the assessment of different domains. A good knowledge of pharmacology will help in drug reviews, which is an essential part of geriatric assessment. Atypical presentation is a common feature of frail elders who tend to present more typically as geriatric syndromes like falls, confusion, incontinence and poor feeding.³ This feature has important implication during the period of SARS. Frail elders infected with SARS are often labelled as "invisible SARS" patients because of this unusual feature. Compared with the younger population, polypharmacy and comorbidity are the rules rather than exception in the elderly, therefore managing the elders is relatively complicated and delicate. The elderly population is heterogeneous, meaning that a population of the same age group represents a spectrum from frail and totally dependent to successfully aged and totally independent elders. The chronological age is not a reliable indicator of how well an elder can cope with daily activities. Others like cognition, emotion, behaviour, social, environmental and physical conditions are also important determinant factors. Hence, it is not uncommon to see an old old elderly to out perform a young elderly in coping with the activities of daily living. There is a difference between adding lives to years and years to life. The aims are to increase the quality of life and avoid heroic attempts that may cause further sufferings from prolonging lives. Finally, it is interesting to know that a small improvement in the functional ability of an elderly patient may lead to a huge improvement of his well-being.

Traditional VMO duties

In Hong Kong, primary geriatric care is still at its early stage of development. We treat our elderly patients the same way as we do with other patients. Physicians with inadequate knowledge of geriatric medicine may consider them as difficult patients to handle because these patients tend to come up with all sorts of problem that are overwhelming. Unless trained, certain important specific questions that are essential for geriatric assessment may be missed. Keeping our elders from residential care is our goal but our responsibility does not end when the elders are institutionalized, in fact we should further provide continuity of care by paying regular visits to OAHs. The question is: are we capable of providing formal geriatric care for elders in OAHs?

Based on casual exchange of views with superintendents, proprietors, VMO physicians, and nurses of OAHs, I have gathered the following information. For years, VMOs have been general practitioners/family physicians who visit OAHs once or twice a week to look after the elders. The VMO is usually asked to manage minor ailments such as aches and pains, write referral letters, treat common colds, and perform yearly physical examination. Nearly all VMOs then were not asked to manage the more complicated geriatric problems. Recently, while carrying out a yearly check up on an elderly, I discovered he was suffering from major depression for some time. I was utterly astonished to learn that instead of referring the patient to me, the nurse had arranged for him to consult the visiting psychiatrist who was scheduled to come one month later. She presumed VMOs were not competent enough to manage such cases. Undoubtedly, the contribution of VMOs is limited to the care offered by average general practitioners. >From my observation of several OAHs, the OAH staff has some reservation about the abilities of certain VMOs. The sick elders are segregated into different categories and only those with minor problem will be seen by the VMOs who are viewed as visiting general practitioners. Their attitude towards VMOs is not encouraging because VMOs are looked upon as someone who can offer symptomatic treatment only. In view of their views and attitude about traditional VMO, a survey may be needed to find out how receptive of the changed role of VMO to OAH staff.

Current situation in OAHs

Currently, in addition to VMOs, Community Geriatric Assessment Team consisting of doctors and nurses are dispatched by the Hospital Authority (HA) to treat patients in OAHs. Also, resident staff can transfer elders to out-patient clinics and casualties for treatment when they think necessary. Surely, the elders are not short of medical care but it is a care that lacks coordination and continuity.

Improving staff recognition

Learning more about geriatric medicine is an important first step towards successful management of patients in OAHs. In the United Kingdom, geriatric diploma courses have been organized since 1985. The recent establishment of the Hong Kong University's postgraduate diploma course of Community Geriatrics has helped family physicians to better equip themselves to manage the more complicated cases. However, house staff usually will not seek advice from even well trained VMOs on serious medical cases because of the lack of recognition. To reverse the situation, trained VMOs can do the following:

1. In order to gain recognition, the first step is to build up clients by establishing good rapport with the OAH house staff and the elders' families; after all, option is always on their side. Family physicians with their learned skill of communication should have few problem, if any, in building up rapport.
2. Advise the house staff that you have received formal geriatric training.
3. Prove to them that you are capable of active participation in the daily care of elders.
4. Use patient-centered and holistic approach for caring elders.

Benefit gained from the extended role of VMO

1.	Saving hospital admissions With the ever-increasing geriatric population, the growing HA fiscal deficit and the shortage of hospital beds, there is a need for better management of OAHs. OAH patients occupy a large proportion of hospital beds, and trained VMOs can play a role in alleviating this problem. The VMOs with improved medical skills will provide better medical management such as early detection and intervention of serious disorders such as congestive cardiac failure, pneumonia, exacerbation of COPD, urinary tract infection, infection control, dehydration, electrolyte imbalance, malnutrition, failure to thrive, pressure sores, uncontrolled behavioural problem, depression and fall prevention. VMOs can help offering less expensive non-hospital care to frail elders, saving them from the expensive hospital care.
2.	Additional benefit Trained VMOs practising in OAHs can ascertain the provision of coordinated and continuity of care to the elders. They will improve not just patient and family satisfaction but also sense of security, and accountabilities. The elders are saved from the discomfort of transportation, spreading and contracting infections, and nosocomial complications such as delirium and functional decline. During influenza seasons or epidemics, VMOs can help implement and enforce infection control and assist in medical surveillance of infectious diseases.4 They can provide anticipatory cares like primary, secondary and tertiary prevention and help conduct regular group meetings to discuss issues like psychological, interpersonal, and social problems. They can help enhance efficient use of public services including utilization of hospitals, casualties, specialties and OPD facilities. Finally they can take part in educating resident nurses who play an important role to alert VMOs to attend elders requiring medical assessment.

New role, new title

The title VMO should be discarded because it does not differentiate between physicians with formal geriatric training from those without. New titles such as Family Physician with Community Geriatrics training or Family Physician with special interest in Community Geriatrics should be used instead. The new title will help build up confidence in VMOs, nursing staff and patients.

Obstacles to change

1.	Manpower shortage Formally trained physicians are in short supply; it may take several years before there is an enough supply of the trained physicians. Other alternatives to speed up supply will include: increasing the enrolment of the diploma course, setting up certificate courses specially formatted for OAH VMO training, encouraging young graduates to undertake volunteer work at OAHs.
2.	Financial arrangement The potential benefit of having trained VMOs to manage OAHs is tremendous; it is worthwhile for the government to negotiate with the proprietors of the OAHs to set up a shared payment scheme to purchase trained VMO services. As mentioned above, the sick elders are referred to different areas for treatment including the general out-patient clinics, specialist clinics, casualties, private clinics, drug stores and others. Except those few with exemption papers, the elders have to pay for the services one way or the other, usually by their families. Using the trained VMO services, many unnecessary consultations, and admissions can be avoided. Eventually, the expenditure of resources on the elderly care will be reduced. At the same time, the OAH occupancy will improve because of better medical management. Hence, it is not unreasonable to ask both the government and the OAH proprietors to share the cost of the trained VMO services. In the end, there will be little or no added financial burden to the elders' family.
3.	Logistic consideration
	a.	Filling prescriptions Since all medicines are dispensed from hospital dispensaries therefore the elders cannot obtain their medication without certain delay. Solutions to this problem may include either setting up a drug cabinet in the OAHs or having the VMOs to carry a portable medicine box for dispensing drugs for urgent purposes such as antibiotics, diuretics and bronchodilators.
	b.	Information sharing The elder's hospital record is important for follow up management in OAHs, hence every hospitalized elder should be discharged with a complete set of reports including progress notes, laboratory results, various imaging and invasive examination results. With these information, VMOs can pinpoint the elder's problem with confidence and accuracy. Unfortunately, some elders are discharged from certain district hospitals with only a copy of drug list, which is claimed as "discharge summary". In such cases, follow up management becomes difficult. We should seriously consider using information sharing in OAHs in particular.

Conclusion

The inevitable explosion of geriatric population in the next decade will definitely lead to rapid increase of elderly patients residing in OAH. Since sick OAH residents occupy a large proportion of hospital beds, therefore there is a need to improve the management of frail elders in OAHs. VMOs can help in various ways to shift the treatment of sick elders from the expensive hospital care to more economical non-hospital care. In order to meet this challenge, VMOs have to better equip themselves through further geriatric training.

Key messages

1. The inevitable expansion of our elderly population in the next decade will add burden to our medical system, the hospital bed situation in particular.
2. Visiting medical officers of old age homes can help to reduce this problem by offering less expensive non-hospital care to frail elders when expensive hospital care is unwarranted.
3. The role of VMO has to change in order to accomplish such task, physicians with family medicine background and secondary geriatric training are ideal VMO candidates to take over this new role.
4. There are obstacles to the change; including views and attitude of the resident staff, financial arrangement, manpower shortage and logistic problems.

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References