Clinical Geriatrics

Recently, the chairs of the various departments at my hospital were asked to make a presentation to members of our Board of Directors at their annual planning meeting. We were challenged to come up with 10 items that we believed would influence the future of medicine over the next few decades. Clearly, my task was more complicated than most, as internal medicine has so many areas of subspecialization. After careful consideration, the following made my list, including an 11th item I could not exclude:

1. Changing demography
We will witness an increase in the number of older persons and thus will face more individuals with frailty, age-prevalent disease, and atypical/nonspecific presentation of illness. Many diseases will be diagnosed later in their course, with longer hospital length of stay and increased morbidity and mortality an increasing reality. Difficulties in diagnosing certain problems may increase the cost of diagnostic testing. There will be a greater need for nursing home and subacute beds, home care services, geriatrics-trained nurses and professionals, and rehabilitation programs.

2. Increased number of medically uninsured
Unless there is some universal health program adopted, there will be an increasing number of individuals who cannot afford health insurance. Who will pay for their health care? What will be the quality and access of their care?

3. Increased number of persons with HIV infection
HIV remains a great concern, with many more women and children continuing to become infected than in years past. Just how much of a major burden this disease will become to society and our medical economic structure remains to be determined. Prevention is key!

4. New technology for diagnosing and treating disease
Every year, a wealth of new equipment is required to keep up with advances in medical technology. We have seen major advances in our ability to diagnose and treat problems in a less invasive manner and, in certain cases, without the need for costly hospitalization. Improved technology (eg, DEXA, ultrasound, nuclear imaging, PET scanning) will be more available in ambulatory sites, and ease of use may alter the way the internist and family physician of tomorrow practice medicine. Who will pay for this technology and its development remains a major issue if we are to continue to provide basic needs to all.

5. Gene therapy and new organ transplantation
These techniques offer the possibility of a cure for many diseases and may reduce the burden of chronic illness. Many societal, religious, and scientific issues will need to be resolved before this emerging science has any additional major impact.

6. Vaccinations
Many diseases remain in search of a vaccination. Prevention is always better than cure! Medical-legal restraints, financial incentives, and scientific limitations remain significant obstacles for the continued development of these potentially life-saving modalities.

7. Emerging diseases
New diseases will likely emerge over time. HIV, influenza, Ebola virus, West Nile virus, and avian flu are just a few examples we have seen in the recent past. Some diseases “come and go,” but there are those who believe a pandemic is in our future—exactly what will affect us remains a mystery, however.

8. Antibiotic resistance
Antibiotics have an increasingly shorter lifespan, with drug resistance a major threat to our society’s health. Public health strategies and our continued ability to “keep ahead” of the infecting organism’s ability to mutate are key to our success in this area.

9. Chronic disease
More individuals are living longer with chronic illness and disability than ever before. Patients with HIV who are on antiretroviral therapy can now look forward to living more than 20 years, patients with cystic fibrosis are living into their 40s, and patients with Down syndrome are living into their 50s. This is a major advancement from only a few decades ago.

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