The Role of Specialized Geriatric Services in Acute Hospitals

Rory Fisher, MB, FRCP(Ed)(C), Director, Regional Geriatric Program of Toronto and Interdepartmental Division of Geriatrics, Faculty of Medicine, University of Toronto, Toronto, ON.

In Canada, the sustainability of the health care system is a major issue. Two commissions have been established to address the future of health care.^1,2 Improvements in technology and changes in the delivery of health care have led to major restructuring of the system. Acute hospital beds and the length of hospital stays have decreased with the concomitant expansion of ambulatory services. The aging population, which is increasing dramatically in Canada, particularly with regard to the oldest old, is a major priority policy issue in these discussions.³ However, the current management of the elderly in acute hospitals is of concern. In the United Kingdom, an enquiry into the care of older people in acute wards in general hospitals entitled "Not because they are old" found that problems existed with older patient and relatives' dissatisfaction with the care, numerous deficiencies in physical environments, clear evidence of staff shortages and concerns about nutrition.⁴ Problems were also identified with preserving dignity, interactions with staff, insufficient training, discharge planning and the accessibility of services in the community. In addition, a recent study by Health Canada on unmet needs for health care reported, an estimated 7% of Canadians, or about 1.

Harrison’s Principles of Internal Medicine, 15th edition

Harrison's Principles of Internal Medicine, 15th edition

Editors - Eugene Braunwald, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, Dan L.Longo, J. Larry Jameson

Reviewed by: Shabbir M.H. Alibhai, MD, MSc, FRCPC, Senior Editor, Geriatrics & Aging.

How does an internist go about reviewing a textbook such as Harrison's? A copy of Harrison's has been with me since I began medical school, which already says something, although I'm not sure exactly what. Certainly when one thinks about a short list of great Internal Medicine texts, this book comes to mind. I suspect that almost every reader has encountered Harrison's in one way or another during training or practice. Thus, I approached this review slightly differently. I examined my clinical Internal Medicine practice in the last month to select the last six questions where I required additional information and thought it fair to consult a textbook rather than a specific study. I then evaluated the 15th edition of Harrison's with respect to its ability to answer these questions. The questions were as follows:

1. In a patient with an elevated growth hormone level, how does one go about making the diagnosis of acromegaly?
2. What is the best non-invasive test for an older patient with clinically suspected renal artery stenosis?
3. Which physical exam maneuvres are useful in diagnosing aortic stenosis?
4. Which groups of patients benefit from perioperative beta-blockers?
5. How does one treat a patient with relapsed polymyalgia rheumatica (PMR)?
6. What is the role of testosterone in the treatment of male osteoporosis?

In general, the text is well laid out, and the index is detailed and reasonable to navigate through. The 15th edition maintains the traditional layout of chapters, although in comparison to an earlier edition, there is a larger chapter on genetics and the somewhat sparse chapter on psychiatry has been subsumed in the chapter on neurology. As usual, I was dismayed to find no chapter or even section devoted to geriatrics and related issues (such as the biology of aging organ systems). The text is clear. Tables, charts, figures and flowsheets abound (even more than in previous editions), and there are new symbols to highlight specific headings such as genetic considerations and treatment (although there is no symbol for diagnosis, which is a pity).

So how did it do in terms of my queries? With respect to the question of acromegaly, Harrison's had nice sections on etiology, presentation and diagnosis. It discussed the role of both growth hormone and IGF-1 in screening and the utility of the glucose tolerance test to help rule in or rule out the diagnosis. Unfortunately, there was no mention of the test characteristics (i.e., sensitivity, specificity) but there was a good reference in the bibliography. With respect to the diagnosis of renal artery stenosis, the material provides a useful algorithm (although only in text form) to make the diagnosis, and actually includes some information on the sensitivity and specificity of magnetic resonance angiography as the best non-invasive test (although it does not provide comparative information for other non-invasive tests). When it comes to physical examination of aortic stenosis, classic findings are described, although the emphasis on detailed physical exam is less in this edition, perhaps reflecting the general decline in popularity of physical examination in modern medicine. What is lacking is information about the utility of any specific physical exam maneuvres in ruling in or ruling out aortic stenosis, which would have been more valuable to me than simply listing some common findings in the JVP, the pulse or the apical impulse.

On to therapeutics. After a frustrating time searching for a discussion of perioperative beta-blockade, I found nothing mentioned about this topic. Perhaps I missed it, but it was neither in the index, the table of contents nor selected portions of the text I examined. Moreover, I noted an absence of any section dedicated to preoperative assessment of patients, which was a clear deficiency. With respect to relapsed PMR, I was surprised to find no separate section for PMR. There was little mention of PMR under temporal arteritis either. There was no information on how to treat relapsed temporal arteritis. Finally, with respect to the use of testosterone in male osteoporosis, there was no mention of testosterone as either a standard or an experimental agent to treat osteoporosis, despite considerable recent interest and a small but accumulating body of evidence. For that matter, the discussion on male osteoporosis was virtually non-existent.

At the end of the day, my assessment of the current edition of Harrison's was less than flattering. Perhaps my questions were esoteric or my standards were too high; I will leave that up to the reader to judge. For myself, I would still keep a copy of Harrison's on my shelf, but I am not sure when I would update my older edition and how often I will use this edition. The information in Harrison's is great for summarizing rare diseases and discussing well known aspects of common diseases. But practical information with respect to diagnosis and management was less than I was looking for, despite over 2600 pages of information. And, the lack of emphasis on quality and quantity of evidence was rather disheartening. Maybe it's time to look at online versions of classic texts.

The Time of Our Lives: Why Ageing is Neither Inevitable nor Necessary

Orion Books Ltd, London, 1999; 277 pages with index
Reviewed by: A Mark Clarfield, MD, FCFP, FRCPC

As a geriatrician, I did not expect to learn a lot from a book on aging written for the intelligent layman. But I was wrong.

Tom Kirkwood, one of the world's foremost researchers into the study of human gerontology, has written a book that looks deeply and clearly into this fascinating subject--which he rightly calls "one of the last great mysteries of the living world." And, as I tell my medical students, whoever unlocks this secret will no doubt be a candidate for the Nobel Prize in Medicine.

In the preface of this slim volume [Time of Our Lives: Why Ageing is Neither Inevitable nor Necessary] Kirkwood lists the questions that he promises to answer: Why do we age? How does aging happen? Why do some species live longer than others? Do some parts of the body wear out sooner than others? Why do women live longer than men? Why do women have a menopause half way through their life span?

Even if the above-listed puzzles interest neither you nor your patients, this final one should exercise us all, "Can science slow my aging process, or help me age better?" We may not want to grow old, but as a wag once put it, "I prefer old age to the alternative." And, if most of us will try to postpone this particular alternative for as long as possible, how can we hope to age "successfully?"

On the latter subject, the self-help shelves of your local Chapters outlet fairly groan with books touting all kinds of nonsense on the subject. But if you want a clear, concise and scientific answer to the last question for you and your patients, read this book.

Early on, Kirkwood dispels a pernicious notion that unfortunately many gerontologists milk for all it's worth; that is, that the demographic changes we are observing constitute some kind of a catastrophe. That soon the world will comprise a majority of balding cripples demanding an ever increasing portion of the health and social services budgets. As Kirkwood puts it, "There is an unfortunate tendency to see the graying of the world's population as a disaster in the making instead of the twofold triumph that it really is. Firstly, we have managed --not a moment too soon--to begin to bring soaring population growth numbers under control. Secondly, we have succeeded --through vaccination, antibiotics, sanitation, nutrition, education and etc-- in bringing death-rates down."

One of his major points is that despite the rapid increase in the growth of the 80 plus age group, there is increasing evidence (originally from the United States but now supported by Canadian and European data)¹ that the period of sickness and disability concentrated at the end of life is actually getting shorter, not longer, as life span increases. These new data add further support to the optimistic prognostications of Crapo and Fries' "Squaring of the Curve" hypothesis.² In sum, this theory suggests that while maximum life span has not changed much over the past few millenia, average life expectancy (at every age) has increased in the last two hundred years. More to the point, healthy life expectancy has lengthened so that more and more old people are living longer and healthier lives, with the period of end-of-life disability shrinking concomitantly.

One of the most interesting chapters, entitled "What's in a Name?", attempts to define aging and to distinguish it from disease--not an easy task. And Kirkwood admits that despite our supposed familiarity with the process, "…the precise concept of ageing is slippery to grasp, like a bar of soap in a bath." He begins by quoting a British biology professor, J.M. Smith, "Ageing is a progressive, generalized impairment of function resulting in an increasing probability of death."

But we cannot make much sense out of this definition until we understand why we age and how our cells, organs and body gradually lose function. This chapter begins, as do all in the book, with a relevant, pithy quote, in this case from Eubie Blake, the famous jazz musician, on reaching age 100: "If I'd known I was gonna live this long. I'd have taken better care of myself."

Kirkwood attempts to answer the "why" question by elucidating his now famous "disposable soma" theory. The fact that all mammalian species have a fixed maximal life span (e.g., rat: 4 years, elephant: 70 years, Homo sapiens: 120 years) was adduced to support the hypothesis that we are all endowed with "killer" genes, activated by some kind of an internal clock. According to this school of thought, when our time is up, our genes do away with us.

However, Kirkwood does not accept this theory and musters impressive data to refute it. He explains that it is not our genes that actually destroy us--this does not make biological sense. Rather, their function from the evolutionary point of view is actually to keep us going for as long as possible. In the end, it is our bodies (the soma) and not our genes (germ-line) which are disposable. The genes have evolved to invest "…enough in maintenance to enable the organism to get through its natural expectation of life in a wild environment in good shape." From an evolutionary point of view, from which Kirkwood and others insist we must view aging, more than this minimal investment is a waste.

Furthermore, the theory goes on to suggest that there may be design constraints which favour the organism when young at the expense of its long-term durability. A good example would be the central nervous system's once-only development of a fixed network of neuronal connections set down early in life. Despite cell loss over the years and a lack of the usual repair mechanisms, which are present in many of the rest of our organs, the expanded human brain works well for nearly a century but finally begins to "break down" in very old age.

In the end, "natural selection in the wild is not much concerned with late-acting mutations, which may accumulate unchecked within the genome."

He also clarifies the fascinating connection between aging and cancer. After all, the incidence of most tumours rises asymptotically with age and both involve cellular regulatory systems. At first, Kirkwood disposes of the notion that aging is some kind of anti-cancer mechanism:

"It is not. And yet there is a real connection between ageing and cancer, which has, I believe, much to do with the fundamental distinction between the germ-line and the soma. Somatic cells are cheaply made and disposable, but each somatic cell contains within itself the genetic wherewithal to become germ-like again. Cancer is an accidental reversion to a germ-like state."

Therefore, Kirkwood continues, "The same general mechanisms that protect against cancer protect against ageing. This is why long-lived species [such as Homo Sapiens], with their better cellular protection, get cancer later than short-lived species [such as the rat]."

This book explains a complex and fascinating subject with both clarity and panache. Kirkwood, an accomplished scientist, also enjoys the unusual ability for such a professional of being able to write clearly and well. For example, in describing the semelparous form of reproduction (familiar to us through the antics of the salmon) where the parent gives birth and then dies shortly thereafter, he describes in some detail the case of the octopus.

After the babies hatch, the female octopus loses interest in feeding herself and dies shortly thereafter. Kirkwood writes: "In the case of the mother octopus, it is not at all clear why she does not resume normal feeding when the little octopuses hatch. It is not as though she is rushed off her feet&emdash;all eight of them&emdash;ministering to her little one's needs. All she does is die."

Another example of his way with words relates to the menopausal pituitary's upsurge in FSH and LH in an attempt to get the aging ovaries to cycle once again. As Kirkwood puts it, "…the glandular equivalent of yelling over the telephone at someone who is deaf."

My favourite example of his literary style involves Kirkwood's description of the sperm, the main job of which, as we know, is merely to race up the Fallopian tubes seeking out an egg to fertilize. "…and it is therefore no surprise that sperm have evolved to become little more than DNA packages with big outboard motors."

Aging is a fascinating yet paradoxically still understudied subject. Perhaps like its related subject death, we tend to deal with the topic via the psychological mechanism of denial. But how and why we grow old is too interesting and too influential a subject to be ignored for much longer. Kirkwood's book is a good beginning for anyone interested in what will inevitably happen to them and their patients.

And, of course, we must never forget that aging is a process, indeed a long drawn out and relative one. As Oliver Wendell Holmes at age 92 had to say on seeing a pretty girl pass by, "What I wouldn't give to be seventy again!"

Dr. Clarfield, MD, FRCSC, is the Chief of Geriatrics, Soroka Hospital Centre, a Professor and Sidonie Hecht Chair of Gerontology, Faculty of Health Sciences at Ben Gurion University of the Negev in Beersheva, Israel , and an Adjunct Professor in the Division of Geriatric Medicine, McGill University and Jewish General Hospital, Montreal, QC.

References

1. Jacobzone S. International challenges: what are the implications of greater longevity and declining disability levels? Health Affairs 2000; 19: 213-25.
2. Fries JF. Aging, natural death, and the compression of morbidity. N End J Med 1980;303: 130-5.

Natural History of Long-Term Care Clients

Madhuri Reddy, MD, Associate Editor, Geriatrics & Aging.

In order to effectively plan future long-term care (LTC) environments, it is important to ascertain the natural history of clients once placed in these environments. What, for instance, are the predictors of client mortality and the probability of a change in function, either to improve or deteriorate, once placed in a certain level of care? Environments need to be flexible and, most of all, promote independence and an enhanced quality of life.

Changes in Care Requirements Over Time
It is well established that the functional status of many nursing home (NH) clients improves after NH placement or after transitions between different levels of care. Some aspects of functional status (hygiene, dressing, grooming and transferring), as well as depressed mood, are likely to improve shortly after NH admission.¹ One study of over 9,500 elderly clients admitted to a NH for at least 100 days found that 51.5% experienced a change in function during the first 90 days. This change usually represented an improvement rather than a decline. In fact, thirty-seven percent of this long-stay client sample was able to return home.²

Predictors of Mortality
Several studies have indicated that predictors of mortality in the elderly are increased age, male sex, poor physical status, poor social supports and poor cognitive functioning.^3,4,5 Few studies, however, have investigated the predictors of mortality specific to the NH population.

Victor M, Ropper AH. Adams and Victor’s Principles of Neurology

Seventh Edition. McGraw-Hill 2001.

Reviewed by: David J. Gladstone BSc, MD
Fellow, Division of Neurology, University of Toronto.

The collaboration between Raymond Adams and Maurice Victor dates back to the early 1950s at Massachusetts General Hospital and includes over 100 co-authored papers with seminal descriptions of alcoholic cerebellar degeneration, Wernicke-Korsakoff syndrome, central pontine myelinolysis and normal pressure hydrocephalus. Now in its seventh edition, their Principles of Neurology remains a classic text.

This single-volume work summarizes the core of clinical neurology. The organization follows a logical sequence from "symptom to syndrome to disease." The first half of the book deals with the cardinal manifestations of neurologic disease; the second part is devoted to the major neurologic disorders. The book is strong in its clinical descriptions, classifications and diagnostic approach.

In this era of multi-authored and multi-edited textbooks, the limited authorship of Principles of Neurology is a unique accomplishment that distinguishes this book from many others currently available. It is co-authored with Allan Ropper, Professor of Neurology at Tufts University School of Medicine.

The book has appeal for medical students, trainees and clinicians in general practice, internal medicine, geriatrics, psychiatry and neurosurgery. Many practicing neurologists have a personal copy of this text on their bookshelf but need to consult more exhaustive, multi-volume references for the minutiae. A practical pocket companion book is available separately and may be particularly suitable for students and housestaff.

As so much of neurology involves geriatric medicine, practitioners involved in the care of the elderly will find this book to be a valuable resource. Sections of particular interest to the geriatrician are chapters on The Neurology of Aging, Degenerative Diseases of the Nervous System, Delirium and Other Acute Confusional States, and Disorders of Stance and Gait, among others. General practitioners will find useful sections on seizure disorders, cerebrovascular diseases, tremor and other movement disorders and painful neurologic conditions. Psychiatric illness and neuropsychiatry are given special prominence based on the authors' "belief that these diseases are neurologic in the strict sense." Chapters on pediatric, developmental, metabolic and inherited neurological disorders are also included.

The field of neurology continues to advance at rapid pace and this revised edition is updated with knowledge gained over the past four years, during the culmination of the Decade of the Brain. However, in certain places I found the coverage of neurologic therapeutics to be incomplete or outdated, such as the discussion of Alzheimer disease pharmacotherapy. Readers looking for in-depth discussion of current treatment specifics may need to consult other sources. Neuroimaging and (black-and-white) illustrations are relevant and useful, although the ratio of text to figures is high. Many of the tables are excellent. Additional photographs, imaging scans and colour may enhance future editions.

With the passing of the Canadian-born Maurice Victor on June 21, 2001 at the age of 81 years, this textbook is a legacy of his lifetime of contributions to the practice and teaching of neurology.

The Risk of Homocysteine

Cross-sectional studies have indicated that elevated plasma homocysteine levels are associated with poor cognition and dementia. As elevated plasma homocysteine levels might result from poor nutrition and vitamin deficiencies, both easily modifiable factors, a group of researchers decided to investigate whether elevated homocysteine levels precede the onset of dementia.

The group studied 1,092 subjects without dementia (667 women and 425 men; mean age 76 years) from the Framingham study cohort. The researchers examined the relationship between plasma total homocysteine measured at baseline and that measured eight years earlier, to the risk of newly diagnosed dementia at follow-up. Adjustments were made for a number of factors including age, sex, apolipoprotein E genotype, vascular risk factors other than homocysteine, and plasma levels of folate and vitamins B12 and B6. A committee, comprised of at least two neurologists and a neuropsychologist, evaluated the patients and made the final diagnosis.

Over a median follow-up of eight years, 111 subjects developed dementia: 83 AD, 11 vascular dementia, 11 non-Alzheimer degenerative dementia and other types of dementia in 6 subjects. The results suggested that there is a strong, graded association between plasma total homocysteine levels and the risk of dementia and Alzheimer disease. An increment in the plasma homocysteine level of 5 mol per litre increased the risk of AD by 40% and a plasma homocysteine level in the highest age-specific quartile doubled the risk of dementia or AD.

Unfortunately, the results of the study do not determine whether or not this is a modifiable factor. Additionally, there is a lack of racial diversity in the overwhelmingly white Framingham cohort. Other cohort studies and controlled trials will be necessary to determine if there is a causal relationship between homocysteine and dementia.

In the meantime, don't forget to eat a healthy diet including green, leafy vegetables and enriched cereal grain products, to ensure adequate intake of folic acid and vitamins B6 and B12.

Source

1. Seshadri S, Beiser A, Selhub J, et al. Plasma homocysteine as a risk factor for dementia and Alzheimer's disease. NEJM 2002; 346:476-83.

Drinking to Preserve Memory?

We all know that light-to-moderate alcohol consumption may help lower the risk of coronary heart disease, ischemic stroke and total mortality, but did you also know that it might reduce the risk for dementia? Because vascular disease has been linked to the development of cognitive impairment and dementia, researchers from the Rotterdam Study decided to test the hypothesis that alcohol consumption might affect the risk of dementia.

Cognitive impairment at baseline and data on alcohol consumption were obtained for 5,395 patients, aged 55 and older, with almost complete follow-up (99.7%) an average of six years later. A number of baseline variables were used as possible confounders, including age, sex, diabetes, systolic blood pressure, education, smoking and body-mass index.

During the study, 197 individuals developed dementia--146 Alzheimer disease, 29 vascular dementia and 22 other dementia. Light-to-moderate alcohol consumption (defined as one to three drinks per day) was significantly associated with a lower risk of any dementia and vascular dementia. Interestingly, the results did not appear to be influenced by the type of alcohol consumed. The authors suggest that alcohol might act to reduce cardiovascular risk factors, supported by the fact that lower risk was seen mainly for vascular dementia, or may have a direct effect on cognition through alcohol-induced release of acetylcholine in the hippocampus.

Authors acknowledge that one limitation of the study is that the alcohol consumption data were based on a semiquantitative food-frequency questionnaire. Although these are highly reproducible, both under and over-reporting are possible.

Source

1. Ruitenberg A, van Swieten JC, Witteman JCM, et al. Alcohol consumption and risk of dementia: the Rotterdam study. Lancet 2002; 359:281-6.

Functional Neurobiology of Aging

Editors: Patrick R. Hof and Charles V. Mobbs
Academic Press, San Diego 2001, ISBN 0-12-351830-X

Book Reviewed by: Dr. Barry Goldlist

This is a large multi-authored textbook that was developed by the editors to be a source of information for those involved in teaching the neurobiology of aging or doing research in the field. Although the two editors are both Americans, they have recruited many contributors from outside the United States.

The first section is an excellent review of the important concepts of neural aging research. The topics include the epidemiology of age-related neurologic disease, nature vs. nurture in the aging brain and the neurochemistry of receptors. These are clearly reviewed in more detail than is necessary for the casual reader, but are exhaustive and authoritative. The section on the epidemiology of neural aging is superb, and goes well beyond the usual bromides about the aging imperative.

For a practicing geriatrician, I found the chapter on the memory changes that occur with aging and dementia superb. The language is clear and concise, and the chapter gives the reader an excellent understanding of the concept of different memory functions and how they vary in the aging process.

After this, the text becomes very detailed and comprehensive. It is clearly not designed for continuous reading, but rather to be dipped into for specific data and insights. Whatever question I formulated, I could find an answer with relevant references in this text. The first question I asked was "What is the relation between Alzheimer's pathology and disorders with Lewy bodies?" I found an entire subsection on this topic. There are also excellent sections on various treatment modalities in Alzheimer disease.

In summary, this text satisfies its intended objectives to serve as a reference source for those teaching the neurobiology of aging and for researchers in the field. It could also be a useful reference text (probably in the hospital library) for clinicians with an active interest in neurodegenerative disorders.

PC, M.D.: How Political Correctness is Corrupting Medicine

By Sally Satel, MD
Perseus Books Ltd. 12/2001
ISBN: 046507183X

Reviewed by: A Mark Clarfield, MD, FCFP, FRCPC

As a physician and as one who is no great admirer of the American system of health care, I was of course intrigued to dig into a book with such a title. Dr. Sally Satel, a practicing psychiatrist and fellow of the American Enterprise Institute, has issued a fierce broadside against the forces that she reckons are "corrupting" American medicine. Dr. Satel gives chapter and verse as to how what she labels "identity politics" [that is, giving preference to women, minorities and even "victims" of psychiatric treatment] has taken precedence over clinical imperatives. In other words, how "political correctness" has deformed the judgement of senior academics, medical and government officials so that not only are patients not helped, but they are actually harmed by the turn that things have taken.

An excellent example would be the movement of those who would "protect" schizophrenics from forced therapy with sometimes catastrophic results for the patient's (and others') health. Although Satel agrees with the purveyors of PC (whom she labels "the Indoctrinologists") that social forces can be a major health determinant, she takes strong issue with the implied notion that we should thus give up our sense of personal responsibility for our health.

The book is closely argued, with multiple examples from the fields of women's health, cancer, psychiatric illness and what she calls the "dumbing down" of nursing education. The book is well referenced and Satel seldom makes a factual point without a citation being listed to support her point.

Indeed, from her litany of complaints, the reader can see that there is indeed a lot remiss in the direction that some elements in the American health system are taking. However, there is unfortunately an element of "the sky is falling" to this book. This tractate is clearly a polemic and a call for action. If we heed not her warnings, "...their prescriptions [those of the Indoctrinologists] will be hazardous to our health."

There is hardly a word in the book about the other ills of American medicine; for example, the waste and inefficiency of it all or the fact that the US health outlay is more than 14% of its GNP (Canada of course spends far less and has better health statistics to boast for her smaller investment). Neither is there a word about the shocking fact that more than 40,000,000 Americans survive without any form of health insurance and that many millions more are underinsured.

Perhaps it should come as no surprise to the reader that Dr. Satel is a fellow of the American Enterprise Institute, not exactly the last bastion of social democracy. Her concern over the beliefs of the "Indoctrinologists" includes her oft-expressed fear that they might succeed in "…social actions that would disrupt our prevailing economic and social systems." Perhaps this is unfair but there is just the whiff of McCarthyism in her style.

The book has the tone not only of a warning. As one reads one example after another of some admittedly rather foolish notions of the PC crowd, I began to think that perhaps the lady doth protest too much. And my initial impression was strengthened by something which appeared in the New England Journal of Medicine (April 12, 2001, pp. 1170-1). In a most unusual move, Dr. Satel wrote to criticize a review of her book which appeared in that journal, protesting strongly what she perceived as a serious slight by the reviewer.

From the Right, Satel rightly criticizes the PC pushers for being more concerned with social and political issues than with the notion of health. However, the book is more of a polemic, albeit with an interesting message, than a sober account of what is so wrong with the American health care system today.

Dr. Clarfield, MD, FRCSC, is the Chief of Geriatrics, Soroka Hospital Centre, a Professor and Sidonie Hecht Chair of Gerontology, Faculty of Health Sciences at Ben Gurion University of the Negev in Beersheva, Israel , and an Adjunct Professor in the Division of Geriatric Medicine, McGill University and Jewish General Hospital, Montreal, Canada.

History of Geriatrics

Dr. Clarfield, MD, FRCSC, is the Chief of Academic Affairs at the Herzog Hospital in Jerusalem, Director of Geriatrics in the Ministry of Health, and on staff in the Division of Geriatric Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, PQ.

Geriatrics, the medical specialty which deals with the old, is still relatively young. Although not all Canadian medical schools offer a comprehensive approach to teaching this subject, progress has been made especially in the last two decades. There are now more clinical units, more research is being carried out, and certainly more attention is being paid to the subject of the elderly than ever before.

The roots of geriatrics can be traced back to the beginning of this century, and two of its pioneers hail from opposite sides of the Atlantic: Dr. Ignatz Nascher, an American whose medical career began at the end of the 19th century;¹ and an English physician, Dr. Marjory Warren, who reached the zenith of her influence in the 1940s.²

Dr. Nascher was born in Vienna in 1863 and was brought up in New York. In 1882, aged 19, he graduated in pharmacy and several years later completed his MD and began private practice. Little is known about his early years, but Dr. Nascher's first paper on geriatrics ("Longevity & Rejuvenesence," New York Medical Journal, 1909) was to have a profound influence on the discipline simply by giving us its name.