Most people appreciate the importance of a pediatrician, often going to great lengths to choose one. After all, the pediatrician becomes a special friend and guardian for our children, a relationship that will extend well into adolescence.

Childhood, especially the early years, is certainly a fragile period in a person’s life and modern medicine has responded by creating pediatrics, which in turn has branched off into even more specialized sub-fields, including pediatric cardiology, pediatric oncology (for cancer) and in recent years, even adolescent medicine.

In contrast to the attention we give to childhood health and pediatrics, we forget that the elderly also have their special needs. We do go to specialists, for example, a cardiologist, a diabetologist, or one of the other specialists dealing with chronic illnesses that beset the elderly, but these specialists sometimes become so focused on the illness that they forget the patient. Others may not even be aware of very important differences in the way the elderly’s bodies and minds function when compared to younger people.

Glamour, drama

Last June The New York Times featured an article about the shortage of geriatricians in the United States. The article focused on Dr. Rosanne Leipzig, a geriatrician based at Mt. Sinai School of Medicine in New York who has been pushing hard for medical schools to give more attention to geriatrics.

Leipzig admitted that even if medical schools give time to geriatrics, it is not a specialty that too many Americans (and, I suspect, Filipinos) want to go into. Geriatrics doesn’t have the glamour and drama that’s found in other specialties like surgery.
I was able to find an article by Leipzig and her associates in the journal, Academic Medicine, which is devoted to medical education. The title of her article is a bit unorthodox: “Keeping Granny Safe on July 1: A Consensus on Minimum Geriatrics Competencies for Graduating Medical Students.” It urges more attention to some of the skills all doctors should have so they can be more effective with elderly patients.

Geriatrics relies much less on laboratory tests and emphasizes physical examination and observation of the patient. In the Philippines, we associate that physical examination with taking blood pressure, but geriatric medicine involves much more, including observation of the patient’s physical activities.

One important set of competencies revolves around assessment of a patient’s self-care capacity. The “tests” here will include something like tying one’s own shoelaces. If the patient has had falls recently, the doctor should be observing if that patient can get up from a chair, and move around.

Many of you may have heard of the term homeostasis, which refers to biological feedback mechanisms that maintain equilibrium. For example, when you’re hungry, you eat, and as you eat, your stomach expands and nerves send a message to our brain telling us “enough, you’re full now,” and you usually stop eating. You do have the option of disregarding those signals but the biological mechanisms generally work well.

Aging can result in something different called homeostenosis, where the feedback mechanisms do not function as well or may even be blocked. A geriatrician is more sensitive to these changes, and can therefore spot trouble more quickly. For example, many non-geriatricians miss a serious infection that’s brewing in a patient because they don’t know that in many elderly patients, there may be no fever even with the infection. A fever is actually part of the body’s response system to infections, but because of homeostenosis, lolo’s or lola’s temperature will be normal.

When ill, the elderly will often show signs of distress and disorientation, so even without the fever, a doctor should be looking for an infection in such patients. In societies where the elderly are expected to be stoic and strong, the physician needs to be alert to the possibility that the patient may be suppressing those feelings of distress.

Geriatrics is also about developing more autonomy or independence for the elderly. That includes encouraging the elderly to set their own goals for health. This is where problems often arise. Non-geriatricians tend to keep patients passive: take this medicine, don’t take that food, stay in bed. Unfortunately for the elderly people, that passive role often leads to a further deterioration of their health. This is worsened by Filipino cultural norms that also emphasize passivity and dependence for the elderly.

Less is more

Geriatricians want their patients to be active whenever possible. When it comes to medicines, less is more for geriatricians because of more risks of side effects, and of drugs interacting with each other. Again, this sometimes runs counter to local culture: our elderly sometimes boast that they are taking 10 pills a day.

We will need more geriatricians who have both the biomedical skills and cultural competence or sensitivity to care for our elderly. Moreover, geriatricians could play another important role of training caregivers, friends and relatives, somewhat like para-geriatricians. I know The Medical City offers such training workshops from time to time.

This takes us to the matter of caregivers. For many years now, thousands of our women have been going overseas to work as nannies, caring for other people’s children even as they leave behind their own very young children. In more recent years, we have been exporting caregivers, both men and women, now specializing in caring for the elderly. Again, this is often at the cost of our own elderly being neglected.

Lately, too, there has been talk about training more geriatricians and caregivers to care for elderly foreigners who come to the Philippines to retire. There are already entire subdivisions devoted to these foreign retirees. As usual, it takes an external dollar-driven demand to wake us up to a certain social need, and even then, we forget about Filipinos who have those needs as well.

Our elderly—defined as people above the age of 60—is only about 5 percent of the total compared to more than 20 percent in many developed countries. But that 5 percent means about 4.5 million Filipino elderly, and the percentage is going to keep growing. Geriatrics should be integrated into our health care system, all the way down to the barangay health centers.

Email to mtan@inquirer.com.ph