The establishment at the University of geriatric ...

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The establishment of geriatric medicine at the University of Cape Town P. DE V. MEIRING,

S. R. BENATAR

Summary The birth of modern geriatric medicine in the USA and UK is briefly described as a prelude to the recognition of the need to establish facilities to teach this discipline at South African medical schools. The response of the University of Cape Town to this clearly shown need, the steps taken to endow a chair and the subsequent plans to commence a service are outlined. Consideration of population projections for the age group above 60 years between 1970 and the year 2020 suggests that formal training in the various disciplines involved in caring for the aged has been introduced none too soon. The first incumbent of the William Slater Chair of Geriatric Medicine commenced duty on 1 October 1981 and the milestones in the subsequent development of a service based upon the University of Cape Town and Groote Schuur and otner hospitals are described. S AfrMed J 1986; 69: 565·569.

The birth of modern geriatric medicine is anributed by both de Beauvoir l and HowelP to Dr 1. L. Nascher of New York, who applied himself to an interest in diseases of the aged, wrote a textbook, and in 1912 founded the Society of Geriatrics. On 11 June 1942, the American Geriatrics Society was established 3 with Dr Milford W. Thewlis as its first President and Dr Nascher as Honorary President. The first issue of the society's journal was published in 1953. Geriatric medicine began in the UK when the West Middlesex Hospital took over the adjacent poor-law infirmary and Dr Marjorie Warren was given the duty of caring for its 714 patients. 4 She introduced total care on a multidisciplinary basis which included consideration of social, preventive and economic needs as well as rehabilitation of the disabled and their return whenever possible to the community. Her enthusiasm, supported by a wealth of publications, undoubtedly put British geriatric medicine on the map. The Medical Society for Care of the Elderly was established and later reconstituted as the British Geriatrics Society with Lord Amulree as President soon after the introduction of the National Health Service in 1948. At this time the first consultants in geriatric medicine were appointed. Establishment of chairs of geriatric medicine followed in due course, and at a recent count there were 14 academic departments in British undergraduate medical schools.'

Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town

P. DE V. MEIRING, F.R.C.P. S. R. BENATAR, F.F.A. (S.A.), F.R.C.P.

The need to establish departments of geriatric medicine at South African universities was foreseen as long ago as 1955. In a resolution to a National Conference on Welfare of the Aged held that year under the chairmanship of Mrs Zerilda Steyn it was resolved that 'Medical schools be requested to establish departments of gerontology and geriatrics for investigating the handicaps of ageing and for the training of medical personnel in their treatment' (Z. Droskie - personal communication). In her opening remarks at the inaugural meeting of the National Council for the Care of the Aged on 13 December 1956, Mrs Steyn stated that the provision of geriatric units in general hospitals was a matter requiring immediate attention. This far-sighted woman was not alone, and Dr W. J. B. Slater (personal communication) recalls that Dr Louie Blumberg, then a member of the Executive Committee of the Cape Peninsula Welfare Organization for the Aged (CPWOA), also voiced the need for a chair in geriatrics at about the same time. The executive of the National Council for the Care of the Aged expressed these views in writing to the various medical faculties in South Africa. The replies indicated that there were no staff capable of teaching geriatrics as a subspecialty, and that this aspect of medical teaching was considered to be covered adequately by the basic training given to medical students. The National Council rejected this rebuff and resolved that 'we should continue to state our objectives and urge their implementation'. The Council executive persisted in its efforts, and a number of approaches were made to the directors of hospital services of the four provinces and to medical schools by Mrs Zerilda Droskie, Mrs Steyn's daughter (personal communication), who in her capacity as Director of the National Council had taken up the torch in this crusade. She was able to report to the Executive Committee meeting in March 1978 that some facilities exclusively for the care of the aged had been established at Tygerberg Hospital. Other institutions continued to drag their feet despite continuing pressure from the National Council, although there had been a stirring of enthusiasm in October 1975 when the Division of Continuing Medical Education of the University of the Witwatersrand held a geriatric conference at which optimism was expressed regarding the future of geriatric medicine in South Africa. At the University of Cape Town, Mrs Droskie's perseverance bore fruit in March 1976. Following a meeting between the National Council and the newly formed South African Geriatrics Society, further approaches were made to the universities, and Professor S. J. Saunders, then Professor and Head of the Department of Medicine at UCT, responded favourably. He agreed that the medical care of old people would have to be given academic status in order to stimulate interest in the fundamentals of geriatric medicine (personal communication). .By this time Dr Slater, then Chairman of the CPWOA, had added his considerable influence and a meeting took place in the office of the Dean of Medicine on 8 March 1977 to negotiate a chair of geriatrics at the University of Cape Town. Dr Slater, Mrs Droskie, Dr R. Schapera, the Dean (the late Professor B. Bromilow-Downing), Professor L. S. Gillis, Professor Saunders and Mr R. Schell were present. The Dean quoted the sum of R200000 as being the capital required by the University to meet the costs of its 51 % contribution to a chair under the joint agreement between the Cape Provincial

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Administration and UCT. The remammg 49% of the total costs would be met by the CPA. The consensus at this meeting was that a chair should be esrablished within the Department of Medicine, under University conditions of service, with the intention of embracing all academic and clinical aspects of gerontology, the promotion and encouragement of this discipline, and the co-ordination of medical and paramedical aspects of care for the aged. The CPWOA Executive Committee recommended acceptance of the University's offer at a meeting on 25 March 1977, thereby cementing the agreement with the University. Professor Sir Ferguson Anderson (David Cargill Professor of Geriatric Medicine at the University of Glasgow, the foundation chair in the UK) provided Professor Saunders with relevant data on the impottance of developing academic geriatric departments, and this was made available to the South African National Council for use in its subsequent fund-raising efforts. Immediate attention was given to raising R200000, and the CPWOA transferred R30000 from its own reserves to start this fund. An agreement existed between the CPWOA and the London-based charitable organization 'Help the Aged Fund' whereby the CPWOA made available its fund-raising number to the local representatives of the London fund. This organization, known in South Africa as the Voluntary and Christian Services (VCS), provided entertainment at local schools at which collections were taken, and the net proceeds were paid over to the development fund of the CPWOA. It is symbolic of the interdependence of all ages in society that a substantial amount of the money needed for the inauguration of an academically based clinical service providing care for the aged was generated from schoolchildren. The sources from which the R200000 was subsequently collected are listed in Table I (Dr Slater - personal communication).

TABLE I. SOURCES OF THE R200000 COLLECTED TO ENDOW THE WILLlAM SLATER CHAIR OF GERIATRICS

0'

Grant ex reserves CPWOA Net amount from school functions organized byVCS Public collections by CPWOA Interest on donations collected, and temporarily invested Grant from SA National Council for the Aged

R30000 R86000 R63000 R16000 R5000 R200000

This first chair in geriatric medicine in South Africa was formally named the William Slater Chair of Geriatric Medicine, reflecting nor only the enormous contribution made by Dr Slater in bringing this dream to fruition but also the love, respect and admiration felt for him. Dr Schapera also deserves special mention, as his vision and active campaigning since 1968 made a significant contribution to the establishment of this first geriatric service. 6 His name recurs frequently in minutes of the ational Council and in the pages of the SAMJ as the driving force behind the formation of the SA Geriatrics Society on 8 September 1975. Dr Schapera must be regarded as one of the key people in this development in Cape Town and in the RSA.

Plans to commence the service During 1980 UCT advertised the chair in geriatric medicine. Several' applicants were considered by the selection committee, and in November 1980 an appointment was recommended. The incumbent designate was informed that the geriatric unit would be

created within the UCT Department of Medicine, and he was invited to submit a memorandum outlining his needs for the establishment for such a unit. In this document, submitted to the University on 25 November 1980, the new Professor acknowledged the need for the unit's placement within the Department of Medicine. He requested office accommodation, secretarial assistance, access to some junior medical staff and paramedical support to provide the nucleus of an academic and service unit. He also requested as an 'ultimately' non-negotiable requirement some specifically designated geriatric beds for acute assessment of patients prior to their rehabilitation to community life or failing this their appropriate placement in optimal conditions in long-stay residential facilities. In recognition that this process could be a prolonged one for geriatric patients, he added the caveat that such geriatric beds should not be subject to the intensive turnover characteristic of teaching hospitals. The long-stay wards at Conradie Hospital were mentioned as a possible suitable initial location for such beds. Considerable assistance was obtained from the findings and recommendations of Tibbit 7,8 in the formulations of this memorandum. While the Health Act of 1977 had made overall legislative provision for co-operation between various medical and non-medical disciplines and authorities responsible for health care delivery, there was no practical plan in operation to co-ordinate all aspects of hospital and community geriatrics. It was envisaged that the UCT geriatric unit would have the first opportunity to demonstrate the effectiveness of such a co-ordinating function. The two major reasons for placing the new geriatric unit in the Department of Medicine rather than creating it as an entirely independent department were frrstly the lack of resources to provide a complete geriatric team capable of providing a 24-hour service 7 days a week, and secondly the recognition that it was neither possible nor desirable to plan the development of geriatrics into a discipline which would provide a service for all elderly patients. The major considerations being the provision of an academic base from which to develop appropriate undergraduate and postgraduate teaching, the stimulation of improved care for elderly patients by all practising doctors, and the encouragement _of rapid growth and recognition of this discipline, it was thought both wise and practical to allow geriatrics to draw strength and support from a major department rather than to create a completely independent department which would have to compete disadvantageously with other, also urgent, priorities. Subsequent reports from the UK9 and the USAIO endorsed this view, initially espoused by Professor Saunders in Cape Town (and acted on by those charged with the responsibility for developing geriatric

TABLE 11. DISCIPLINES AND AGENCIES INCLUDED IN THE TYPICAL GERIATRIC SERVICE* Geriatrician or doctor with interest and training in care of the aged, as conductor and co-ordinator Other medical, surgical and dental practitioners and specialists as required in consultation Hospital, community liaison and community nursing services Physiotherapists with special interest in the elderly Occupational therapist with special interest in the elderly Social workers with special interest in the elderly Dietitian Speech therapist Optometrist Hospital technical personnel Hospital administrative personnel and planners Hospital domestic staff and drivers Chiropodists Voluntary workers, home helps, visitors Community agencies for care of the aged 'The informal sector', e.g. schoolchildren, church members, neighbours, friends, etc. *As all elements have a role without which the team cannot function optimally, the order of arrangement does not imply any precedence.

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medicine at UCT), that geriatrics should be firmly grounded in the mainstream of clinical medicine. It is important to record, with regret, that the endowment of a new university chair does not bring with it any of the additional resources required to develop academic and clinical facilities around the incumbent. Against the background of even greater than usual financial stringency operating at that time, it would not have been possible for geriatrics'to mobilize adequate staffing and resources to meet even its inaugural activities. The closure of the physical medicine unit and re-allocation of some of its resources to geriatrics (with the willing co-operation of the Director of Hospital Services and Dr H.-Reeve Sanders, Chief Medical Superintendent of Groote Schuur Hospital) overcame this initial difficulty. This is a most unsatisfactory means of establishing a new and important area of medical practice, in particular if adequate plans are not being made for future needs.

TABLE Ill. SCOPE OF GERONTOLOGY

Clinical medicine in the elderly (geriatrics) Clinical manifestations of disease in the elderly Psychogeriatrics Clinical pharmacology and therapeutics in the elderly Long-term care under domiciliary, residential and hospital conditions Social gerontology Health maintenance (preventive geriatrics) Psychosocial aspects of ageing Community support systems and facilities Public health Basic sciences of epidemiology and demography Demonstrations and model projects Policy development Advocacy: approaches to clinicians, medical, hospital and community administrators and planners, providers of community care for the aged, politicians and their supporting electorate, in order to obtain equitable treatment of the elderly throughout South Africa . Research Initially at a level designed to produce cost-effective service and generate knowledge for dissemination Eventually at the level of basic science Teaching Medical undergraduates Medical postgraduates Paramedical and nursing undergraduates, postgraduate staff in training and trained Administrators and planners and other workers for the aged The public Those caring for the aged in the community Preventive geriatrics for the general public, the workforce, etc.

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TABLE IV. MILESTONES IN A DEVELOPING GERIATRIC SERVICE Services 1 October 1981: 1 November 1981:

1 April 1982:

June 1982:

1 February 1983: 1 February 1985:

Basic science Biology of ageing Aetiology and pathogenesis of diseases of the elderly Pharmacology

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cope with the health needs of an ageing population. Shapiro '2 has defined geriatric patients as elderly people who are not able or likely to be able to maintain independence in the community without some assistance towards their supportive, remedial or basic needs. Gillis and Elk's" report that 85% of elderly white people in our community manage adequately and are satisfied

The need for geriatric services Population projee,.tions for the age groups above 60 years between 1970 and 2020 in South Africa suggest an increase in the over-65s from 7% in 1980 to approximately 14% in 2010." These projections must obviously be accepted with considerable reserve, but enough is known about the increase in numbers of elderly people both here and in most other countries to leave little doubt about the need for the development of geriatric services. If additional resources are not going to be made available for developing these in the future, current resources will have to be redistributed to

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William Slater Professor of Geriatric Medicine assumes duty Geriatric outpatient clinic and inpatient consulting services introduced at Groote Schuur Hospital. Consulting service at the Psychogeriatric Unit at Valkenberg Hospital commenced Weekly consulting service to long-stay wards at Conradie Hospital commenced Regular geriatric consultant visits to Frere Hospital in East London commenced Geriatric outpatient clinic commenced at Conradie Hospital Geriatric consulting service introduced in the newly opened beds for the elderly at Volkshospitaal

Research Completed Establishment of the characteristics of geriatric patients, 1982 Identification and study of preventive factors for independent ageing Psychosocial psychiatric and medical community survey of the coloured elderly of Cape Town, 1983 Activity analysis of Frere Hospital geriatric service completed In progress Monitoring drug use in the elderly Investigation of management modalities in total care for the aged Study of the profile and spectrum of disease in the age group 75 years and over Teaching Medical undergraduates Lectures on functional and clinical aspects of ageing 2, 3, 4 and 5 years Clinical demonstrations' of a geriatric unit (Conradie Hospital) and patient care - 4th-year community medicine students Nursing and paramedical Orientation lectures and seminars for B.Sc. Nursing, occupational therapy, physiotherapy, dietetics, social sciences courses Medical postgraduates Four medical registrars rotate through the geriatric unit each year. Education of the public in preventive geriatrics UCT Summer School courses, public lectures, two lectures at a high school on adoption of healthy lifestyles, symposia and seminars to business and industry on retirement planning

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with their life circumstances makes it clear that under good socioeconomic conditions only a small minority of elderly persons may need to be classified as medically 'geriatric'. '4 An important potential objective is therefore the institution of preventive measures designed to keep the aged independently integrated into society for as long as possible." Geriatrics is therefore not the exclusive monopoly of the medical profession but involves many disciplines (Table 1I). The new UCT unit planned to contact, mobilize, publicize '6 and co-ordinate representatives from these disparate elements together with the teaching and research roles of the academic geriatrician with the objective of realizing the full scope and potential of gerontology (Table Ill). Finally, the new unit planned to institute a flow system for a hospital-based service along the lines of the prototype of a typical British geriatric unit (Fig. 1).

Introduction and development of the service, 1982 - 1983 The first incumbent of the William Slater Chair of Geriatric Medicine commenced duties on I October 1981; these included general medical ward consultant duties at Groote Schuur Hospital consonant with the intention of basing geriatrics firmly within the overall sphere of activity of the Department of Medicine. The main milestones of the developing geriatric service are listed chronologically in Table IV. After the inauguration of an outpatient service at Conradie Hospital it became possible to offer a screening service for applica-

tions for admission to the long-stay wards. This enabled the selection of patients with potential for eventual return to the community following longer rehabilitation than had hitherto been available in the acute medical wards of various feeder hospitals. This in turn led to a more effective turnover of patients, the development of a more optimistic anirude in the staff of these wards, and the facility to offer a small number of beds for holiday relief admissions. The laner is an important support service with acknowledged potential for keeping some elderly and otherwise completely dependent patients at home in the community. In order to carry out this multidisciplinary teamwork characteristic of geriatric practice it was necessary to co-ordinate the efforts of members of many disciplines from Groote Schuur and Conradie hospitals, and the community listed in Table II. Community outreach was greatly facilitated by the simultaneous development by the Department of Health and Welfare of community nursing, physiotherapy and occupational therapy services. Social workers from various governmental and nongovernmental bodies and a wide variety of formal and informal care-giving organizations and individuals have been sought out for inclusion. This has led to a fairly comprehensive multidisciplinary geriatric team functioning both in hospital and in the community.

Conclusion The establishment of the first chair of geriatric medicine in South Africa at the University of Cape Town is a monument to the foresight, persistence and planning of many dedicated

OPD consultation Home visit Emergency admission

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Admit

Acute geriatric ward - average stay 2 wks

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Long-stay wards average stay 2 - 3 years (90% died, 10% home)

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Referred from ;general medical, surgical, _ - - - - - - ' - - - - - - - - - - - - - - - - - j ! o r t h o p a e d i c and gynaecological wards in general hospital

Fig. 1. An ideal flow system for a hospital-based geriatric service (based on a typical UK geriatric unit).1a

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people. The need was there, but without the spadework done by all who prepared the ground it would not have been possible for development to take place so rapidly in the short space of time that this unit has existed. With regard to the apparent growth of the unit, from 8 members in 1982 to 24 in 1985, it must be emphasized that most of the workers in 1983 were already employed in the co=unity and available in 1982. They had simply not yet been co-ordinated into one team. We believe that the key to success in geriatrics in South Africa (and indeed to success in many other aspects of health services) lies in learning how best to utilize existing services. We should not, however, become complacent over these achievements, because there is a vast pool of unmet needs among our elderly citizens, especially in the coloured and black communities. These include poor access to the system of health care for the aged, deficiencies in facilities and services for home care to maintain the aged of all races in the community, inappropriate utilization of residential care by elderly persons who could have retained their independence, and general lack of preparation for old age. 17 We can do so much, and individuals or communities a linle more, but lip-service to individual responsibility must never become a smokescreen behind which society evades its collective responsibility. We owe the potential for a dignified old age to all our citizens. The establishment of academic geriatrics is just one step in raising the community's awareness, its conscience and its ability to respond expertly by the production of properly trained cadres of health workers. This must, however, be matched by a response by society and its elected representatives, or, in a society where many people are not yet represented, by a spirit of compassion on the pan of authorities responsible for delivering health care. Two important roles of academic gerontology are those of advocacy for patients and policy planning, in which this unit is already playing a considerable part. 17 It has been fining that the first chair of geriatric medicine in South Africa was established at its oldest medical school, the

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University of Cape Town. But it is perhaps equally fining that the first incumbent is a graduate of the University of the Witwatersrand, so that this pioneering achievement in South African medicine is to some extent shared between these two universities.

REFERENCES I. De Beauvoir S. Old Age (English translation by Patrick O'Brian). London: Andre Deutch/Weidenfeld & Nicholson, 1972: 22.

2. Howell TH. A Seudent's Guide 10 Geriaerics. 2nd ed. London: Staples Press, 1970: 11. 3. Thewlis MW. Tbe history of the American Geriatrics Society.] Am Geriaer Sac 1981; 12: 544-549. 4. Matthews DA. Dr Marjorie Warren and the origin of British geriatrics. ] Am Geriaer Sac 1984; 32: 253-258. 5. Smith RG, Williams BO. A survey of undergraduate teaching of geriatric medicine in British medical schools. Age and Ageing 1983; 12: suppl, 2-6. 6. Schapera R. The economics of caring for the aged. S AIr Med] 1977; 51: 431-433. 7. Tibbit LR. A critical look at geriatrics in a teaching hospital: Part I. The situation. S AIr Med] 1979; 56: 646-653. 8. Tibbit LR. A critical look at geriatrics in a teaching hospiral: Part Il. The remedy. S AIr Med] 1979; 56: 681-684. 9. Picton-Williams TC. The furnre of geriatric medicine.] R Call Physicians Land 1981; 15: 45-47. 10. The Federal Council for Internal Medicine. Geriarric medicine. Ann Intern Med 1981; 95: 372-376. 11. Droskie A. The older adult - his contribution to the community of Sourh Africa. Physioeherapy 1982; 38: 90-91. 12. Shapiro E. Home Care: A Comprehensive Overview. Ottawa: Policy Planning and Information Branch, Department of Narional Health and Welfare, 1979. 13. Gillis LS, Elk R. Physical and mental capacity in elderly white persons in Cape Town - a community survey. S AIr Med] 1981; 59: 147-149. 14. Meiring P de V, Blake A], Grobbelaar JP. The identification and definition of rhe geriatric parienr in a reaching hospital. S AIr Med] 1983; 64: 670-673. 15. Meiring P de V, Blake AJ. The exrent of individual responsibility for an independent old age. S AIr Med] 1984; 65: 657-659. 16. Gunston E, Meiring P de V.Informarion Manual 01 Services Available 10 rhe Aged in ehe Cape Peninsula. Cape Town: Geriarric Unir, UCT, and Cape Peninsula Welfare Organizarion for rhe Aged, 1983. 17. Meiring P de V. Emerging problems in health care and management of rhe aged - the advocacy role of the doctor. S AIr] Cant Med Educ 1984; 2 (Aug): 117-122. 18. Brochlehurst JC, Hanley T. Geriaeric Medicine lor Scudents. London: Churchill Livingstone, 1981: 204.

News and Comment/Nuus en Kommentaar Circadian variation in myocardial infarction

Chorionaspirasie in prenatale diagnose

One of the factors that finally triggers off an acute myocardial infarction (MI) may be environmental or in some way related to daily activity. Muller er al. (N EnglJ Med 1985; 313: 13151322) anempted to determine whether the onset of MI was distributed randomly throughout the 24 hours or had a circadian rhythm. They analysed the time of onset of pain in 2999 patients admined with an infarct and detected a circadian rhythm in the frequency of onset with a peak between 06hOO and noon and a trough at 23hOO. The existence of this rhythm was confirmed by serial estimates of plasma creatine kinase MB elevation. A further finding was that in patients on a f3adrenergic-blocking agent during the 24 hours before the onset of MI no significant morning peak was shown. The next step will be to examine further the rhythmic processes that lead to this marked change in susceptibility to infarction in the hope that the pattern may bring a clue to the identity of underlying processes that could be modified either by drugs or other methods.

Daar het die afgelope paar jare 'n toenemende aantal verslae verskyn oor die waarde van chorionaspirasie as 'n diagnostiese metode tydens die 8ste tot lOde week van swangerskap. Tipies van hierdie verslae is 'n onlangse artikel deur Sachs er al. van Rotterdam (Ned Tijdschr Geneeskd 1985; 129: 1968-1974). Hulle het chorioniese materiaal geaspireer in die 9de en lOde week van swangerskap van 350 vrouens met 'n verhoogde risiko om geboorte te skenk aan babas met aangebore abnormaliteite of erflike afwykings. Deur gebruik van spesifieke analitiese metodes was dit in alle gevalle van chromosomale en biochemiese ondersoeke moontlik om binne 1 of 2 dae van die aspirasie 'n diagnose te maak. By metaboliese afwykings was resultate binne 10 - 14 dae beskikbaar in gevalle van hemoglobinopatie of spierdistrofie. Die skrywers beskou die risiko van chorionaspirasie in ervare hande as klein en die spontane aborsiesyfer vergelykbaar met die in kontrolereekse.