Solid-organ transplantation in older adults: current status and future research.

An increasing number of patients older than 65 years are referred for and have access to organ transplantation, and an increasing number of older adults are donating organs. Although short-term outcomes are similar in older versus younger transplant recipients, older donor or recipient age is associated with inferior long-term outcomes. However, age is often a proxy for other factors that might predict poor outcomes more strongly and better identify patients at risk for adverse events. Approaches to transplantation in older adults vary across programs, but despite recent gains in access and the increased use of marginal organs, older patients remain less likely than other groups to receive a transplant, and those who do are highly selected. Moreover, few studies have addressed geriatric issues in transplant patient selection or management, or the implications on health span and disability when patients age to late life with a transplanted organ. This paper summarizes a recent trans-disciplinary workshop held by ASP, in collaboration with NHLBI, NIA, NIAID, NIDDK and AGS, to address issues related to kidney, liver, lung, or heart transplantation in older adults and to propose a research agenda in these areas.

Database Conference January 27-30, 2000, Washington D.C.--Do existing databases answer clinical questions about geriatric cardiovascular disease and stroke?

EXECUTIVE SUMMARY: Most randomized, controlled trials evaluating the effectiveness of pharmaceutical, surgical, and device interventions for the prevention and treatment of cardiovascular disease have excluded patients over 75 years of age. Consequently, the use of these therapies in the older population is based on extrapolation of safety and effectiveness data obtained from younger patients. However, there are many registries and observational databases that contain large amounts of data on patients 75 years of age and older, as well as on younger patients. Although conclusions from such data are limited, it is possible to define the characteristics of patients who did well and those who did poorly. The goal of this conference was to convene the principal investigators of these databases, and others in the field of geriatric cardiology, to address questions relating to the safety and effectiveness of treatment interventions for several cardiovascular conditions in the elderly. Seven committees discussed the following topics: (I) Risk Factor Modification in the Elderly; (II) Chronic Heart Failure; (III) Chronic Coronary Artery Disease: Role of Revascularization; (IV) Acute Myocardial Infarction; (V) Valve Surgery in the Elderly; (VI) Electrophysiology, Pacemaker, and Automatic Internal Cardioverter Defibrillators Databases; (VII) Carotid Endarterectomy in the Elderly. The chairs of these committees were asked to invite principal investigators of key databases in each of these areas to discuss and prepare a written statement concerning the available safety and efficacy data regarding interventions for these conditions and to identify and prioritize areas for future study. The ultimate goal is to stimulate further collaborative outcomes research in the elderly so as to place the treatment of cardiovascular disease on a more scientific basis.

Demographic peristalsis. Implications of the age wave for gastroenterologists.

With the advent of the twenty-first century, a new phenomenon in human history emerged, one that is expected to dominate the social, economic, health, and health care agenda of the United States and the world. This so-called "age wave" represents an unprecedented demographic trend that will make the oldest cohorts, especially those older than 75, 85, and 100 years old, the fastest growing segment of the population for at least the next 50 years.

The department of internal medicine: hub of the academic health center response to the aging imperative.

In the 21st century, geriatrics will increasingly dominate U.S. health care as the median age of the population progressively increases. Academic departments of geriatrics have been created in nations that have already experienced this shift. As an alternative strategy that builds on traditional strengths of academic medicine in the United States, departments of internal medicine should lead a multidepartmental, pan-institutional response to the aging imperative. Recognition of gerontology and geriatric medicine as central to the missions of internal medicine in clinical care, education, and research must be increased. In the process, academic departments of internal medicine will develop a high level of geriatric expertise and will launch many programs that address this challenge. Successful development of geriatric programs will serve as a catalyst to strengthen the integration among and between generalists and subspecialists. This will entail developing optimal sites and systems of geriatric care--at different levels of care and over time--that can enhance the geriatric education of medical students, residents, fellows, and practicing physicians. The study of aging and geriatric health care will also become an integral part of departmental research, in its subspecialty divisions as well as its divisions of general internal medicine and geriatrics. This strategy is urgently recommended as both a challenge and an opportunity for all departments of internal medicine.

Revisiting the one-year geriatric fellowship option: a preliminary assessment.

OBJECTIVE: To ascertain early opinions of geriatric fellowship program directors regarding the 1-year clinical training option. DESIGN: A brief mail survey of the 100 program directors listed in Graduate Medical Education, 1998-1999. MEASUREMENTS: Answers (favorable (+), no effect (0), or negative (-)) to questions regarding the effect on the training program, position of the director, and geriatrics as a discipline. RESULTS: This preliminary assessment produced decidedly mixed results. Seventy-six program directors responded (76% response rate). The clearest positive effect on the program itself was on the quantity of applicants (63% +, 4% -) but less so on their quality (33% +, 15% -). The clearest negative impact was on research aspects of the fellowship (0% +, 67%-). Other effects on the program were either null (clinical aspects and faculty morale) or moderately negative (educational, administrative, and financial aspects and the position of the program director), with few effects on the geriatrics division as a whole. Overall, the 1-year option was felt to have adversely affected geriatrics as a respected professional field (11% +, 41% -). Nevertheless, the majority (61%) answered that introduction of the 1-year option was wise. Although not attributed to this training pathway, program directors overwhelmingly perceived (75 % +) that geriatrics has enjoyed enhanced strength and attractiveness as a discipline since introduction of the 1-year option in 1992. CONCLUSIONS: The 1-year geriatric fellowship option has, at best, proved a mixed blessing to program directors. However, optimism regarding the future would seem to justify continuing to offer this option because of several observations and trends: (1) the increase in quantity and also perhaps quality of applicants; (2) growth in numbers of fellows and higher percentage program fill rates; (3) success of both 1- and two-year fellows in passing the Certificate of Added Qualifications examination and consequent increased generation of certified fellowship-trained geriatricians; (4) strong sentiment that geriatrics is gaining strength and attractiveness; and (5) that introduction of the 1-year option was wise.

Aging kidneys in an aging population: how does this impact nephrology and nephrologists?

The 'demographic imperative' of a progressively aging society will place unprecedented demands on the health care system in the 21st century. Although improved education, public health measures, personal lifestyles, and health care will result in a large proportion of those born surviving to old age in robust health and vitality, the sheer numbers of 'baby-boomers' who will become the elderly and the inevitable association between aging and the associated multiple, especially chronic diseases and physiological impairments of old age will require more efficient and more effective systems of health care to meet the needs of the aging population. Generalists, specialists, and medical and surgical subspecialists will play important roles in meeting these needs, often in the multidisciplinary mode. Geriatricians will directly provide but a small minority of the care, focusing upon education, research, and consultation and in delivering primary care to the frail elderly and especially in long term care. Collaboration with subspecialists will be frequent in all these domains. Nephrologists, who already practice multidisciplinary team care of frail, complicated, chronically ill patients with end-stage renal disease, have much to contribute as their patient population progressively grows in numbers and age. Hence geriatricians and nephrologists have much to learn from and contribute to each other in addressing the 'age wave' of the 21st century.

Ways to make "usual" and "successful" aging synonymous. Preventive gerontology.

Preventive gerontology is the study and practice of those elements of lifestyle, environment, and health care management that will provide the maximal longevity of highest quality for individuals and the population. As such, it focuses on a personalized hygiene agenda that varies in its emphasis according to a person's age, sex, and risk factor profile. It includes a matrix of strategies relating to diet, exercise, and the avoidance of substance abuse and adverse environmental exposure. Preventive gerontology carries differential emphases according to the life stage of a person, featuring long-term, low-cost, and low-risk lifestyle strategies in youth and middle age (generally to age 75) and more short-term, low-risk interventions in old age (> 75), especially secondary prevention, according to individualized estimates of risk, cost, and benefit. The aggregate effect of widespread application of this approach--especially insofar as it is coupled with a rising level of education and continued psychosocial development--will be progressive congruency between usual and successful aging. A by-product will also be an ever-advancing median age of the population and, inevitably, a growth in long-term health and social service needs. Responsible planning for this consequence of success in the 21st century will require a rededication of North Americans to care for those in need regardless of age.