Towards Clinical Excellence in Geriatrics | Sunday Observer

Towards Clinical Excellence in Geriatrics

Diseases in elderly are very non specific. They have multiple non communicable and degenerative diseases and are on multiple medications. An interdisciplinary/multidisciplinary approach is an absolute necessity to manage these complex problems.

The recently concluded Academic sessions of the Sri Lanka Association of Geriatric Medicine at which Director General of Health Services Dr Jayasundara Bandara was the Chief Guest and Dr Lalith Wijerathne, Consultant Rheumatologist and the Founder of the Association was Guest of Honour, has reiterated the need for a holistic approach to manage the complex problems of the elderly. Speakers emphasized that an inter- disciplinary approach was an absolute necessity to manage the complex physical, social and psychological problems of the elderly. They explained that delivery of care by an interdisciplinary team consisting essentially of a Geriatrician/physician, nurse, physiotherapist, occupational therapist and a social worker would offer the long overdue need to provide a comprehensive package to the elderly. Other members such as, dieticians, speech and language therapists, podiatrist, tissue viability nurse would be useful to care for these elderly patients.

Elderly care in Sri Lanka has up to now received a step motherly treatment, considering the rapidly growing aging population in the country and the limited investments by both, state and private sector to improve their quality of life.

The Sunday Observer spoke to the President of the Sri Lanka Geriatrics Association, Chairman of the Specialty Board in Geriatric Medicine and Consultant Physician, Colombo South Teaching Hospital, Kalubowila, Dr Dilhar Samaraweera for more insights into this long neglected field and his views on how existing gaps could be filled.


Q.When Elders’ Day was observed recently the focus was on Participation of Older Persons in the Society. Can you explain the theme of the International Elders’ Day this year.

A. The theme of the International Day of older persons this year was, “Stepping into the Future: Tapping the Talents, Contributions and Participation of Older Persons in Society”. This year’s theme is about enabling and expanding the contribution by the elderly to their families, community and society at large.

It focuses on the pathways that support full and effective participation in old age, in accordance with older persons’ basic rights, needs and preferences, The elderly have contributed to the development of the economy, culture, and society. Their talents have been unrecognized and underappreciated.

The 2017 theme will explore effective means of promoting and strengthening the participation of older persons in various aspects of social, cultural, economic, civic and political life.

Q.The theme of the 3rd Academic sessions was different, You chose “Clinical Excellence in Geriatrics” Could you explain.

A. Geriatric Medicine is a relatively new specialty. The Postgraduate Institute of Medicine initiated the Diploma in Elderly Medicine, and already four batches have passed out. The MD in Geriatric Medicine is on the brink of starting. The elderly population is rising rapidly in the country. Thus all Health personnel need to master the technique of managing the elderly. The Association will strive to achieve clinical excellence in Geriatrics to deliver quality care for the elderly.

Q. Since your Association was formed in 2014, you have spearheaded several innovative projects for the elderly. Tell us briefly what they are, and what your mission and vision is?

A. The Sri Lanka Association of Geriatric Medicine was launched in February, 2014. The vision of our Association is to ensure active healthy ageing in Sri Lanka. Our Mission is to ensure promotion of geriatric education among the medical fraternity and the public in order to facilitate the development of an elderly friendly environment in health care institutions and the community.

This year’s theme of the International Day of Older Persons is in keeping with our vision ensuring an active healthy ageing. The first Academic sessions of the Sri Lanka Association of Geriatric Medicine was held in November 2014. The theme of our inaugural Sessions in 2014 was “Towards Clinical Excellence in Geriatrics.”

In 2015 we held the second Academic sessions attended by resource persons from India, United Kingdom, Australia, Singapore and France. The theme of the sessions was “Clinical Excellence in Geriatrics”.

In 2016 the focus was on community services and capacity building rather than academic events. An exhibition and workshop on “Ageing and Aged Care” was organized for the elderly and held at the Sri Lanka Foundation in October 2016.

The exhibition and workshop was a great success with over 500 participants from Elders societies in the Western Province and the general public.

Many teaching programs for doctors , nurses and allied health staff were held in various parts of the island with the participation of a specially invited Consultant Geriatrician Dr Duncan Forsyth who volunteered to assist the teaching program. The Association also actively involved with the “Maha Jana Suwa Dhana” Public Health Exhibition held in July 2017 to commemorate the Golden Jubilee year of the Ceylon College of Physicians, with an innovative stall to educate the elderly, particularly, on falls, mobility and Dementia.

This year we held the third Academic Sessions of the Association on November 16 and 17. The theme was “Towards Clinical Excellence in Geriatrics” The theme of our Academic sessions is in keeping with the mission of the Association.

The cultural show which featured the talents of the elderly was a highlight of the ceremony.

Q. What is the link between the theme for this year and the quality of life and geriatric services in the world and in Sri Lanka, in particular?

A. The objective of the Geriatric services globally is to improve quality of life and achieve active healthy ageing. Universal Health Coverage (UHC) for all, at all ages, is the foundation for achieving the health objectives of the Sustainable Development Goals.

This is the focus of WHO’s celebration of the International Day of Older Persons 2017. In Sri Lanka the focus has been to promote health and provide social and financial support to the elderly with various programs conducted by the National Secretariat for elders and the Ministry of Health. The development of infrastructure to make hospitals elderly friendly has been initiated.

Q. With an aging population rapidly growing, and expected to hit 20 percent of the population in Sri Lanka by 2039, the country needs to gear towards an elders friendly environment. Compared to other fast developing countries, how would you rate Sri Lanka in this respect?

A. A national action plan on elderly services has already been developed and future activities focused accordingly.

The National Elderly Health Policy was launched in February 2017, together with an Elderly Health Care Delivery Plan by the Ministry of Health. The establishment of elderly friendly wards is a prioritized activity of the national program on elderly care under the purview of the Directorate of the Youth, Elderly and Disabled persons(YED) of the Ministry of Health.

The Health system in the country needs to be reoriented to meet the demands of the rapidly ageing population.

Re orienting the health system needs to pay attention to the following key segments: Strengthening health promotion and prevention to ensure a better quality of life of the remaining life in elderly persons; integrate management of primary prevention and primary care for the elderly using the maternal and child health network in the community; increase public funding on improving the infrastructure of the hospitals and expanding the intermediate care facilities for the elderly; promoting education and research in elderly care.

Q In what age group does an elderly person fall into?

A. Elderly group is considered to be over 60 years of age

Q. What are the main problems associated with old age?

A. .Mental Health problems of the elderly.

The Psychological well being of a person consists of self esteem, self worth new learning and healthy relationships and not merely the absence of mental disorder. Mental health problems common in old age are: Dementia Delirium Depression; organic mood disorders and organic delusional disorders; additional factors that influence mental illness in old age; sedentary lifestyle; shift from suburban extended family living to complex nuclear family living; change in social contact, burden of care falls on a few people often a single child

Physical problems in the elderly

Increased prevalence of NCD, e.g. Ischaemic heart disease, Hypertension, Diabetes Mellitus, Malignancies.

Impairment of hearing, vision

Problems with gait, balance and falls.

Incontinence of bladder and bowels.

Poor nutritional status.

Osteoarthritis Impairment of activities of

daily living Osteoporosis

Q. Are they different from elders living in urban environments and those in rural environments? Why?

A. Yes, elders living in the rural environments live in their own villages with extended family. Thus they are unlikely to experience, loneliness, isolation, depression. The physical problems in urban and rural communities are similar.

Q. Do you see a spike in age related problems in the recent past?

A. Age related problems are being increasingly detected due to increased awareness of problems and care of the elderly among the medical fraternity. There is also an increase in age related problems due to the rapidly ageing population of the country.

Q. What key factors have triggered these problems ? Could you elaborate on some of these problems that have been caused by recent intrusions into our lives e.g. high technology, in ternal migration, breakdown of extended family units, rise in divorces, neglect of family values and parental bonds – how far have these contributed to the fact that so many of our elders are now living alone without help?

A. There has been a paradigm shift from increased prevalence of non communicable diseases to communicable diseases. The development of infrastructure facilities and equity in health care resulted in a decrease in communicable diseases. A few decades ago many people died of infections like malaria, dysentery and other infections.

The change in lifestyle diet also has contributed to the increased incidence of non communicable diseases. More and more people are surviving and live into old age due to advanced treatment of myocardial infarction, stroke and other diseases.

Q. What do you feel are the most formidable health impacts geriatrics must face in their twilight years? Elaborate.

A. As we grow old our muscles and bones become weak. The result is poor mobility, which further leads to regression of bones leading to osteoporosis, and falls and fractures which result in restriction of movement and even in death. Impairment in memory leading to dementia, cognitive impairment and other mood disorders which occur as a result of isolation of elders also leads to a reduction of our functional abilities. Sensory problems such as, hearing and vision deficiencies further complicate lives of the elderly. It is important to correct sensory impairments which enable the elderly to actively participate in family and social activities.

Sensory problems should not be taken for granted in elderly. Being physically and mentally active and engagement in social activities will enable the elderly to delay dementia and reduced mobility and falls.

Q. Home care is still the most common type of care given to elderly persons , by family, neighbours, friends. Still there is a lot to be said about gaps in such care which is often done without proper knowledge of the person’s illness – e.g stroke victims sent home from hospital or a heart patient sent back for home care after surgery. Your comments?

A. Home care and support at home is indeed a necessity, especially, in managing chronic non communicable diseases and diseases needing rehabilitation. Patients are being prematurely discharged due to pressure of beds in hospital wards. Thus, physiotherapy, rehabilitation has to done in the patients’ homes. As we do not have community rehabilitation facilities the informal caregivers in patients’ homes play a pivotal role in managing these elderly patients who need intermediate to long-term care.

Q. What is the role of palliative care in helping geriatric patients?

A. As we grow old diseases tend to accumulate. It is called the cumulative effect. In particular non communicable diseases tend to accumulate in the elderly.

The older persons could have life limiting and life threatening illnesses. When they are encountered with life limiting illnesses for which cure is not an option, palliative care has to be offered.

The goal of palliative care is to improve the patient’s quality of life, by alleviating suffering and providing relief to the patient’s problems in the physical, psychological, social and spiritual domains.

Palliative care gives a support system to the patient to live as actively as possible during the course of the illness. It offers a support system to the family to cope during this difficult period, as well as during bereavement.

Palliative care is considered as a human right and is offered in the management of cancer and non cancer related diseases.