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Introduction

The demographic changes in the United States with its increase in people

over age 65, both in absolute numbers and as a percentage of the population,

has great importance to many aspects of American life. Before World War II

the major changes which increased longevity were better sanitation and public

health measures. Since World War II the changes have been largely the effects

of new treatments of individual patients. In this issue we consider changes

over the past 50 years which have increased both longevity and the quality of

life for older people. As could be anticipated, new problems arise from suc-

cesses, and some of these will be addressed. Since most readers will now or

later fall into the category of older patients, the subject matter crosses all

specialties of the Washington Academy of Sciences.

Kingsley M. Stevens

Guest Editor

Journal of the Washington Academy of Sciences,

Volume 79, Number 4, Pages 147-152, December 1989

Why Geriatrics?

William S. Zirker

Geriatric Medicine Section

Veterans Administration Medical Center, Northport, New York

and

Department of Medicine

State University of New York at Stony Brook

ABSTRACT

Americans are growing increasingly older. Over the next 50 years we expect a significant

growth in the segment of the population over age 65. This will present unprecedented

challenges to our social, economic and health care institutions. Geriatrics, a relatively

new field in American medicine, focuses on the health problems of the elderly.

While the maximum human life span of some 100 years has not changed

over the course of time, it is quite clear that the number of individuals living

into old age has increased dramatically. During the twentieth century alone

the average life expectancy of Americans has gone from 47 years in 1900 to

73 years in 1980.' Environmental, social and medical advances in such areas

as sanitation, nutrition, health behaviors, infant mortality, antibiotics, surgical

techniques and cardiac care are known to have contributed to this remarkable

increase in life expectancy. Demographic data show that by 1990, 32 million

Americans, or 12.7% of the population will be 65 years of age and older. By

the year 2030 the expectation is that approximately 20% of American pop-

ulation will be 65 and over.?”

Among our aging population, the group over 85 years old is proportionately

increasing at the greatest rate. Currently there are some 2.7 million people

over the age of 85 and this group is predicted to double in size by the end of

the century. Since the 1960’s there has been a strong downward trend in the

mortality rates for the very elderly in western society. Between 1933 and 1966,

the death rate in the U.S. for those over 85 years old had declined only 10%.

In contrast, the death rate for this group declined 26% between 1966 and

1977. It appears that reductions in the risk of dying from heart diseases and

stroke may account for a substantial part of this change. If current trends

continue, by the year 2050 half of all American may live to age 85.*

147

148 WILLIAM S. ZIRKER

While the majority of older Americans enjoy relatively good health and

independence, they clearly have a much higher incidence of disease and dis-

ability. Heart disease, stroke, arthritis, cancer, diabetes and obstructive lung

disease are all for the most part diseases of the elderly. In a health survey

performed in the city of Uppsala, Sweden by Waern,° the prevalence of varieus

diseases for 50 versus 60 year old men revealed 5 times more circulatory

diseases, 10 times more musculoskeletal disorders, 8 times more diabetes,

respiratory diseases and cancer, 4 times as many nervous diseases and twice

the number of mental disorders among the older as compared to the younger

age group. The incidence of dementia, depression, hip and vertebral fracture

rates, urinary incontinence, and malnutrition all increase significantly with

age. Along with this high incidence of disease comes a high incidence of

disability and the need for more medical, nursing, rehabilitative, home care

and nursing home care. A number of health surveys have estimated the prev-

alence of disability to be from 3% to 18% of people between the ages of 65

to 74 years old, and from 6% to 50% of those above the age of 75.° Currently

there are more nursing home beds than acute hospital beds, and those over

65 years old have a 20% chance of being admitted to a nursing home during

the remainder of their life time.

With this weight of disease and disability it is easy to see why the elderly

consume more health care services than their numbers alone suggest. Pres-

ently, the 12% of the population over the age of 65 utilizes 40% of all acute

hospital beds, 25% of prescription drugs, and accounts for 30% of the nation’s

health care expenditures and half of all federal health dollars.’ By the end of

the century half of all health care encounters will be with patients 65 and over.

These overwhelming demographic changes challenging our health, social,

economic and political institutions have been referred to as the “geriatric

imperative”. Given this imperative one would have expected the American

academic medical community to have championed the cause of geriatrics and

gerontology, and to have produced a large cadre of clinicians and researchers

interested in geriatrics. In spite of the need this has not happened, and for

most medical students and postgraduate physicians in training there is little if

any formal training in geriatrics. This is particularly ironic since it was Ignatz

Nascher, an American pathologist, who is credited with coining the term

geriatrics in his 1914 text book Geriatrics: The Diseases of Old Age and Their

Treatment. But today, some 75 years later, the study of geriatrics is still new

to American medicine.

In Great Britain the importance of geriatrics has been formalized by it’s

recognition as a medical specialty. There are established academic depart-

ments in half of the medical schools, formal curricula in 93% ,* postgraduate

specialty training in geriatrics, hospitals specializing in the care of the elderly,

and certification and consultant status for physicians trained in geriatrics.

Geriatrics developed in Great Britain in the 1930’s when Dr. Marjory War-

ren and several other physicians began to take an active interest in the patients

on the long term care wards of the hospitals. They came to appreciate that

there was much to learn from these chronically ill and frail elderly patients

whose problems had been viewed as beyond the scope of medical practice.

These were patients with severe strokes, dementias, neurological disorders,

WHY GERIATRICS? 149

and other chronic disabling diseases who had often been viewed as medical

failures. It was from this attempt to uncover previously overlooked medical

problems and to find practical approaches to dealing with the disabilities

imposed by chronic diseases that the field of geriatrics grew in the United

Kingdom.

In the United States modern academic medicine has concerned itself largely

with basic science research and technological development. We have been

fascinated by high technology topics such as lasers, coronary by-pass surgery,

magnetic resonance imaging, monoclonal antibodies, and gene splicing.

It is only in recent years that American medicine has begun to address

geriatrics.

In reaction to the demographics of aging it has been the political and social

leaders, and a few evangelical senior academic physicians who have pushed

for the academic medical community to take an interest in aging.

One of the most important events in the development of American geriatrics

was the passage of the 1974 Research on Aging Act authorizing the estab-

lishment of the National Institute of Aging as one of the National Institutes

of Health. The NIA has become a leader in the effort to get geriatrics into

the mainstream of American medicine. During the past decade there has been

significant growth in geriatrics. A number of medical schools and hospitals

have established divisions of geriatrics with clinical and research faculty, and

fellowship training programs. In 1988 the first examination for special com-

petency in geriatrics was given jointly by the American Board of Internal

Medicine and the American Board of Family Medicine. The vast majority of

those taking the exam were practicing physicians without formal training in

geriatrics.

Kane’, in a 1980 Rand Corporation study of geriatric manpower needs,

estimated that in order to have enough geriatricians just for academic positions

and as consultants in practice, we would currently need about 8000 specialty

trained physicians. Several surveys of physician members of the American

Geriatrics Society and the Gerontological Society of America have estimated

the number of physicians who consider themselves geriatricians to be in the

range of 750 to 1200, and only a quarter of these could be considered as full

time academic faculty. In 1987 there were 66 geriatric medicine fellowship

programs graduating approximately 100 trained geriatricians per year.* It is

clear that these numbers fall far short of what is needed if geriatrics is to be

established as significant presence in American medicine. The training of

geriatricians has been severely limited by program funding, number of pro-

grams, availability of faculty and dearth of qualified applicants. The problem

of recruiting physicians to train in geriatrics is difficult because of a lack of

exposure to formal geriatrics during medical school and residency, negative

steroetype images of the elderly, and comparatively low Medicare reimburse-

ment for the time consuming physician visits which are typically needed in

evaluating elderly patients.

The argument has been made that since physicians (especially internists)

who treat adults treat a large number of elderly patients, there is no need for

geriatrics as a specialty area. But just as there are significant anatomic, phys-

iologic and clinical differences between children and adults, there are signif-

150 WILLIAM S. ZIRKER

icant differences between 40 year old and 80 year old.” Important physiologic

and functional changes occur in most organ systems with aging. While it has

often been difficult for researchers studying the biology of aging to differentiate

normal age related changes from disease related changes, a number of sig-

nificant age related changes have been identified. The heart and lungs are two

organs systems which illustrate age related changes and their clinical signifi-

cance.

In the heart there are sclerotic and calcific changes which occur principally

in the high wear areas of the aortic and mitral valves. These may lead to aortic

stenosis and mitral insufficiency. Calcification also occurs in the electrical

conduction system of the heart and may lead to abnormalities in heart rhythm.

The pacemaker cells of the heart are reduced both in number and rate of

firing and there is slowed conduction through the heart’s electrical conduction

system. There is a reduction in response to adrenergic stimulation. Although

it is unclear whether this reduced response is because of a decline in the

number or function of the receptors, the result is seen in the increased sen-

sitivity of elderly individuals to antagonist medications such as beta-adrenergic

blockers and channel blockers. Physiologically healthy older people have been

found to have decreases in maximum stroke volume, cardiac output, oxygen

uptake, and maximum heart rate in response to exercise.

The respiratory system shows some of the greatest age related changes. The

chest wall becomes increasingly more rigid and less compliant. The lungs lose

elasticity and there are fewer alveoli to effect gas exchange which results both

in ventilation perfusion mismatching and reduced gas diffusing capacity. While

total lung capacity remains relatively constant with age, residual lung volume

increases and there are marked decreases in airflow rates which become most

prominent in response to exercise. Lung defenses are also altered by reduced

cough force, impairments in mucocillary cleaning of the upper airways, and

the response of macrophages, lymphocytes and neutrophils to bacteria and

other antigens. The result of these changes, compounded in many cases by

smoking and environmental pollutants, leads to the increased incidence of

pneumonia and chronic obstruction pulmonary disease in the elderly. How-

ever, in spite of this decreasing respiratory capability, training and conditioning

can result in high levels of fitness.

While research into the biology and physiology of aging is key to the future

development of geriatrics and gerontology as a discipline and scientific data

base, it has been in the clinical arena that geriatrics has been most active and

faces it’s greatest challenges. The elderly and the frail elderly in particular

have their own set of rather unique problems which are rarely well addressed

by the mainstream of medicine. In addition to the high incidence of the diseases

mentioned above, there is a high incidence of gait disorders, falls, urinary

incontinence, dementia, depression, delirium, hearing and visual loss, skin

pressure ulcers, osteoporosis, adverse drug reactions, excessive medication

use, psycho-social dysfunction and ethical treatment dilemmas. A number of

these problems are frequently overlooked, and for many there is no clear and

effective therapy.

WHY GERIATRICS? 151

Urinary incontinence serves as a good example of such a problem. It is a

major health problem of the elderly estimated to affect 10 million American

adults and conservatively costing 10 billion of dollars per year"! in home,

hospital and nursing home expenses. It is a disruptive disorder which can lead

to urosepsis, falls, rashes, skin breakdown, social isolation, embarrassment,

loss of independence and often to nursing home placement. Although several

studies have demonstrated that combined medical and behavioral therapy

predicated on specific diagnosis can be effective in yielding a number of pa-

tients either continent or substantially drier, most patients receive no system-

atic evaluation. In a 1987 study of incontinent health related nursing home

patients, Zirker’* found that although these patients had been incontinent an

average of two years, only 16% had ever received a systematic evaluation to

diagnose the problem. After medical and functional assessments, half of the

patients were clinically improved using behavioral techniques and drug ther-

apy. However, in order to carry out such a program the combined efforts of

physicians, nurses, social workers, and physical therapists were required.

In an attempt to deal with such complex problems and disabilities, geriatrics

has recognized the need to go beyond the traditional medical model of disease.

For many chronic diseases such as diabetes and stroke, it is the resulting

disability, rather than the disease itself, which diminishes the quality of life.

While organ damage cannot usually be reversed, the functional disabilities

and quality of life can frequently be improved through physical therapies and

nursing care. Geriatrics has employed batteries of cognitive and functional

assessment tools, and interdisciplinary teams of health professionals to eval-

uate and coordinate the care of frail elderly patients. It is from this perspective

that the concept of geriatric assessment teams and geriatric evaluation units

for both inpatients and outpatients has grown. The Veterans Administra-

tion has been a leader in geriatrics and has established many such units.

The purposes of these units is to evaluate frail elderly patients, uncover prev-

iously overlooked diagnoses, dementias and psychiatric disorders, provide

medical, nursing and rehabilitative care, and coordinate services so that,

whenever possible, patients could return home. Although the goals and

basis for such units appears to be sound, their cost effectiveness remains to

be proven.

Conclusion

To provide good quality care for frail elderly patients is clearly an expensive

and very labor intensive activity. From the demographics of aging it is obvious

that there will be increasing need for hospital, nursing home, outpatient and

home care services. Given the “geriatric imperative’, it is logical to develop

geriatrics into a field of medicine capable of producing researchers, teachers

and clinicians, who can provide the leadership needed to meet this challenge.

152

11.

12;

WILLIAM S. ZIRKER

References Cited

. Rowe, J. W., R. W. Besidine. 1982. Health and Disease in Old Age. Little, Brown, and Company,

Boston.

. U.S. Bureau of Census, July 1977. Series P-25, No. 704.

. Office of Technology Assessment. June 1985. Technology and aging in America. US Congress,

OTA-BA-264, Washington, D.C.

. Report of the Institute of Medicine. 1987. Academic geriatrics for the year 2000. J. Amer. Geriatrics

Soc. 35: 773-791.

. Waern U. 1978. Health and disease at the age of sixty. Uppsala Journal of Medical Sciences. 83: 153-

166.

. Bourliere, F. & J. Vallert-Massan. 1985. Epidemiology and ecology of aging. In Brocklehurst, J. C.

Textbook of Geriatric Medicine and Gerontology. Churchill Livingstone, Edinburgh. pp. 3-28.

. Gibson, R. M. & C. R. Fischer. December 1978. Age differences in health care spending, FY 1977.

HCFA Health Note.

. Barker, W. H. 1989. Adding Life to Years. The Johns Hopkins University Press, Baltimore. pp. 87-

100.

. Kane, R., D. Solomon, J. Beck, E. Keeler, & R. Kane. 1980. The future need for geriatric manpower

in the United States. N Engl J Med 302: 1327-1332.

. Beck, J. C. 1985. Development of pediatrics and family practice from a historical perspective: lesions

for geriatrics. J. Amer. Geriatrics Soc. Vol 33, No. 10:727-729.

National Institutes of Health. 1988. Consensus Development Statement, Urinary incontinence in adults.

Vol. 7, No. 5.

Zirker, W. S., R. Kennedy, K. Freeman. 1988. Evaluating and treating urinary incontinence in the

nursing home. Proceedings of the American Geriatric Society/ American Federation of Aging Research

Annual Meeting, Anaheim, CA.

Journal of the Washington Academy of Sciences,

Volume 79, Number 4, Pages 153-158, December 1989

Where Technology Fails

Kingsley M. Stevens, Linda O’Connor, Barbara Cartabuke-Mule,

Louise Hueppe, Sue Carlson, Madeline Fox and the Staff

of the 9A Hospice

Veterans Administration Medical Center,

Northport, New York 11768

ABSTRACT

While medical science has made amazing progress over the past half-century, clinical

applications have fully solved only a small number of diseases. Hence blind application

of all of our technology not only will not halt these diseases but will produce many

complications, medical and otherwise. In our society, the individual patient should make

his own informed decisions on how much technology is appropriate for him. These de-

cisions are needed for specific medical situations and for more general areas such as ““Do

not resuscitate orders” and “‘hospice”’ care.

One hundred and forty years ago, a prominent Boston physician vividly

presented a central concept for geriatrics. His presentation was non-medical,

but highly appropriate. Oliver Wendell Holmes, in ““The Deacon’s Master-

piece” or ““The One-Hoss Shay,” described a chaise which lasted without

repairs for 100 years to the day, then disintegrated. One section goes like this:

Now in building of chaises, I tell you what,

There is always somewhere a weakest spot,

In hub, tire, felloe, in spring or thill,

In panel, or crossbar, or floor or sill,

In screw, bolt, thoroughbrace, lurking still,

Find it somewhere you must and will,

Above or below, or within or without,

And that’s the reason, beyond a doubt,

A chaise breaks down, but doesn’t wear out.

This is certainly the way to live in old age! Holmes picked a time span for

the chaise of 100 years, the actual life span attained by a few people, so the

analogy as an ideal is realistic and probably intentional. It has often been

stated that an objective in geriatric care is to “‘add life to the years, not years

to the life.”” This emphasizes the concept of functional ability even though it

may be at the expense of a longer life span.

153

154 KINGSLEY M. STEVENS ET AL

The objective of the deacon, so well carried out, was to have the chaise

remain integrally sound for a long time and then collapse in toto. No one is

really expecting medical technology to provide people with functional integrity

for 100 years and then suddenly die. The preceding papers have briefly de-

scribed ways in which medical and dental programs have helped older people

approach this goal. The key to this progress has been technology and Jennett

has written a good overview of high technology.' If the advances enabling

patients to retain or regain full function had kept pace with the advancing

longevity, the impact of technology would be overwhelmingly beneficial. This

has not happened. Technology is much more successful at making precise

diagnoses and at keeping people alive than in restoring them to full function.

Consider those polar extremes. At one end are the prosthetic devices such as

eyeglasses and contact lenses. They are tremendously effective and enable

users to be almost 100% functionally effective in vision. However, they do

not cure the visual defect and they are a nuisance. The decision on the benefit

is clear; the technology should be, and is, extensively used. At the other

extreme is the demented patient who has had several strokes and is kept alive

for years on respirator, feeding tube and antibiotics. The technology is “‘ef-

fective” but of negative value. Hence this technology should not be used, but

itis used. The United States leads the world in the percentage of its population

who are over age 85. While many of this group are highly functional, far too

large a number lead a vegetative existence due to technology. These examples

are extremes and most technological applications will not offer such clear

choices.

The development and application of medical technology follows a certain

sequence. First, the question is raised as to whether a certain procedure or

effect can be carried out. Research and development follow which provide

a “‘yes” answer. Once available to physicians, the approach is “Since it is

available, it may be desirable to use it.”’ Soon this changes to “If it can be

done, it should be done.”’ Usage expands and, all too soon, the stage of the

technological imperative has arrived which says, “If it can be done, it MUST

be done.”’ There are, of course, clear medical contraindications to diagnostic

and therapeutic interventions. Yet the overwhelming pressure is toward the

technological imperative. To some degree, it comes from patients and families.

But in the United States the major players are the medical profession, which

is extremely technologically oriented, and the legal profession, which often

appears ready to turn any omission of a diagnostic or treatment procedure

into a malpractice claim. Hence in this country, medical care runs largely on

the technological imperative.

Application of technology will increase longevity and American courts have

often ruled that length of life is vastly more important than any other consid-

eration. The desires of the spouse and other family members are usually

ignored by courts; the only person who can say “‘no”’ is the patient. Court

rulings throughout the United States in both state and federal courts have

established the right of a competent patient to accept or refuse any type of

treatment or life support system. This position is basically sound, but often a

formerly competent person is not competent when the decision concerning

WHERE TECHNOLOGY FAILS 155

his care must be made. Emphasis on self-determination then turns from an

asset to a liability, since many courts will not accept “‘substituted judgment”’

by the patient’s representative.” In operational terms, this means that even if

you felt very strongly that you did not want to exist in a severely disabled

state, you might well be forced by law to exist in that state for many years.

The answer to this problem is by writing a “‘living will” or “‘advance direc-

tive” which specifies in reasonable detail what you do or do not want and

under what circumstances. Since certain states refuse to accept tube feedings

as a medical treatment, it is very important to specify that you refuse forced

feeding by tubes or intravenous methods under certain circumstances. How-

ever, no advance directive can be both broad enough yet contain enough

specifics to cover the large range of actual situations which may arise. Hence

you should also complete a form often titled “‘Durable power of attorney for

designation of health care agent.’ The individual(s) so designated will make

specific medical decisions consistent with the general provisions of your ad-

vance directive. Both documents should have witnesses and be notarized.

Neither of these documents are fully accepted by all states. Irrespective of

their “official”? status, they demonstrate clearly that you have considered this

problem and reached definite conclusions and that the individual selected to

make decisions knows of your wishes and expects decisions to be made along

the lines you determined when competent.’

Important as they are, such advance planning does not in itself resolve

ongoing medical decisions which we all face in varying degrees. The pervasive

technological imperative will be urging us on. How does one make a logical

decision? As a scientist, the reader knows that the way to make medical

decisions is to obtain the needed facts and be able to interpret them. Faith in

technology often dominates the facts on technology: Consider the facts about

cardiopulmonary resuscitation (CPR) and do not resuscitate orders (DNR).

The application of effective CPR using electrical defibrillation began in 1962

with patients who had acute heart attacks who were on EKG monitors. Many

had episodes of cardiac arythymmias, some of which were ventricular fibril-

lation producing cardiac arrest. These patients were essentially dead, but about

half of them resumed cardiac function following CPR. Since the patients were

constantly monitored, CPR began within seconds of the arrest. Here we have

the original technological advance with appropriate application under specific

conditions. Its application under these circumstances quickly spread. Soon it

was being used on non-monitored cardiac patients as well; then on non-cardiac

patients. Malpractice suits soon emerged when patients died from any cause

and were not given CPR; this vastly increased the numbers of patients who

received CPR. By the 1980s most patients who had a cardiac arrest when in

a hospital received CPR unless they specifically requested a DNR order. The

technology of CPR had clearly reached the state of the technological imper-

ative. It could be done and it was done. That was not the end. In New York

State, the legislature passed a DNR law so that doctors could be absolved

from liability if they withheld CPR under defined conditions. These were

highly defined conditions: The order could only be written for terminal pa-

tients, it had to be reviewed every three days and there were other strictures.

156 KINGSLEY M. STEVENS ET AL

Since the law specified what was required so as not to be liable, it in effect

also specified that if the doctor did not provide CPR when a DNR order was

not in place, then he may be liable. Hence since 1988, a technological medical

procedure has been demanded by state law.

State laws may require other technological procedures such as immunization

against certain diseases before entering grade school. The above terse history

covering 26 years would certainly imply that CPR was an extremely valuable

technology which should be widely utilized. But how effective is CPR? For

the type of patients for which it was developed, about 30% of those receiving

CPR leave the hospital alive. For other groups, the results are much less

successful. Many will have cardiac function partially restored but few will

leave the hospital alive. The time lapse from cardiac arrest to defibrillation

is extremely important, with much higher survivals when the time is less than

three minutes. Patients who have sepsis, pneumonia, cancer and renal failure

have almost no survivors from CPR and older patients, as a group, fare very

poorly.** The facts on CPR today are that most patients receiving CPR attain

only added misery. The rigidity of legal requirements makes it very difficult

to apply this valuable technology as it should be applied.

An escape from the technological imperative can be by use of palliative and

“hospice” type programs. The shift in emphasis is to couple length of life

more closely with the quality of life. The technological imperative, in practice

if not in theory, almost invariably comes out favoring length of life over quality

of life, so leads to frenetic activity to the very end. This does not happen in

the hospice type programs in the United States.

The need for an “escape hatch” from current mainstream medical practice

is due to society’s views on two subjects: Liability litigation and refusal to

accept death. True malpractice certainly exists, but the number of malpractice

suits filed in the U.S. is totally out of line with actual malpractice. These

charges are so frequent that a doctor is almost forced to act as though every

episode of illness he treats must be treated as though he will be sued. A

malpractice lawyer might claim this is as it should be. It is not. This approach

is incredibly expensive for society. At the individual level, each patient is

forced to undergo all that technology can muster, often repetitively. American

views on death set the stage for the American scene. Our society does not

accept death as part of the natural order. Our society also has great faith in

technology (even though society is not infrequently very anti-scientific!) The

combination demands that medicine see death as the ultimate enemy and

technology the way to defeat death. Given American views on litigation and

death, it is small wonder that physicians as a group do everything possible to

extend life, no matter what. Many social trends have shaped this view toward

death. Low death rates, most people dying in hospitals and widely scattered

families, all make death unfamiliar to Americans. In addition, Americans

traditionally take the view that everything can be improved, so everything

should be tried to forestall death. Yet in 1989, as it has for billions of years,

death comes to every living organism.

The need for a haven from the dominant societal pressure for frenetic

activity to the very end is all too real. That need has not been adequately met

WHERE TECHNOLOGY FAILS 157

but the hospice concept of care is spreading and there are now about 2,000

hospice programs in the U.S. The patient accepts that there is no more specific

treatment which might cure or arrest his progressive disease. The patient

desires to be free of pain and have his other symptoms controlled so that he

can continue to maintain maximum independence and maximum social inter-

actions until he dies. These goals are surprisingly hard to meet in both acute

hospitals and nursing homes. For most hospice programs, the patients is not

expected to survive over six months. Because of the nature of the disease,

cancer patients make up the large majority of hospice patients. But certain

patients with advanced heart, lung or liver disease, and those with advanced

AIDS are also appropriate.

The term “‘hospice” as used in medieval Europe often referred to rest houses

supported by religious groups where pilgrims, en route to an important reli-

gious site, could find food, lodging, rest and some nursing care. Refreshed

and remotivated, the pilgrims continued their journey. Today, as then, the

hospice is a way-station, a place of rest and relaxation for the sick as they

travel to the end of their personal journey. The involvement of third-party

payers had led to rigid definitions of their requirements for a hospice. It is

ironic that both federal and state regulations define hospices as being primarily

an “‘at home” function, while in the original definition the pilgrim was far

from home. Since hospice care is a concept of care, the term is appropriate

whether the care is given primarily in the home or in a hospital or other

institution. Home-based programs utilize many community volunteers which

enhances this type of hospice program and the home model is the ideal type.

The National Hospice Organization (U.S.) has prepared this definition:

Hospice is a medically directed, nurse coordinated program providing a

continuum of home and inpatient care for the terminally ill patient and

family. It employs an interdisciplinary team acting under the direction of an

autonomous hospice administration. The program provides palliative and

supportive care to meet the special needs arising out of the physical, emo-

tional, spiritual, social and economic stresses which are experienced during

the final stages of illness and during dying and bereavement.

Since death is the expected outcome for hospice patients, the staff does not

view death as representing failure. The staff is well satisfied if they can provide

a good quality of life leading to an easy death. If the person can come to

terms with his death and find renewed support from family members, some

previously alienated, so much the better. The team spends much time with

family members to reach the objectives. The nurse, especially, must play

multiple roles. She or he needs to know current technical options, although

the nurse may not apply many of them. The nurse needs to understand the

steps of adjusting to death and dying and interact with the patient as he works

his way through the process. Team members need time to listen and talk with

the patient far more than happens for most patients today. ‘Standard pro-

tocols” are often inappropriate for hospice patients and nurse and physician

must be ingenious and flexible in developing individual solutions to promote

physical and emotional comfort. All this should be done with the patient

158 KINGSLEY M. STEVENS ET AL

actively participating in decision making. A sense of humor is especially helpful

in hospice-type programs. These programs can lead to surprisingly contented

patients despite their destructive diseases; visitors to our hospice often com-

ment on the cheerful appearance of our patients.

Conclusions:

is;

Medical technology has two sides. While designed to decrease disability and suf-

fering, at times technology increases both of these.

The technological imperative is prevalent in this country and often inappropriate.

Some of its negative effects can be countered by the preparation of “‘living wills”

and ‘durable power of attorney” documents.

. For many terminally ill patients, a hospice-type setting will provide superior care

to an acute hospital.

References Cited

. Jennett, B. 1986. High Technology Medicine. Oxford University Press, Oxford.

. NY. State Court of Appeals. 1988. Matter of Westchester County Medical Center (O’Connor), 72 N.Y

2d 517, October 14.

. Society for the Right to Die. The Physician and the Hopelessly Ill Patient, New York, and the 1988

Supplement.

. Peatfield, R. C., R. W. Sillett, D. Taylor and M. W. McNicol. 1977. Survival after cardiac arrest in the

hospital. Lancet 1: 1223-1225.

. Bedell, S. E., T. L. Delbanco, E. F. Cook and F. H. Epstein. 1983. Survival after cardiopulmonary

resuscitation in the hospital. New Eng. J. Med. 309: 569-575.

. Rozenbaum, E. A. and L. Shenkman. 1988. Predicting outcome of inhospital cardiopulmonary resus-

citation. Crit. Care Med. 16: 583-586

. Taffet, G. E., T. A. Teasdale and R. J. Luchi. 1988. Inhospital cardiopulmonary resuscitation. J. Amer.

Med. Assoc. 260: 2069-2072.

. Murphy, D. J., A. M. Murray, B. E. Robinson and E. W. Campion. 1989. Outcomes of cardiopulmonary

resuscitation in the elderly. Ann. Int. Med. 111: 199-205.

Journal of the Washington Academy of Sciences,

Volume 79, Number 4, Pages 159-169, December 1989

Antibiotics and the Older Patient

Kingsley M. Stevens

Geriatrics Section, Medical Service,

VA Medical Center, Northport, N.Y. 11768

and

Dept. of Medicine,

State University of New York at Stony Brook

ABSTRACT

Effective antibiotics were introduced in 1935 and the field has expanded steadily since

then. Their application has influenced almost every aspect of medicine, either directly or

indirectly. Because of this pervasive aspect, antibiotics have been the most important

single determinant of improved medical care for older patients over the past half century.

In the 1980s, the bacteria causing most infections in hospitalized patients are not classical

pathogens but normal flora growing in abnormal locations. This had led to widespread

use of antibiotics active against many species of normal flora; this extensive usage has led

to the emergence of many resistant strains of bacteria. Approaches to lessen damage to

normal flora and also decrease the development of resistant microbes are presented.

Use of Antibiotics

Statistics on the causes of death in the United States are available over the

1900-1985 period.'* These data are not directly comparable over time due to

changes in classification, changing age distribution and improved diagnostics.

Despite these factors, the major trends are clear. It will be a surprise for many

to find that not only today, but even in 1900, the largest cause of death was

cardiovascular. After that, however, the 1900 picture was dominated by in-

fectious deaths: Pneumonia, influenza, tuberculosis, enteric infections, diph-

theria, measles. By 1935 the frequencies of all these diseases had fallen,

especially the enteric infections. Although the death rate for syphilis had not

changed greatly from 1900, in 1935 it was among the top ten causes of death.

In 1985 the overall death rate was 874/100,000 population. Heart disease

accounted for 37%, cancer for 22%, stroke for 7% and chronic obstructive

lung disease for 4%. The only infectious disease producing more than 1% of

159

160 KINGSLEY M. STEVENS

deaths was pneumonia, listed at 3%.* From these mortality data, it would

appear that bacterial infections are not now a major problem as causes of

death. The amounts of antibiotics used today are immense and at great cost.

What have antibiotics done, how are they being used today and what appears

ahead?

Social changes, better hygiene and sanitary engineering were the major

causes of decreases in tuberculosis and enteric infections produced by Sal-

monella and Shigella species. However, antibiotics have effectively treated

most of those cases which did develop. Antibiotics have been highly effective

against pneumococcal pneumonia, streptococcal infections, gonorrhea, men-

ingitis and syphilis. They have cured innumerable cases of bacterial infections

of the lungs, bladder and other internal organs. Antiseptic technics made

major surgery possible and remain a critical requirement. Nevertheless, an-

tibiotics have also greatly increased the ability to carry out surgery on patients

formerly considered at too high risk. They have also provided effective treat-

ment of local and systemic infections which occur following surgery.

Drug treatment of rickettsial infections such as typhus and Rocky Mountain

Spotted Fever works well but drug treatment for viral infections is still prim-

itive. However, antibiotics have played a major role in the development of

viral vaccines. The major technical problem for such development was ob-

taining large supplies of purified virus. Some viruses, such as influenza virus,

could be grown in adequate quantities in chick embryos although purification

remained a problem. But most viruses required the development of tissue

culture technics. These were begun by Alexis Carrel before World War I and

were successful at the laboratory level because of his extreme methods of

maintaining sterile conditions. However, commercial development was im-

possible without antibiotics. Addition of antibiotics to the medium prevented

destruction of the tissue culture cells by the ubiquitous contaminants. This

led directly to viral vaccines, both killed and attenuated.

When organ transplantation began, there was need to depress the immune

system to prevent rejection of the transplant unless it was from an identical

twin. We now have very effective immunosuppressive drugs, but they could

not be used if antibiotics were not available. Chemotherapy of most forms of

cancer is widely used in the United States. Since these drugs almost invariable

depress host responses to infections, their use also depends on antibiotics.

The Antibiotics

We have presented the successes of antibiotics without any consideration

of their history, how they act and how the bacteria react. The word “antibiotic”’

is defined as ‘“‘a substance produced by a microorganism and able in dilute

solution to inhibit or kill another microorganism.” It is now over a half century

since the first really satisfactory antimicrobial drug was introduced. That was

in 1935 and the drug was an azo dye named Prontosil. The azo dyes containing

a sulfa nucleus were developed by the I.G. Farbenindustrie as dyes which

bound very tightly to the proteins of wool and silk. Their synthesis began in

1909 and soon afterwards it was suggested that these dyes might also bind

ANTIBIOTICS AND THE OLDER PATIENT 161

tightly to bacterial proteins and thereby inactivate them. Twenty-five years

passed before Domagk demonstrated that mice would be protected from ex-

perimental streptococcal infections with Prontosil. Soon after, French workers

found that in mice and other mammals the azo bond was cleaved and the

active agent was sulfanilamide, shown below:

ANS COO

We now know that the mode of action of sulfa drugs is not by binding of

bacterial proteins but by competitive inhibition of para-amino benzoic acid

(PABA), shown below:

EN 0) -se.NE,

PABA is one of three major precursors of the vitamin folic acid. Sulfa drugs

inhibit those microbes which must synthesize folic acid as they have no trans-

port mechanism whereby extracellular folic acid could be taken into the cell.

The first true antibiotic was penicillin and its history is well known. Although

Fleming described its antibacterial effects in 1929, the instability of penicillin

and the small amounts produced delayed commercial production until these

problems were solved by British and American teams in World War II. The

toxicity of penicillin G is so low that the lethal effect of huge doses is due to

the cation in the salt, potassium or sodium. This pharmacological inertness

for mammalian cells reflects penicillin action on cell walls, which mammalian

cells lack.

Since the “‘antibiotic era’”’ began, between 5,000 and 10,000 natural anti-

biotics have been described and between 50,000 and 100,000 semi-synthetic

analogues have been made! Yet fewer than 150 antibiotics are available com-

mercially in the United States. In 1986, 29 of these were naturally occuring

with the remainder being either partially or totally synthesized.’ Antibiotics

can be grouped by mode of action, shown in Table 1:

Table 1.—Major antibacterial agents.

Mode of action Examples

Inhibition of cell wall synthesis All penicillins

All cephalosporins

Vancomycin

Inhibition of nucleic acid synthesis Quinolones

(e.g. nalidixic acid, ciprofloxacin)

Inhibitors of ribosome function Streptomycin

Gentamicin

Tetracycline

Erythromycin

Inhibitors of folate metabolism Sulfa drugs

Trimethoprin

162 KINGSLEY M. STEVENS

The penicillins and the cephalosporins have been the least toxic of the

antibiotics and they share a B-lactam ring, the active group, which is labeled

‘‘A”’ in the structural formulae.

General Formulae

Penicillin Cephalosporin

KH Ras aa

COOH N R

ah)

COOH

These two groups of antibiotics, plus new groups called the carbapenems

and the monobactams, comprise the B-lactam antibiotics. The B-lactams dom-

inate development work in antibiotics. Cephalosporins have greater changes

in activity than penicillins when side chains are modified. The mode of action

of all B-lactam antibiotics is the same. The bacterial cell wall is synthesized

by enzymes on the cell membrane. The B-lactam ring, on interacting with a

specific bacterial membrane bound peptidase, opens at the site of the arrow

and binds to the enzyme, inactivating the enzyme and thereby halting cell

wall synthesis.‘

Bacterial Infections Today

The general concept of a bacterial infection in 1935 was that you “caught

it” from another person, as occurs today with such minor virus infections as

colds or a major one such as AIDS. Pneumococcal pneumonia, streptococcal

sore throats, scarlet fever, diphtheria, whooping cough, gonorrhea, syphilis

and local infections with Staphylococcus aureus followed this pattern. These

still occur, but in much smaller numbers, and in 1989, the bacteria we deal

with in hospitals are primarily the opportunistic normal flora of man. Normal

flora are those species found on skin and in the respiratory, digestive systems

and the genital tract in a high percentage of normal people. These bacteria

rarely produce disease in people without risk factors. Yet these- bacteria now

comprise the vast majority of isolations from hospitalized patients who,

through debilitation or various treatments, become at high risk for infection.

Many of the strains are not “‘caught”’ from another person; they are from the

normal flora of the infected patient, with the bacteria now growing in an

abnormal site. The bacterial groups and culture sites appear in Table 2.

ANTIBIOTICS AND THE OLDER PATIENT 163

Table 2.— Bacterial isolations in the clinical microbiology laboratory at the Northport VA Medical Center

during 1988.

No. of Normal

Bacterial Type isolates location Cultured from

Enteric bacteria 2484 Colon

Pseudomonas sp. 520 urine >sputum>wounds/abcesses

Escherichia coli 503 4 urine >wounds/abscesses>blood

Enterococci 490 t ‘ 4 :

Proteus sp. 279 i ‘ " >sputum

Other gram-neg bacilli 692 : f , r

Staphylococcus aureus 685 Nose wounds/abscesses>sputum>nose

Staphylococcus 314 Skin blood>urine>wounds/ abscesses

coagulase negative

8-streptococci 158 Upper resp. tract wounds/abscesses>sputum>throat

Pneumococcus 72 i sputum>blood

Hemophilus sp. 71 f sputum>throat

The isolates were predominantly normal enteric bacteria found in other lo-

cations. Staphylococcus aureus has always been a prominent pathogen? es-

pecially of wounds and abscesses. The Staphylococcus coagulase-negative

group primarily represent S. epidermidis, the universally abundant normal

skin microbe. But it also includes S. saprophyticus, found in bladder infections

and other newly defined species.° In the past, blood cultures which grew out

S. epidermidis usually represented contamination from the skin. In contrast,

many positive blood cultures today represent true bacteremias by this orga-

nism.’ This marked change in pathogenicity is due to two factors. Staphylo-

coccus epidermidis colonizes foreign bodies very effectively, rarely establishing

itself internally without a foreign body as a primary site. The number of foreign

bodies used today is extensive: Permanent ones, such as prosthetic joints and

heart valves, vascular grafts, pacemakers, cerebrospinal fluid shunts, perito-

neal dialysis catheters, and temporary intravascular catheters which now con-

stitute almost routine care.” The other major change is that S. epidermidis,

formerly sensitive to penicillin and many other antibiotics is now often resistent

to not only penicillin but to many other antibiotics also.° This brings us to the

problem of antibiotic resistance.

Antibiotic Resistance

Microbial resistance was first noted in 1913 when Paul Ehrlich reported that

certain strains of trypanosomes were not killed by usually lethal concentrations

of a dye, and these strains did not take up the dye. Biochemical studies on

the basis of antibiotic resistance began with penicillin, with the penicillin-

destroying enzyme, penicillinase, being described even before penicillin was

used clinically!® Strains of $. aureus produced this enzyme which was later

shown to cleave the B-lactam ring. Beta-lactamases have been isolated from

many species but none from pneumococci or B-hemolytic streptococci, which

therefore remain highly sensitive to penicillin. For S. aureus, however, pen-

164 KINGSLEY M. STEVENS

icillinase production has become the normal with 93% of our hospital strains

doing so and 83% of community strains.’

By altering side chains near the active site of the B-lactam ring, penicillins

resistant to penicillinase action have been produced. The first commercially

successful one was methicillin, marketed in 1960. But even before being used,

methicillin-resistant Staphylococcus aureus (MRSA) strains had been found.’

These MRSA strains were first noted in England and spread rapidly in Europe

with 34% of strains being MRSA in Denmark in 1968. However, by 1980,

the percentage of such strains in Denmark had fallen to 2%" and fell to <1%

in 1986."' Australian hospitals reached peak MRSA values of about 35% in

1982,’* which figure was not attained in Italy until 1987.'* Emergence of MRSA

strains began in the U.S. in 1967 with waxing and waning in different areas.

In our hospital, the percentage of MRSA strains stayed between 10 and 20%

from 1981 through 1987. In 1988 there was an abrupt rise to 42% which

in 1989 is beginning to fall. The actual 1988 percentage of resistant strains

was probably nearer 35%, the maximum figure found elsewhere, since the

42% figure included large numbers of cultures taken specifically to trace the

spread of MRSA. Epidemic strains have been described'* and such sud-

den fluctuations probably reflect introduction of such strains. As others have

found'*!° these MRSA strains are often multiply resistant. Our 1988 results

showed the following percentages of MRSA strains resistant to: Cephalothin

42%, clindamycin 41%, erythromycin 48% and gentamicin 35%. Very little

resistance was found to the heavily restricted drugs chloramphenicol (3%)

and vancomycin (0%) or to the new drug ciprofloxacin (3%). The older

trimethoprim/sulfamethoxazole combination showed 20% resistant strains.

These drugs represent all major modes of action (Table 1). Hence, many

different biochemical changes, directed by DNA, have taken place in these

resistant bacteria. Many of these mechanisms have not been thoroughly

worked out but Neu* presents much current information.

As noted earlier, S. epidermidis has developed multiple resistance, overall

more so than S. aureus.°? Our 1988 figures confirm this, with 70% of S.

epidermidis isolates from foreign body sources being resistant to oxacillin

(methicillin equivalent), 70% to cephalothin, 58% to clindamycin, 68% to

erythromycin and 57% to gentamicin. Aside from vancomycin, the S. epi-

dermidis are much more often resistant to those antibiotics now most often

active against S. aureaus: Chloramphenicol with 22% of S. epidermidis isolates

resistant vs 3% S. aureus, ciprofloxacin, 12% vs 3%, trimethoprim/sulfa-

methoxazole, 51% vs 20%. The primary drug used to treat these multiply

resistant staphylococci of both species is vancomycin. This antibiotic was 1so-

lated 30 years ago but has been little used due to toxicity and cost. Although

vancomycin inhibits cell wall synthesis, it does so by direct attachment to a

cell wall chain during synthesis, preventing completion of the chain.'’ Recently

a strain of S$. epidermidis has shown vancomycin resistance.'* To date, no

strains of S. aureus are vancomycin resistant’ but it is probably only a matter

of time before some appear.

Bacterial resistance to antibiotics is genetically determined but through two

mechanisms. Chromosomal mutations are the normal genetic mechanism for

ANTIBIOTICS AND THE OLDER PATIENT 165

all types of cells, including bacteria. But much of bacterial resistance is trans-

mitted by DNA outside the chromosome in particles called plasmids. Spread

by this mechanism can be much more rapid than by chromosomal mutation

since the plasmids can be taken up by other bacteria, sometimes even of

different species. Although spread by plasmids is more rapid than through

chromosomal transmission, it is less stable. Bacteria contain a chromosome

but lack a nuclear membrane. Hence incorporation of information from cy-

toplasmic DNA into the genome is not infrequent. In the staphylococci, the

production of penicillinase was originally plasmid directed but it is now in-

corporated in the genome of most strains. Methicillin resistance was also

plasmid linked, but it too appears incorporated into the genome in certain

strains} )°.?

Resistance to penicillin and ampicillin is present in about 90% of both

staphylococcal species in our hospital isolates. Since antibacterial agents active

against penicillinase producing staphylococci are very widely used in hospitals,

why have the methicillin resistant strains of $. aureus peaked at about 35%

and those of S. epidermidis at 70%? To answer this, we must first address

another question: Do MRSA strains produce more or less severe disease than

methicillin-sensitive strains (MSSA)? No study presents MRSA as producing

more severe disease but several reports claim that MRSA and MSSA are

equally virulent.'*'*!° Clinical studies of such infections cannot have controls,

so animal studies are important. The best such study was by Peacock et al’

who isolated two MSSA and one MRSA strain from patients and determined

relative virulence for them plus an American Type Culture Collection standard

strain. Using both intravenous and intraperitoneal injections into mice, they

found no marked differences amongst the strains. Despite this, most reports

and reviews consider MRSA and other resistant bacteria less virulent than

sensitive strains.”'’?! Relative frequencies of MRSA compared to MSSA

strains in specific infections also support the greater virulence of the sensitive

strains: The ratio of MSSA/MRSA in 39 cases of complications of bacteremia

was 12:1,” the ratio in 22 cases of bacteremia in AIDS patients was 11:1,”

in 400 cases of S. aureus bacteremia the ratio was 133:1!** Even when MRSA

cases are specifically reported, the number are small: A pediatric study cov-

ering seven years recorded only 20 cases, primarily from intravascular

catheters’® as is found with the normally non-pathogenic S. epidermidis. A

report on MRSA in pulmonary cases presented only nine cases.”

The reason that multiply resistant bacteria have not more extensively re-

placed sensitive bacteria and are, overall, of lower virulence, appears due to

the fact that they do not grow as well.*'*?!“° The acquisition and maintenance

of resistance factors will increase the energy requirements of the bacterial cell

compared to the “‘wild”’ (sensitive) type. Hence, unless the selective pressure

of the specific antibiotic is constantly present, the plasmid or the chromosomal

mutation will be lost'’’’ as the sensitive type is subjected to positive selection

by its faster growth rate.

Production of bacteria resistant to most antibiotics is fairly easy in the

laboratory by growing the bacteria in increasing concentrations of the anti-

biotic. Under such circumstances, the bacterium is grown in its ideal medium

166 KINGSLEY M. STEVENS

with the only restraining influence being the antibiotic. The selective condi-

tions in clinical situations are very different. The antibiotic concentration is

widely variable in place and time. Perhaps more importantly, the many host

resistance factors and the geneal biochemical mileau of the host will often

select positively for the sensitive strain while the antibiotic is selecting posi-

tively for the resistant strain. Particularly if isolates from a large number of

hospitals are pooled, it may appear that there is almost no increased resistance

from the use of antibiotics.** Due to the factors noted in this and the preceding

paragraph, resistant strains are always in a state of flux. It is clear that clinical

use of antibiotics does increase resistance.*”? Our hospital laboratory followed

resistances of three species to three different B-lactam antibiotics over the

1981-1988 period. S. aureus tested against oxacillin showed 8% resistant

strains in 1981 which rose to 17% in 1982. It remained between 10 and 20%

until 1988 when it rose to 42%. Escherichia coli in 1981 had 20% of strains

resistant to ampicillin. This rose to 50% in 1984 but fell to 30% in 1986 and

has remained there. Pseudomonas sp tested against ceftaxime had only 8%

resistant strains in 1981 which showed little increase through 1983. The figure

then began to rise so that in 1988, 66% of strains were resistant.

As was noted earlier, methicillin-resistant $. aureus peak at about 35% of

the total strains while S. epidermidis reaches about 70%. This large difference

probably reflects the additive effects of two factors. Since S. epidermidis col-

onizes everyone, staff and patients alike, the pool for new mutants and plas-

mids is much greater. The vast quantities of antibiotics used in most hospitals

ensure that all people spending long hours on a hospital unit will have much

skin exposure to antibiotics. In addition, the skin has fewer immune systems

at work than the wounds and abcesses where S. aureus abounds.

Antibiotics and the Older Patient

Although this heading is the title of the article, so far we have dealt with

general features of antibiotics, microbes and patients without regard to age.

In actual clinical practice, patients over age 65 largely determine the course

of events in antibiotic use. Not only are their numbers rapidly increasing but

they are the group with repeated hospitalizations. Catheters, especially urinary

catheters, are much more frequently used in this group. They populate the

nursing homes which are rife with resistant bacteria.“” Carcinomas are more

frequent over age 65 and most types increase linearly with age.

The medical-pharmaceutical complex is at war with the normal flora of man.

The resources on both sides are formidable. The result is an antibiotic race

which is certainly advantageous to the antibiotic manufacturers. The three

synergistic weapons of the bacteria are their universal presence, their genetic

variability’? and their incredible growth rates. Common gram-positive and

gram-negative bacteria can replicate as rapidly as every 20 minutes in standard

media in vitro. This means that in 12 hours a single bactertum could produce

10" progeny!

ANTIBIOTICS AND THE OLDER PATIENT 167

Physicians tend to treat defined infections and most often use “broad spec-

trum” antibiotics; not infrequently two or even three at the same time. Al-

though each is chosen for a specific “‘coverage,”’ nonetheless all have wide

spectra. Hence, with such treatment, almost all of the hundreds of billions of

bacteria which constitute the normal flora of that patient—dozens of spe-

cies—are subjected to selection for resistance to each of the antibiotics. Med-

icine uses many foreign body devices which in themselves turn normal flora

into pathogens. Increasing resistance develops in certain bacterial groups. A

- manufacturer introduces a new antibiotic highly active against these resistant

organisms. Sales soar due to extensive use which occurs despite attempts to

restrict use. Since resistant strains grow more slowly, they are also less sus-

ceptible to bacteriolytic antibiotics, thereby often requiring longer to clear.

This increases the number of mutants to the new drug. A prime example of

such indolent growth was that of a vancomycin resistant S. epidermidis, grow-

ing intraperitoneally, which persisted for 14 weeks! without either killing the

patient or disappearing.’®

A Modus vivendi—Is It Possible?

While “‘classical’’ bacterial infections still exist and are treated effectively

with antibiotics, most bacterial infections seen in hospitals today are produced

by common bacteria which were infrequent opportunistic pathogens when

antibiotic use began half-century ago. When a classical contagious bacterial

disease is under treatment, the objective is to eradicate the alien invader. But

if that bacterium is part of the host’s common normal flora, it can only be

eliminated on a transient basis and then from ‘‘abnormal”’ sites where it nor-

mally does not grow. From the preceding sections and other sources, we

develop the following principles regarding bacterial resistance to antibiotics:

1. The normal flora in a healthy individual represents a stable but dynamic equilibrium

and should be altered as little as possible.

2. The indigenous antibiotic resistances of the normal flora are their most stable form.

3. Foreign bodies of all kinds increase the invasive potential of normal flora.

4. Contact between a specific antibiotic and a sensitive population of bacterial cells

will promote proliferation of those bacterial cells resistant to the antibiotic.

5. Such induced resistant strains will tend to regain their native sensitivities if left

unexposed to antibiotics over several generations.

6. The dosage of an antibiotic and its length of use will directly correlate with selection

of resistant strains of bacteria which are not the target strain of the treatment

program. (E.g.: A patient has a symptomatic urinary tract infection and the or-

ganism and sensitivities are known. Dosage with an appropriate antibiotic could

vary from 500 mg every 12 hours for five days to 1 g every eight hours for ten

days. For this and other situations, the higher dosage schedule would make it less

likely that the targeted bacterium would develop resistance and more likely that

the infection would be completely cleared. But that same higher dosage and longer

time would produce a larger antibiotic gradient and longer time of exposure to

every bacterium in his body, wherever located.)

168 KINGSLEY M. STEVENS

. In the hospital setting, antibiotics are not given only to the patient. The greater

the use, the greater the distribution of antibiotics throughout the unit at low levels

to staff and other patients by air and hand spread.

From these principles, one may formulate principles of antibiotic use de-

signed to diminish emergence of antibiotic resistance:

Do not use antibiotics at all unless the need is clear. This has too many aspects to

discuss here. A main point is that.a “‘positive’’ bacterial culture, per se, is not an

indication to administer antibiotics.

Foreign bodies should be used as sparingly as possible and removed as soon as

possible. This includes simple devices used to give intravenous fluids and urinary

catheters.

. When antibiotics are used, it must be realized that multiple antibiotics, high dosages

and long courses are the most effective way to increase resistant strains of all types.

Adherence to good handwashing practices and to standard aseptic technics to

prevent spread of resistant strains is extremely important.

. Unless restricted antibiotics are really tightly restricted, a major purpose of re-

striction, i.e., to keep them highly effective, will always be lost.

Conclusions

In this article, the major emphasis has been on the development of resistance

by the normal flora to antibiotics. Antibiotics have indeed been a great boon.

However, their continued effectiveness will depend heavily upon more judi-

cious usage.

Acknowledgement

The data on Northport VA Medical Center bacterial isolations was gener-

ously provided by the Clinical Microbiology Laboratory (Dr. C. Saceanu,

Director). Typing was provided by Angela R. Wright.

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Journal of the Washington Academy of Sciences,

Volume 79, Number 4, Pages 170-179, December 1989

Dental Developments Over the

Past Fifty Years Which Affect the

Geriatric Patient

Saul Kamen

Parker Jewish Geriatric Institute, New Hyde Park, New York 11040

and

Paul Kornfeld

VA Medical Center, Northport, New York 11768

ABSTRACT

In the past half-century dentistry has changed from a narrow emphasis on the mechanics

of restoration of the dentition to the interrelationship between medical problems and oral

health. At the same time, the demographic imperatives of an aging population have given

rise to a new subdiscipline of the profession—geriatric dentistry, which may be defined

as oral health care for elderly persons, usually with multiple medical disorders, poly-

pharmaceutical regimens, and/or psychosocial problems which render them more vul-

nerable to dental intervention. This chapter will explore the impact of medical develop-

ments since World War II on the clinical management of geriatric dental patients.

Concomitantly it will describe refinements in our understanding of the normal and path-

ological effects of aging on the hard and soft tissues of the mouth. New technology with

special implications for geriatric oral rehabilitation, and which are relevant to total health

care, will be delineated. All of these factors have produced significant changes in the

epidemiology of dental disease in the elderly and have given us new insights into the

maintenance and preservation of the oral health of the elderly.

Introduction

Although dentists have always treated older patients, qualitative and quan-

titative changes in the past half century have resulted in the emergence of a

new subdiscipline of the profession—geriatric dentistry. This may be defined

as the delivery of oral health services to elderly patients, usually with at least

one major chronic disorder, frequently on polypharmaceutical regimens, and

170

DENTAL DEVELOPMENTS WHICH AFFECT THE GERIATRIC PATIENT 171

often with psychosocial problems, all of which render them more vulnerable

to stress in the environment.

With some exceptions the life span of patients with major diseases which

influence dental care has been increased, primarily because of effective med-

ical treatment. Thus, although degenerative disease of the cardiovascular sys-

tem is still the number one cause of death in the elderly (40% of all deaths

beyond 55 years), there has been a dramatic reduction in fatalities due to

ischemic heart disease in the past two decades. This is true for both sexes and

for whites and nonwhites over 65 years of age, and is demonstrated by the

fact that for white males in the 65—74 year cohort the mortality rate has fallen

from 2119 per 100,000 individuals in 1968 to 1642 per 100,000 in 1977.' This

decline in cardiovascular mortality is attributed to changes in lifestyle as well

as newer pharmacologic agents and surgical interventions.* This trend, of

course, is good news to potential victims of heart disease, but it also increases

the number of elderly patients at higher risk for dental treatment because of

pre-existing cardiac deficits and valvular heart prostheses who will require

antimicrobial prophylaxis prior to invasive procedures.

The Changing Epidemiology of Dental Disorders

A dramatic change in the oral health status of the U.S. population in the

past fifty years is demonstrated in a definitive epidemiological study reported

by the National Institute of Dental Research (NIDR) in 1986. It must be

contrasted with the fact that in the early 1940’s, ten percent of potential recruits

for the army in World War II were rejected because they could not meet the

requirement that they must have at least six opposing natural teeth in occlu-

sion. The NIDR study, entitled, ““The National Survey of Oral Health in U.S.

Employed Adults and Seniors: 1985-1986,” reported on the dental status of

21,000 adults ranging in age from 18 to 103 years—this sample being statis-

tically significant for 105 million people. It revealed an almost complete ab-

sence of edentulism (the loss of all teeth) in persons less than 40 years of age.

Additional findings were that only 4% of working adults under 65 years of

age were completely edentulous, and half of them had lost at most a single

tooth. This is indeed a tangible reflection of the benefits of dental research

in the prevention of dental disease and clinical practice in the past half century.

The survey, however, did not paint the same optimistic picture for many

older Americans who grew up before World War II and did not benefit from

programs of prevention. The 1985 study compared 16,000 working adults

under 65 years of age with 5,000 older patients in senior citizen centers and

other ambulatory elder care agencies. In the latter group, 42% are still ed-

entulous, a disturbing fact despite a reduction of 10% from previous studies

conducted in the early 1970’s. And although both groups demonstrate coronal

decay, i.e., occlusal or interproximal lesions, the older age group has three

times a higher incidence of cervical caries—decay occurring at the junction

of the crown and the gingiva (also called root surface caries) than the younger

group. Both groups showed a significant prevalance of periodontal disease—

172 SAUL KAMEN AND PAUL KORNFELD

inflammatory processes of the gingiva and supporting structures of the teeth,

with increasing severity in the older age group. Parenthetically, another NIDR

survey of children’s oral health in 1986-1987 brought the good news of a

dramatic decline in the caries rate in school children aged 5-17, a further sign

that Americans, in general, are experiencing better dental health than did

their predecessors in the first half of this century.’

Much of the progress reflected in these epidemiological statistics is a result

_of the changing focus in dental science from a narrow emphasis on the me-

chanical restoration of carious lesions and treatment of gum disease to a broad

understanding of the interrelationship between oral disease and the total health

status of the patient. While this is true for individuals of any age, it is partic-

ularly applicable to the elderly, who are more vulnerable to pathological effects

of aging on the hard and soft tissues of the mouth, as well as normal age-

related changes which result in regressive physiological decrements in function.

Research in aging in the past 40 years, furthermore has given us a new un-

derstanding of the impact of immunity and endocrine gland function on the

oral tissues, and the reciprocal relationship between oral health and systemic

disorders common in the elderly.

Salivary Function

Salivary function is too often ignored or underestimated as a factor in health

and comfort particularly in older people. On a cellular and tissue level it

involves the parotid, submandibular, and sublingual glands, as well as acinar

glands in the palatal and pharyngeal mucosa. Whole saliva and its enzymes

play essential roles in the following respects:

—a necessary lubricant for the mastication and swallowing of food

—a diluent for the taste sensations of sweet, bitter, salt, and sour

—comfort or discomfort, depending on the degree of dysfunction

—a natural detergent mechanism for the prevention of decay

—in remineralization of incipient carious lesions

—a liquid film essential for the retention of dentures

Xerostomia, dry mouth, impacts on all of these functions in varying degrees,

and results from four possible etiological factors: 1) anticholinergic medica-

tions, 2) chemotherapy, 3) radiation, 4) benign and malignant obstructions of

the salivary ducts. It has been estimated that 80-90% of drugs prescribed for

the elderly may have a xerostomic side effect.

We have recently refined our knowledge about the effects of aging on

salivary flow based on the results of a study of this oral function in the Bal-

timore VA Longitudinal Aging Investigation.* This study concluded that in a

large group of healthy, aging male veterans there was no significant reduction

in the quantity of salivary production. The universal application of this con-

clusion, however, is difficult to accept, for two reasons: 1) the study excluded

females, who are certainly more numerous and typical of the geriatric pop-

ulation, and 2) 81% of those over 65 years of age have at least one major

DENTAL DEVELOPMENTS WHICH AFFECT THE GERIATRIC PATIENT 173

chronic disorder, and a huge number of drugs consumed by the elderly have

known xerostomic (i.e., mouth-drying) side effects. In our experience, the

loss of intracellular water previously alluded to is implemented by the xeros-

tomic side effects to produce varying degrees of diminution of saliva and

mucous.”

The diagnosis of xerostomia is essentially made on a clinical base. There

are some sophisticated laboratory tests which can be utilized to confirm the

diagnosis, but these are usually employed to verify suspicion of an underlying

systemic disorder, such as Sjégren disease. When the physician or dentist

establishes a positive diagnosis, however, it is incumbent on the professional

to alert the patient and prescribe appropriate therapy, as follows:

—increase intake of water in the diet, e.g. soups

—change drugs to those with least anticholinergic side effects

—counsel patient in oral hygiene procedures, including fluoride dentifrices,

fluoridated mouth washes, and topical fluoride gels. This is best accom-

plished by the dental professional

—artificial saliva substitutes. These are now commercially manufactured

and available as over-the-counter items

—in extreme cases pilocarpine has been shown to oppose anticholinergic

drug effects and may be prescribed in slow-release capsule form. This

drug has possible adverse side effects when the patient is taking certain

drugs

—a 10 percent mixture of glycerin in distilled water, to be used as a mouth

wash.

Salivary gland dysfunction can result in significant morbidity and should not

be casually dismissed as a normal age-caused event. It should be carefully

evaluated and vigorously treated by the physician and/or the dentist.

Burning-mouth syndrome is a pathologic entity well recognized by oral

pathologists and frequently defies treatment. It occurs most commonly in post-

menopausal females and is considered to have a strong psychogenic component

in addition to causing glossodynia and glossopyrexia. Other etiologic factors

that have been implicated include estrogen imbalance, xerostomia, iron de-

ficiency, and malnutrition. The chief complaint is pain, either of the tongue

or in a more generalized pattern. The differential diagnosis should rule out

vitamin deficiency, (particularly B,,), iron deficiency anemia, pernicious ane-

mia, SjOgren syndrome, Mikulicz disease, and Plummer-Vinson syndrome.

Depression can also be a contributory factor, with the mouth as a focus of

somatization of a depressed mental affect.

Treatment consists first in the elimination of frank pathologic factors such

as concomitant lichen planus or candidiasis. Palliative agents include the use

of an artifiical saliva, now available as an over-the-counter oral rinse; a mouth-

wash consisting of equal parts of elixir of Benadryl® with Kaopectate®, with

instructions to expectorate after swishing over the tissues for one minute every

174 SAUL KAMEN AND PAUL KORNFELD

four hours and, for recalcitrant cases, 2% viscous xylocaine applied topically

every four hours.

The Impact of Oral Health on the Management of Geriatric Patients

The past fifty years have taught us that the impact of oral health on the

clinical management of geriatric patients can seriously compromise progress

and alter prognosis. Thus, poor masticatory function may thwart efforts to

provide nutritional support for the victim of a stroke, while noncompliance

with recommendations for antibiotic prophylaxis of the cardiac patient has

been identified as the chief etiologic factor in subacute bacterial endocarditis

following dental intervention. Because the vast majority of geriatric patients

have at least one major chronic disorder, the medical-dental interactions in

their care by both physicians and dentists demand scrupulous attention to the

effects of aging on oral function. As ever-increasing numbers of elderly are

integrated into dental practice, the physician will be called on more frequently

for advice on such diverse aspects of care as the drug profile of the patient

and possible contraindications for certain dental procedures; the use of sed-

ative agents to minimize stress or manage the patients with depression or

dementia, and management of the patient with iatrogenic oral manifestations.

Lessons from the research in the past two decades into dental diseases in

the elderly demonstrate many common denominators between medical and

oral conditions. The major medical-dental interactions in the compromised

older patient are described in Table I, as follows:

Table 1. Medical-Dental Interactions in the Elderly

Medical

Conditions Symptoms Dental Aspects Medical-Dental Interactions

Cardiovascular

disorders

Dyspnea; cyanosis; edema of Minimize apprehension and Consult with doctor regarding

Hypertension

extremities; tachycardia; bra-

dycardia; fatigue; nausea;

vomiting; anxiety; syncope;

thromboses.

Malignant: seizures; retinal

hemorrhages; papilledema;

proteinuria and renal failure.

Essential: Tachycardia; in-

creased cardiac output; head-

ache; sweating; nausea; anxi-

ety; glycosuria; left

ventricular failure; atheroma.

stress; avoid postural hypo-

tension; short appointments

preferable; defer elective

treatment for 6 months fol-

lowing acute myocardial in-

farction.

Patients are prone to stress and

anxiety; for diastolic pressure

over 110 do elective proce-

dures only; can tolerate ele-

vation of pressure better than

depression; avoid postural

hypotension; excessive post-

surgical bleeding possible.

antibiotic prophylaxis, sed-

atives, potentiated rauwol-

fia alkaloids, phenothia-

zines, and antihypertensive

drugs; epinephrine con-

traindicated in patients re-

ceiving monoamine oxidase

(MAO) inhibitors; long-

term digitalis therapy

makes patient prone to

nausea and vomiting; ob-

serve American Heart As-

sociation recommendations

for standard and special

regimens. *

For patients on reserpine

MAO inhibitors used a-

stimulators (e.g., Neo-Cob-

efrin) rather than epineph-

rine; barbiturates increase

CNS pressure; depression

may be secondary to neu-

roleptics; xerostomia a side

effect of drugs such as

methyldopa.

DENTAL DEVELOPMENTS WHICH AFFECT THE GERIATRIC PATIENT 175

Table 1.

(Continued )

Medical

Conditions

Symptoms

Dental Aspects

Medical-Dental Interactions

Cerebrovascular

accident

(CVA)

Diabetes

mellitus

Parkinsonism

Osteoporosis

Paget’s disease

SjOgren’s

syndrome

Carotid (anterior circulation):

contralateral weakness, dys-

phasia, apraxia, and confu-

sion, with dominant hemi-

sphere involvement; transient

ipsilateral monocular blind-

ness; homonymous visual

field defects; ipsilateral

throbbing headache.

Vertebral-basilar (posterior cir-

culation): dysarthria and dys-

phagia; vertigo, tinnitus, and

deafness; unilateral or bilat-

eral sensory-motor defects;

general imbalance with uni-

lateral limb ataxia; visual

field defects.

Glycosuria, polyuria, polydip-

sia; retinopathy; peripheral

vascular changes; periodontal

disease; ketosis and hyper-

glycemia (“‘brittle” diabetic).

Involuntary tremors; progres-

sive rigidity of extremities;

“cog-wheel” effect; masklike

facies; dysphasia, ptyalism.

Loss of 40% of mineral content

of bone; loss of bony matrix,

thin cortex, and large medul-

lary canals in x-rays.

Acromegaly: ‘‘woolly” appear-

ance of bone in skull x-rays;

high serum alkaline phospha-

tase.

Keratoconjunctivitis sicca; par-

otitis; buccopharyngolaryngi-

tis sicca; arthritis; xerosto-

mia.

Circumoral and neuromuscular

imbalance; dysphasia;

aphasia; adverse effect on

dentures; drooling; flexion of

the neck causes management

problems; hemiparesis leads

to poor oral hygiene.

Periodontal disease; lowered re-

sistance to infection; delayed

healing; prone to stress;

prone to irritations (as with

dentures); schedule patient in

AM following usual insulin

dose for routine care.

Bruxism; tongue thrust drool-

ing; slurred speech; problems

in deglutition and swallowing;

stress increases symptoms.

Loss of alveolar bone and loss

of teeth have been suggested.

Progressive enlargement of

maxilla and mandible; “‘flar-

ing” of teeth; dentures be-

come unstable.

Xerostomia; glosspyrexia

(“burning mouth” syn-

drome); increased incidence

of cervical caries; dysgeusia.

*Recommendations of the American Heart Association, Circulation, July, 1984.

From: Kamen, S: Current concepts in geriatric dentistry. In (Levine et al, eds. Current Treatment in Dental Practice.

W. B. Saunder Co. 1986), p. 394.

Inplantology in Geriatric Dentistry

Anticoagulant therapy in-

creases clotting time, af-

fecting oral surgery; pa-

tients are prone to stress;

monitor epinephrine in lo-

cal anesthetics; Demerol

(meperidine) increases in-

tracranial pressure; moni-

tor PT and PTT prior to

invasive dental procedures

if patient is on anticoagu-

lants.

Consult with dentist regard-

ing dose and type of insu-

lin; corticosteroids can

cause hyperglycemia; sug-

gest antibiotic prophylaxis

prior to oral surgery for

“brittle” diabetic.

Use of epinephrine in anes-

thetic agents may increase

stress; extrapyramidal reac-

tions to L-dopa lead to oro-

facial dyskinesia; atropine

causes increases in L-dopa

effect.

Potential benefits of fluoride

supplementation.

Patients often require psy-

chotherapy. in additon to

palliative treatment; if on

steroids will be more prone

to stress, periodontal dis-

ease, and delayed healing.

A major advance in the management of the atrophic mandible, a crippling

problem in the prosthetic rehabilitation of elderly patients, is the new tech-

nology of ridge augmentation inspired by developments in orthopedic surgery

in the past 20 years. Three methods have now been employed by oral surgeons

with varying degrees of success. The introduction of titanium subperiosteal

implants since the mid 1960’s was a great stride forward in meeting the chal-

lenge of the severely resorbed dental arch, but may be contraindicated in

176 SAUL KAMEN AND PAUL KORNFELD

patients with systemic disorders such as diabetes. A more recent innovation

is the use of hydroxylapatite, an artificial bony material which has been em-

ployed along with hip grafts to reconstruct the alveolar ridge. Most promising

however, is the result of a splendid collaboration between the Swedish or-

thopedist, Per-Ingvar Brannemark, and American oral surgeons in the de-

velopment of the osseo-integrated implant, a precisely engineered titanium

implant which is biocompatible with bone and has an excellent track record

of success for the past 20 years. This striking development is a testimonial to

a scientific accomplishment which is particularly beneficial to edentulous ger-

iatric patients.

One of the more recent developments in implantology particularly appro-

priate for relatively healthy elderly patients is the use of surgical alloys (ti-

tanium, titanium alloy and cobalt-chrome molybdenum alloy) coated with a

biocompatible hydroxylapatite (HA). This material has a strong degree of

adherence to the underlying metal over an extended period of time, and has

attractive properties for applications in prosthodontic and orthopedic den-

tistry. This has been demonstrated in both animals and humans to be a viable

materials system for biological fixation because the osteophyilic type surface

of the HA increases the rate of bony adaptation.°’ In humans, a three year

clinical follow-up of four hundred fifty seven HA coated implants placed in

130 patients for prosthetic restorations noted that osseous biointegration was

achieved in as early as eight weeks.*®

One of the promising developments in periodontal and prosthodontic re-

habilitation is the utilization of a new polymer called HTR (hard tissue

replacement) as a synthetic bone substitute. This material is a nonresorb-

able, microporous, synthetic bone grafting agent that combines a poly-

methylmethylacrylate core with a polyhydroxylethylmethacralate (poly-

hema) coating which produces a biocompatible composite without the ad-

dition of catalyst inducers or impurities. This HTR polymer is premixed

and packaged in a sterile unit ready to use.? The material has been

employed in periodontal surgery where it has proven successful in the

repair of osseous deficits and intrabony pockets, and in alveolar ridge re-

construction, in which it acts as a vehicle for a bone-inductive substance

that remodels the mandible by converting connective tissue to alveolar

bone se

Kamen has conducted histological in vitro studies which demonstrate the

kinetics and morphology of the attachment of human gingival fibroblasts to

HTR® polymer. Although he cautions against the interpolation of in vitro

findings to in vivo situations, he is quite optimistic that this material augments

connective tissue repair, promotes wound healing, and will be a valuable

addition to the armamentarium of periodontal and prosthodontic rehabilita-

tion.”

A major consideration in implantology, which has not as yet been adequately

addressed, is the feasibility of the use of these new materials in geriatric

patients with various disorders, and particularly the interface of artificial bone

substitutes with osseous tissue in patients with osteoporosis.

DENTAL DEVELOPMENTS WHICH AFFECT THE GERIATRIC PATIENT 177

Oral Rehabilitation

In the early 1970’s the use of polymethylmethylacrylate resins as an esthetic

material for the repair of carious lesions was dramatically enhanced by the

technique of acid etching of the enamel surface.'’ The teeth are cleaned with

flour of pumice, isolated with a rubber dam, and an unbuffered solution of

phosphoric acid is applied for one (1) minute. This procedure results in mi-

croporosities of the enamel surface which mechanically interlock with bis-

GMA composite resin tags. Retention of the restorative material is aided by

the use of a bonding agent—an unfilled resin of low viscosity which readily

penetrates the microscopic irregularities, and then chemically bonds with a

filled resin. An ultraviolet photocure unit (white light) is utilized to polymerize

the resin restorative materials, and offers the clinician adequate working time

for placement, contouring and polishing. Because people are living to an older

age and are retaining their natural teeth these esthetic materials are constantly

being perfected and are in ever increasing demand. Thus, a new resin called

a glass ionomer cement which bonds to dentin has been found to be more

appropriate for the common carious lesion affecting adult teeth-root surface

decay. Both erosion and carious defects are now restored with the glass io-

nomer cements. The advantages of these materials are their esthetic and

cosmetic appearance, superior retention, slow release of fluorides and pro-

tection against marginal leakage. Their durability remains to be tested in the

years ahead."

The therapeutic effect of fluorides on root and coronal caries in older adults

has been well documented in several studies. Banting and Stamm have com-

pared root caries prevalence in adults in fluoridated and nonfluoridated com-

munities in Canada, and confirm a dramatic reduction in carious lesions in

the fluoride protected subjects.’ Of even greater significance in geriatric oral

rehabilitation is the report of Nyvad and Fyerskov that incipient and active

root surface cavities can be arrested and rendered inactive with rigorous oral

hygiene utilizing fluoridated dentifrices and mouth washes.'*'’ The author

routinely recommends to his geriatric patients the daily application of a stan-

nous fluoride gel before retiring. In view of the technical difficulties in re-

pairing root surface caries the employment of preventive measures such as

these are certainly merited.

The beneficial effects of a sodium fluoride dentifrice was demonstrated in

a carefully controlled study of 810 subjects 54 years of age and older who

were living in 43 communities in Iowa without a fluoridated water supply.

The test dentifrice contained 1,100 ppm F as sodium fluoride, compared with

<1 ppm F in the control group. After one year there was a 41% reduction in

coronal caries and a 67% decrease in root surface caries.'®

The prime etiological factor in periodontal disease is the deposition of

plaque, an invisible film consisting of microorganism in a substrate of mucous

and carbohydrates, which results in a concatenation of events including gin-

givitis, gingival recession, pocket formation, 1.e., loss of gingival attachment,

and the loss of the supporting bony matrix of the tooth. Basic periodontal

178 SAUL KAMEN AND PAUL KORNFELD

therapy therefore, requires the elimination of infection and inflammation by

controlling caries and removing plaque on the coronal and root surfaces of

the teeth by scaling and root planing. Residual bony defects are then surgically

treated with the synthetic bone substitute.

Treatment of the Terminal Dentition

It has been estimated that 42 percent of all individuals over 65 years of age

in the U.S. are completely edentulous, 1.e., have lost all of their natural teeth.

Previously it was common practice to remove any remaining roots and tooth

fragments prior to fabrication of dentures. This often resulted in additional

atrophy and resorption of the alveolar ridges. It is now generally accepted

that the retention of these remnants preserves the integrity of the maxilla and

mandible, and aids in the function and stability of prosthetic appliances.” The

methods employed to retain these roots, and sometimes to bury them beneath

the alveolar mucosa, are highly technical and beyond the scope of this review,

but to a great extent have revolutionized prosthodontic rehabilitation, espe-

cially for the geriatric patient. The appliances constructed over these modified

roots are called overdentures, and have enormous advantages in maximizing

comfort and function.”” A sophisticated array of attachments, bars, and other

devices attached to the roots further enhance the stability of the overdenture,

and are increasingly being utilized by dental geriatricians. It is incumbent on

the patient to practice meticulous hygiene of these appliances and the physician

should reinforce the dentist’s instructions towards this goal. Desjardins has

stated that ‘“‘successful rehabilitation must also incorporate preventive and

maintenance care. To achieve a rehabilitation that cannot be maintained, and

which encourages development of additional disease, defies the goals and

objectives of the dental professions.”!

Conclusions

The experience of the past several decades posits that poor oral health can

have a domino effect on the total health status of the elderly patient, dimin-

ishing the quality of life and leading to metabolic imbalance, malnutrition,

anorexia, and cachexia. Thus, dental disease per se can significantly influence

the multiplicity of chronic illnesses that characterize the elderly, while at the

same time the medical disorders complicate the dental treatment. Although

today’s elderly are healthier than in the past, the very fact that they are living

well into their 80’s and 90’s means that they become more vulnerable to a

variety of chronic illnesses, including cardiovascular conditions, neurologic

disorders, metabolic deficiencies, Alzheimer disease, and other types of men-

tal impairment. These elderly patients are at high risk for dental intervention,

and the gerodontist will frequently consult the physician to discuss clinical

management.

DENTAL DEVELOPMENTS WHICH AFFECT THE GERIATRIC PATIENT 179

Acknowledgment

The authors wish to acknowledge, with appreciation, the technical assistance

of Kathryn Sisley in the preparation of this manuscript.

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Journal of the Washington Academy of Sciences,

Volume 79, Number 4, Pages 180-191, December 1989

Some Social, Scientific and

Technologic Changes in Medicine

from 1935 to the Present

Kingsley M. Stevens

Geriatrics Section, Medical Service, Veterans Administration Medical

Center, Northport, N.Y. 11768

and

Department of Medicine, State University of New York

at Stony Brook

ABSTRACT

Changes in the prevention and treatment since 1935 of the major causes of death and

disability in older people are discussed. Today, these major diseases are not infectious

diseases but chronic degenerative diseases and cancer. For individual patients, there have

been major improvements in several areas. Yet for society as a whole, the prevalence of

these diseases has greatly increased.

In the preceding article, we discussed antibiotics as the single most im-

portant medical advance since 1935. In this article, we will address some of

the many other changes which have occurred. For non-medical readers, a few

definitions are required. The “mortality rate” refers to the number of deaths

due to a certain cause per 100,000 population per year. When comparisons

are made where the demography may vary, it is necessary to correct for age.

For example, both heart disease and cancer are strongly correlated with age.

In 1935, the average age of the U.S. population was considerably younger

than in 1985. Uncorrected mortality rates for these diseases would therefore

show marked increases in 1985 compared with 1935 solely on the basis of the

demographic change. ‘‘Morbidity” refers to illness from a disease or other

cause. “Incidence”? means the number of cases recorded for the first time

during a given year while ‘‘prevalence”’ refers to the number of people ill with

a given disease during a year span. If a person developed chronic heart disease

in 1965 and died from it in 1985, he would be counted in the “incidence”’

statistics for 1965, in the ‘‘prevalence”’ statistics in each of the 20 years. He

would be recorded also in the morbidity statistics for each year and in the

mortality statistics for 1985.

180

CHANGES IN MEDICINE FROM 1935 TO THE PRESENT 181

The diseases discussed represent the major causes of death and disability

in 1985. Hence, many well-known diseases are not discussed or even men-

tioned; this does not imply that important new treatment methods have not

emerged for them over the half-century.

Tobacco Usage

From a medical viewpoint, the most important social change since 1935 has

been the shift in public support for smoking cigarettes. In America, this habit

became prominent among the military during World War I. It spread rapidly

among men and more slowly among women and by the early 1950s over 60%

of men were smokers. But in 1939, Oschner, an American thoracic surgeon,

reported that most of the patients with lung cancer which he saw were heavy

smokers of cigarettes. By 1964, enough data had accumulated on the multiple

adverse health effects of smoking for the Surgeon General of the Public Health

Service to issue his now famous first report on ““Smoking and Health.” Smok-

ing is far and away the most important preventable cause of serious disease

in the United States. In 1985, the overall mortality rate was 874 per 100,000

population. Of this total, 130 are estimated to be due to tobacco use. The

range by states is from 176 in the prominent tobacco state of Kentucky to a

low of 45 in the state of Utah with its large population of non-smoking Mor-

mans. Of the many effects of smoking,the most prominent are lung damage.

Almost every patient developing lung cancer receives extensive treatment with

all the types of treatment which offer any hope—surgery, radiation, chemo-

therapy with multiple drugs. Despite such intensive, high technology treat-

ments, five years after diagnosis 87% of lung cancer patients are dead. Lung

cancer usually develops in patients with chronic obstructive lung disease

(COPD), which includes emphysema and is almost totally due to smoking.

The morbidity for this disease is extreme and goes on for years. Development

of more effective broncho dilating drugs and antibiotics and the extensive

home use of oxygen as compressed oxygen or as oxygen concentrators of room

air has ameliorated the symptoms of COPD without reversing the pathology.

The only bright light in this bleak picture is that since about 1955 there has

been a gradual decrease in cigarette use which from 1974 through 1985 has

been an almost linear decline. The 1985 smoking rates for men was 33.5%

and for women 27.6%. Soon women will outnumber men as smokers. People

aged 65 in 1985 would have been age 35 in 1955 so their smoking patterns

were well-established long before the dangers of tobacco to health became

defined. However, many of the effects are reversible and a great many of this

age cohort and older have stopped. This change in smoking patterns must

rank second to antibiotic development as a major determinant of the health

of the older patient.

Heart Disease

Diseases of the heart lead the list of causes of death producing over a third

of all deaths in 1985. In 1935, rheumatic heart disease and syphilitic heart

disease were frequent causes of death but they have been vanquished by

182 KINGSLEY M. STEVENS

penicillin and today coronary artery disease is the dominant cause with ath-

erosclerosis being the underlying pathology. The past 50 years have seen

advances in the treatment or prevention of heart disease from multiple ap-

proaches: Prevention, medical treatments, surgical treatments, even after-

death treatments with cardiac resuscitation! Prevention has focused on three

approaches: Decrease in smoking, decrease in cholesterol and fat intake and

an increase in exercise. In our frequently lethargic society, it is very encour-

aging that every one of these has shown marked improvement at the society

level, even though many persons have not changed their patterns at all. We

now have more effective and less toxic drugs to reduce cholesterol and/or

lipid levels if dietary changes are insufficient.

Coronary Artery Disease

Atherosclerosis causes mortality and morbidity through myocardial infarc-

tions, cardiac arrhythmias, congestive heart failure and angina pectoris. In

the preceding paragraph we noted preventive measures relating to smoking,

exercise and types of foods. Another preventive measure is the use of aspirin

in low dose to prevent repeated heart attacks by decreasing platelet agglutin-

ation. Diabetes is another risk factor for atherosclerosis and better diabetic

control has helped.

Surgical treatment of heart disease (open heart surgery) has had superb

media coverage and coronary by-pass grafts using vein grafts from the patient

(CABG) has had great success in relieving symptoms, especially angina, and

lesser success in prolonging life. While heart transplants are no longer a rare

surgical procedure, there are many complications and they have little impact

on the overall picture. Mechanical hearts are entirely experimental and will

remain so for a long time.

The drama of cardiac surgery has tended to obscure the amazing advances

in the drug treatments of heart disease over the half-century. In 1935, the

powdered leaf of the foxglove, which contained digitalis, was still the most

commonly used medication. The purified glycosides, digitoxin and the shorter

acting digoxin, were purified in 1925 and 1930 respectively but were not widely

used for about 20 years. Digitalis had been introduced in the treatment of

congestive heart failure (dropsy) by William Withering in 1785. When I was

in medical school in the mid-1940s, I was taught that digitalis, unlike most

drugs, had an “all or none” effect. This meant that blood levels just below

toxic were required and indicated use of the long acting digitoxin to keep the

level more constant. There was no assay method for serum digitoxin then

available, nor was hemodialysis available. As a result, digitoxin toxicity was

rather frequent, especially in older people. When radioisotopes became avail-

able, the development of radioimmunoassay methods became possible. This

was particularly valuable for measuring substances such as digitoxin which

have very low serum concentrations. Using this technic, it was soon demon-

strated that digitalis preparations behaved just like other drugs; they did not

have an “all or none” pattern but the usual dose-response effect. This led

quickly to dropping digitoxin and using digoxin, the shorter-acting and there-

CHANGES IN MEDICINE FROM 1935 TO THE PRESENT 183

fore safer drug. This story illustrates what the results can be when well-

established principles appear inconsistent with clinical experience and the

clinical results are used to justify the practice. In the mid-1940s, the principle

in pharmacology of a dose-response curve was well-established. Both the

glycosides were then available, but the more toxic was deliberately selected

based on inadequately controlled clinical studies. After 200 years, the digitalis

glycosides remain the best cardiotonic drugs but the safety of their use has

greatly increased. Digitalis is also less needed than in 1935 because of new

drugs with different actions which are also needed in the treatment of conges-

tive heart failure (CHF). The most important are the oral diuretics.

In 1935, there were no good diuretics for chronic use; the mercurial diuretics

were effective but required injection and were often toxic if renal insufficiency

was present. In the early 1950s, when penicillin was still expensive, one of

the pharmaceutical companies set out to find a drug which would decrease

the renal tubular secretion of penicillin and therefore maintain higher serum

levels. A chemical which did this effectively in man was found (probenecid),

but very shortly the price of penicillin fell steeply, making the product of less

value. However, probenecid also increased uric acid loss so was useful in the

treatment of gout and the company decided to continue its renal program.

One of the chemicals synthesized for the program was found to have marked

diuretic and hypotensive effects. This was chlorothiazide, the first of the ef-

fective oral diuretics and still today, as hydrochlorothiazide, a very useful drug

in treating both congestive heart failure and hypertension. However, the type

of diuretic most often used today in treating CHF is a “loop” diuretic, such

as furosemide. These drugs very effectively reduce the reabsorption of sodium

and chloride in the renal loop of Henle.

Angina Pectoris

This is the most frequent cause of chronic disability in patients with coronary

artery disease. Since pain is the symptom which most often causes people to

visit doctors, angina causes many Office visits. Yet in 1935, the only really

useful drug was sublingual nitroglycerin. Synthesized in 1846, its medical use

began over a century ago. The very major effect of nitroglycerin on the history

of science began in 1862 when Alfred Nobel patented dynamite, which in-

corporates nitroglycerin with diatomaceous earth and a small amount of so-

dium carbonate. In a very real sense, nitroglycerin was the founder of the

Nobel Prizes! Although sublingual nitroglycerin is very effective in the pre-

vention and treatment of acute anginal attacks, it is very short-acting. Much

effort has been made to prepare oral nitrates which could be used on a con-

tinuing basis to prevent anginal attacks. Several preparations have been used

extensively but have not been highly effective. Today we use nitrates delivered

through the skin rather than orally. However, we also have other effective

anti-anginal drugs. The B-adrenergic blocking agent propranolol was the first

of these. This drug has almost the reverse effect of digitalis in that it decreases

the force of cardiac contraction. The cause of pain in coronary artery disease

is oxygen lack, produced when the ratio of oxygen demand to oxygen supply

184 KINGSLEY M. STEVENS

is too low. Propranolol, by decreasing myocardial contraction, decreases ox-

ygen demand and hence decreases anginal attacks. The effect lasts for several

hours and newer preparations are effective for even longer periods. Just when

the “beta blockers” were well established, a whole new group of cardiac

regulating drugs appeared: The calcium channel blocking agents. The bio-

chemistry of muscle contraction requires that the calcium concentration inside

the muscle fiber be increased. Calcium ions enter the fiber through tiny chan-

nels. These new drugs, e.g., nifedipine, diltiazem, verapamil, inhibit this

Ca** increase, thereby decreasing contractility with decreased oxygen de-

mand. Using combinations of old and new cardiac drugs, many patients with

coronary artery disease can be treated as effectively medically as surgically.

There is now enough data to separate fairly well those patients who will do

well on a medical regime from those who will benefit more from a coronary

artery by-pass procedure.

Hypertension

Although hypertension is found in all ages, it is most frequent over age 65

with about one third of all people in the U.S. over 65 having some degree of

hypertension. The most important sequellae are congestive heart failure and

strokes, although many cases of kidney failure are also due to long-standing

hypertension. In 1935, there was no satisfactory drug treatment. It was not

until almost 25 years later that the effective combination of a thiazide diuretic

coupled with a specific anti-hypertensive drug such as methyldopa became

available. Today there are almost too many antihypertensive medications! The

reason there are so many is two-fold. Some patients have very resistant hy-

pertension so are on multiple drugs and even then may not be controlled. The

“ideal” drug for hypertension is one of the hardest assignments possible for

the drug industry. None of the medications “‘cure” hypertension so long-term

treatment is the norm, even though remissions occur. But high blood pressure

itself causes symptoms in only a small fraction of all people with hypertension.

Therefore, for most Americans under treatment for hypertension, the “‘symp-

toms” of their disease are actually the side effects of the antihypertensive

drugs. This makes long-term compliance extremely difficult. So the quest

continues for an oral drug, taken once or twice daily, that will have almost

no side effects. Despite all these problems, the treatment has vastly improved

since 1935 and is being used by millions of patients. It has decreased mortality

rates from strokes and congestive heart failure.

The most specific, and therefore one of the least toxic, antihypertensive

agents are the angiotensin-converting enzyme (ACE) inhibitors. The back-

ground for these goes back over half a century. In 1934, Goldblatt showed

that chronic renal ischemia would produce persistent hypertension. He felt

that both experimental and clinical hypertension were produced by increased

secretion of a renal enzyme, renin. He tried to inhibit renin but could not

develop a suitable method. While the ‘‘Goldblatt kidney” remained a standard

method of producing experimental hypertension, anti-renin studies were not

pursued. Many years passed before the renin-angiotensin-aldosterone system

was worked out. Briefly stated, renin acts on a serum globulin to produce a

CHANGES IN MEDICINE FROM 1935 TO THE PRESENT 185

decapeptide, angiotensin I, which is not active. A serum enzyme converts the

decapeptide to an octapeptide, angiotensin II, which is a potent vasoconstrictor

thereby raising blood pressure. Angiotensin II also stimulates the adrenal

gland to secrete the mineral-corticoid hormone aldosterone which increases

blood volume and enhances the hypertensive state. One way to block the

effects of increased renin would be by blocking the conversion of angiotensin

I to angiotensin II. Some snake venoms contain toxic peptides which may

produce shock. In 1965, Ferreira isolated a mixture of peptides from the venom

of a Brazilian snake, and in 1967, Ng and Vane found that one of these peptides

blocked conversion of angiotensin I to angiotensin II. By 1971, Ondetti et al

had synthesized the nonapeptide. Laragh and his colleagues demonstrated

that the peptide did, indeed, decrease blood pressure in patients with elevated

renin levels. However, it required intravenous injection so had minimal market

potential. Hence Cushman and Ondetti set about developing a peptide-like

product that would be an ACE inhibitor when taken orally. This they achieved

and captopril was patented in 1977. A decade later we have even more specific

ACE inhibitors. Furthermore, they are often effective even when renin levels

are low, which somewhat confuses the tidy theoretical development of these

important drugs.

Cardiovascular Disease Today

In the preceding pages we have presented the many ways in which we have

improved the prevention and treatment of cardiovascular diseases. In the

1950s, a longitudinal study of cardiovascular diseases was set up in Fra-

mingham, Mass. This is known as the Framingham Study and many people,

originally without any evidence of cardiovascular disease, have been followed

until death or for over 30 years. Over these 30 years, there has indeed been

a fall in the cardiovascular mortality rate of the study population as has also

occurred nationally. But there has been no decline in the incidence of car-

diovascular disease. Hence, we have not yet reached either true prevention

or cure with these many advances, but have made the diseases milder. If the

mortality rate has fallen but the incidence has not, it must follow that the

prevalence of cardiovascular disease has actually increased.

Cancer

Cancer was the second largest cause of death in both 1935 and 1985. How-

ever, instead of declining, the overall rate almost doubled. The most spec-

tacular change was for lung cancer in men, climbing from 7 in 1935 to 74 in

1985. In a reverse trend, stomach cancer fell from 38 to 9. In women, these

values were from 3 to 27 and 28 to 4 for lung and stomach respectively. In

men, cancer of the colon and rectum and of the prostate rose slightly between

1935 and 1945, then leveled off and have remained between 20 and 30 ever

since. Women showed the same initial rise in colon and rectal cancer as men

but this has fallen from a high of 27 in 1947 to 18 in 1985. Uterine cancer

(cervical and endometrial) has fallen from 30 in 1935 to 7 in 1985. Breast

cancer, the most frequent cause of cancer deaths in women from 1933 to 1988

186 KINGSLEY M. STEVENS

(when overtaken by lung cancer), has shown no meaningful change, being 27

in 1935 and 28 in 1985 with only minor variations during the half-century

between. Hence at the statistical level of mortality rates, the only good news

for the major types of carcinoma is for cancer of the stomach and uterus.

Results have been somewhat better for the leukemia/lymphoma malignancies,

especially for Hodgkins Disease where a significant percentage of true cures

have been achieved with aggressive radiation therapy and/or chemotherapy.

Five-year survival rates have shown modest improvement for the major

cancers. Data covering the 1960-1984 period show the percentage of cancer

patients surviving five years rising from 39 to 50% for all types of cancer (for

whites). Colon cancer rose from 43 to 53%, lung cancer from 8 to 13%, breast

cancer from 63 to 75%, prostate cancer from 50 to 73%. Since survival time

begins when the tumor was diagnosed, these figures measure improved di-

agnostic methods at least as much as improved treatment.

Huge amounts of resources have been put into cancer research and treat-

ment and we know much more about carcinogenesis at the cellular level than

in 1935. Yet we understand little about cancer in man and, overall, treatments

have made little progress. The development of genetic engineering has made

the production of such natural products as interferon possible but interferon

has had only limited success in cancer treatment. Demographic studies show

large differences in cancer incidence by country. For example, breast cancer

is almost six times as frequent in England and Wales as in Japan and prostate

cancer is five times as frequent in the U.S. as in Japan. Yet stomach cancer

is almost eight times as frequent in Japan as in the U.S. The causes of these

large differences have not been determined. Difficulties in identifying causes

is shown by the history of cigarette smoking as a cause of lung cancer. This

year marked the 25th anniversary of the first Surgeon General’s Report on

Smoking and Health in 1964. It should be appreciated that the first good

studies showing a correlation between lung cancer and cigarette smoking were

reported in 1939 by Muller in Germany and Ochsner and DeBakey in the

U.S., exactly 25 years before that first Surgeon General’s Report. For gas-

trointestinal cancer, the major focus today is on dietary differences in various

groups. Despite multiple theories, the major factors responsible for breast

cancer and prostate cancer remain undetermined. Even when a general etiol-

ogy has been established, the specific etiology can be extremely difficult to

identify. Cigarette smoking has been known to cause lung cancer for 50 years

and literally thousands of studies of the effects of ingredients of cigarette

smoke have been made. Yet today, there is no firm evidence identifying a

specific chemical compound as the major cause of lung cancer from cigarette

smoking. Hence, we may expect that the much less well defined ingredients

of “diet”? will be even more difficult to unravel.

Diabetes

Insulin was first used in 1922 and crystallized in 1926 so its use in diabetics

was well-established in 1935. The reported death rates for diabetes in 1935

and 1985 were not very different, but such rates cannot be accurate because

CHANGES IN MEDICINE FROM 1935 TO THE PRESENT 187

diabetes is a major risk factor for heart disease and is the chief cause of end

stage renal disease. Our supportive systems are so much better that the number

of deaths from ketoacidosis must be much lower. Despite this, diabetes in

1985 is a much more common disease than in 1935. Today the insulin is a true

human insulin produced either by a genetically engineered bacterium or by

chemical modification. Almost more amazing is how satisfactory pork and

beef insulins were over a sixty-year period. Since these are foreign proteins,

they did produce antibodies which at times required increases in insulin doses.

But only rarely did patients become totally resistant to insulin. Foreign proteins

can produce anaphylactic shock and severe kidney damage but both were rare

with these foreign insulins. The reason must lie in the small differences be-

tween human, beef and pork insulins. Insulin has a molecular weight of six

thousand and has A and B chains joined by disulfide linkages. Pork insulin

differs from beef insulin by two amino acids sequences while pork insulin

differs from human insulin by only one amino acid sequence, clearly dem-

onstrating that humans are more closely related to pigs than to cattle! Since

the difference between human and pork insulin is the C-terminal amino acid,

chemical replacement of the alanine with threonine produces a human insulin.

Alanine is an aliphatic amino acid with a single methyl side chain. In general,

antigenicity in proteins correlates with the complexity of the amino acid side

chains and aromatic radicals are much more antigenic than aliphatic radicals.

Hence, only if pork insulin had a C-terminal glycine instead of alanine could

it be less antigenic in man.

The antimicrobial era was introduced with the sulfonamides in 1935. Even

though true antibiotics became the dominant antimicrobial drugs, work on

finding better sulfonamides continued and lead to the sulfonylureas in 1957.

These drugs, e.g., tolbutamide and chlorpropamide, have no antibacterial

action but lower blood sugar and are effective orally. Recently 100-fold more

potent oral drugs have been introduced. These oral antidiabetic drugs have

been extremely useful in diabetic treatment, but have not replaced insulin for

severe diabetics. In fact, insulin today is given at more frequent intervals than

even a few years ago to better control fluctuations in blood glucose.

In 1935, monitoring of blood glucose at home was done by quantitative

measurements of urine glucose. This method revealed pooled blood glucose

levels over a previous time period but did not measure low levels at all since

the renal threshhold for glucose is in the range of 180 mg%. Today, urine

monitoring is little used with microamounts of blood from fingersticks pro-

viding quantitative blood glucose levels measured in simple machines. Various

attempts to provide implanted insulin pumps and continuous glucose moni-

toring for automated insulin delivery have not yet been perfected but progress

is expected.

Diabetes and its many complications remains a leading cause of death and

disability. Even if automatic infusion pumps improve and become widely

available, they will remain cumbersome and have problems. Research efforts

on the etiology of diabetes give hope that some diabetes may be preventable.

For now, the goal of the diabetic must be to follow a carefully controlled diet

with appropriate drug dosage which keeps glucose levels at near normal levels

but does not subject the patient to severe hypoglycemic episodes.

188 KINGSLEY M. STEVENS

Arthritis

So far, we have dealt with diseases which have high mortality rates. These

same diseases also produce a great deal of morbidity, i.e., discomfort or

disability or both. Of those diseases which produce high morbidity rates but

low mortality rates, arthritis is dominant. In a survey of people over age 65,

almost half reported arthritic symptoms. The actual prevalence of arthritic

changes must be even higher, since x-rays taken for other purposes frequently

show severe arthritic changes in patients asymptomatic for arthritis. Arthritis

is a generic term and has many varieties but two types account for most cases:

Rheumatoid arthritis (RA) and osteoarthritis (OA), also known as degen-

erative joint disease (DJD). Although OA is far more common, RA has been

the subject of much more research. This reflects both the severe crippling

effects of RA and its intriguing immunological factors. Most patients with RA

have a serum factor termed ‘“‘rheumatoid factor” which is an antibody against

denatured antibody of the IgG type. Arthritis attacks joints, but the bone

itself is only secondarily affected. In OA, the primary tissue response is in

cartilage, while in RA it is the synovium which lines the joint.

Soon after cortisone became available in the late 1940s, it was shown to

produce dramatic improvement in certain patients severely crippled with RA.

However, the side effects of chronic steroid use can be severe and improve-

ment was often not maintained. Aspirin was widely used and was effective in

RA but required continued use of large doses. Hence, pharmaceutical com-

panies searched for a drug which would be more effective than aspirin but

less toxic than steroids. The first product was indomethacin, introduced in

1962. This group of drugs carries the acronym of NSAID, for “non-steroidal

anti-inflammatory drugs” and many different products with slightly different

characteristics are now available. RA is a severe inflammatory disease and

these drugs were developed for RA. At the time, OA was felt to be non-

inflammatory, and the British therefore use the term “‘osteoarthosis” instead

of ‘“‘osteoarthritis” which does carry a connotation of inflammation. Since OA

is much more common than RA, the NSAID drugs were promptly tried in

OA and found to be very helpful. Following this therapeutic finding, it has

been shown experimentally that inflammation is indeed an important part of

OA.

Despite these drugs and others used in arthritis, both RA and OA can

progress to make joints non-functional. For such patients, the major advance

has been in orthopedics, with the development of total joint replacements.

Particularly successful has been hip replacement which has made a great many

patients crippled with-arthritis once again ambulatory.

Yet arthritis remains the major cause of morbidity for people over age 65

and much more basic and applied research is required.

Mental Illness

Another area with high morbidity but low mortality is that of diseases

affecting the brain. The original hope that psychotherapy would resolve such

CHANGES IN MEDICINE FROM 1935 TO THE PRESENT 189

functional diseases as schizophrenia and manic-depressive (bipolar affective)

disorders has not been borne out and these diseases are now known to be

heavily dependent upon genetic factors. Chlorpromazine was introduced in

France in 1952 and this group of drugs has had a dramatic effect on the

treatment of schizophrenia. Their extensive use has led to large scale dis-

charges of schizophrenics from mental hospitals. It should be realized that the

drugs do not cure the disease and rarely completely normalize the altered

thought processes. Also in the early 1950s, the simple chemical lithium car-

bonate was shown to be effective in control of manic symptoms. A few years

later an analogue of chlorpromazine was shown to be effective in depressed

patients while ineffective in agitated schizophrenics. The dibenzazepine nu-

cleus of this drug, imipramine, differs from the phenothiazine nucleus of

chlorpromazine in the linkage between the two benzene rings. Imipramine

and related compounds are used with good results in most cases of bipolar

depressed states but are of lesser values in depressions of other types.

Non-psychotic mental illnesses vastly outnumber schizophrenia and manic-

depressive disorders. Depression, anxiety, stress syndromes and substance

abuse with their myriad permutations and combinations permeate our society.

Primary physicians dispense huge quantities of the benzodiazepines typified

by diazepam (Valium). Psychiatrists couple more judicious drug use with

psychotherapy while new professional groups, e.g., clinical psychologists, use

only psychotherapy to aid patients coping with these problems. Perhaps the

greatest change since 1935 is the acceptance of the frequent need for profes-

sional help to resolve problems in which emotion and mood are paramount.

Although there are no good statistics, it appears that there has been a major

increase in depression, anxiety and stress syndromes since 1935 and there

certainly has been a huge increase in substance abuse. Many cases of these

disorders stem, at least in part, from our social organization, and since pre-

vention is certainly more effective and desirable than treatment, psycho-

therapy and medical treatment cannot be expected to have much effect on

the incidence of these problems.

In the older age group which we are primarily addressing, the most prom-

inent mental illness is dementia. The most frequent types, Alzheimer’s Disease

and multi-infarct dementia, are not only untreatable but are devastating for

both patient and caretaker. Multi-infarct dementia is due to strokes which are

highly correlated with hypertension. Hence, we have some preventive mea-

sures for it, but not for Alzheimer’s Disease. Both types of dementia are

highly correlated with age so our aging society will show increasing incidence.

Even more important, however, is the increase in prevalence. This is due in

large part to application of all our modern technology to prolonging the lives

of severely demented patients. It is very effective in that goal, which coincides

with prolonging the suffering of their caretakers. Not only routine technologies

but cardiac surgery, repair of asymptomatic aortic aneurysms, full treatment

programs for cancer, continuing hemodialysis are applied alike to demented

and undemented patients. While research in dementia must be vigorously

pursued, there is no possibility that research will resolve the increasing problem

of dementia in the foreseeable future.

190 KINGSLEY M. STEVENS

Hearing Loss

About 30% of people over age 65 have a symptomatic degree of hearing

loss. We now know that high noise levels have a cumulative effect over the

years on auditory acuity and much more stringent ear protection is required

in the workplace. At the same time, young people have vastly increased noise

levels in their recreational activities! The chief change in hearing aids has been

miniturization. Eyeglasses require only periodic changes in refractive pre-

scription done at periods of years, while hearing aids require ongoing ad-

justments in the volume control. This poses a particular problem in just that

population who need them most. Older people have more arthritis and less

ability to make rapid and fine adjustments of those tiny volume controls.

Putting in batteries and turning them on and off are major problems for

millions of users. Hearing loss isolates people from other people and is a major

cause of depression and withdrawal. We do not realize how often we repeat

or emphasize a point in ordinary conversation. Our superb memory often

reflects not such good memory but the repeated input of the item. The person

who is hard of hearing has much trouble getting the message once, much less

multiple times. A great many older people are thought to show senile memory

loss when the real problem is only hearing loss. All hearing cannot be helped

by hearing aids, but there is no question that the technology in use today is

very unsatisfactory for millions of users and potential users.

Chronic Sinusitis

When a sample of the general population over age 65 was asked about

chronic diseases which affected them, the top four were, in descending order

of frequency, arthritis (50%), hypertension (39%), hearing impairment (30%),

and heart condition (26%). The fifth most frequent, at 15%, was chronic

sinusitis. This definition includes patients with chronic nasal congestion and

post-nasal drip who do not show evidence of chronic sinusitis by x-ray. This

entity does not produce severe morbidity for most but it is certainly uncom-

fortable and a nuisance. The etiology is poorly defined but allergy, low-grade

bacterial infection coupled with structural features of the anterior skull which

alter drainage patterns are probably important. Vasoconstrictor drugs may

give transient relief but have long-term bad effects and indeed can worsen the

symptoms. Antibacterial therapy can be very helpful but again only transiently.

Nasal instillation of steroids can be helpful for some. Various surgical pro-

cedures have never become established as very helpful. Hence, chronic sin-

usitis remains an unexpected but major cause of morbidity and deserves further

study.

Vision Loss

About 10% of people over age 65 have significant uncorrected vision loss.

The major causes are cataracts, diabetic retinopathy and glaucoma. The treat-

ment of cataracts has vastly improved since 1935. At that time, patients spent

CHANGES IN MEDICINE FROM 1935 TO THE PRESENT 191

two weeks in the hospital and were subsequently fitted with very thick glass

lenses which at best produced distortion in size. Today the surgery is usually

done on an out-patient basis and an intraocular lens implanted. Subsequent

fitting of eyeglasses is no different from routine refraction. Diabetic retinop-

athy has been improved by laser treatment and has been very valuable for

individual patients. However, there are more diabetics, they live longer and

the development of retinopathy requires many years in the diabetic state.

Therefore, there are many more cases of vision loss from diabetes which is

today the chief cause of blindness in the United States.

Conclusions

Since 1935 there has been a tremendous increase in biomedical knowledge

and many new drugs and surgical procedures have brought a better life to

older patients with a wide variety of ailments. However, a viewpoint expressed

by Rene Dubos should be kept in mind. In the early 1960s, the University of

Kentucky opened a new medical center complete with schools in all the major

health sciences and a university hospital. Dubos, an eminent microbiologist

at the Rockefeller University, was the major speaker at the dedication cer-

emonies. To the governor, senators, officials from HEW and the university,

faculty and general audience, Dubos noted that everyone in the audience

expected that this new and expensive medical center would decrease the prev-

alence of disease in the Commonwealth of Kentucky. It would not do so,

declared Dubos. All the effort would only change the pattern and mix of the

diseases which presented, but would not decrease the overall prevalence of

disease. Twenty-five years later, he appears to have been correct.

Acknowledgment

I thank Mrs. Angela Wright for her typing.

References are available from the author on request.

DELEGATES TO THE WASHINGTON ACADEMY OF SCIENCES,

REPRESENTING THE LOCAL AFFILIATED SOCIETIES

PB MPT OCICIM OL NVASLIN BION <5 2 on)) fy < Soot ~ -e cfabicin wis = + Aeeee Sion Re eine we ee Thomas Lettieri

Peete SOCIELY Of WaSHINPLON < Soci... is) 3 - iis ol be wie cee Seve ee ee Edward J. Lehman

DET ORRCIC EN OL WASHINOLONG. 9. oes Scie 's ocd Sa Seen cals owes oe eee Peete bss Jo-Anne A. Jackson

EA SOCIELY Of WaSMINOtOn = 0.008 Soe. eee ks cp ee est ee eels oe aa Manya B. Stoetzel

SE RRR SXEATBENTEC SOLELC IN) 1a Pec oc) (chs ork ae Shige care mW eel aoai ea ialer oma ghee Bie Gilbert Grosvenor

SPST STCLY OU VV ASI ONO. 251k ie oe yn Sens ie vine wide nese ee aioe SMe ee James V. O’Connor

Deeecicve cn tie Pistrict of Columbia <2 0. oi. Sc vals Aeinlsie se ee oe aes oh ware ele John P. Utz

REEL ACRITE TH SORIEUV Ec) 34-7. Cees oe elie ee oe hats eas Lea tenes Paul H. Oehser

EEC HUI WV ASHEN ELON 2.5 6 /0n.55.5 5,512, ohe eb So ees eee OT Lhe Cae e mee ae Conrad B. Link

eemeor American Foresters; Washington Section ........2.-......-.225266.-5: Forrest Fenstermaker

DE SMMESO EIU OI HOINCCIS..<.6 2-5 s0 ps ea oe otc heme 2 eo oe Gaels ee oes George Abraham

Institute of Electrical and Electronics Engineers, Washington Section................ George Abraham

Pumencan society of Mechanical Engineers, Washington Section.............-...-...+--- Michael Chi

mennmarica society Of Washington... 3.2 4.2.6 22 ec ieee ws Does eee one Kendall Powers

emecmean society for Microbiology, Washington Branch ...................6...005200- eee Vacant

Society of American Military Engineers, Washington Post...................... Charles A. Burroughs

American Society of Civil Engineers, National Capital Section................... Herbert A. Pennock

Society for Experimental Biology and Medicine, DC Section ..................... Cyrus R. Creveling

Pama socicty tor Metals, Washington Chapter ..........5)..-.55. 6050-2 eee ee Pamela S. Patrick

American Association of Dental Research, Washington Section....................-. J. Terrell Hoffeld

American Institute of Aeronautics and Astronautics, National Capital Section....... Reginald C. Smith

meee eoroorical society. DC Chapter 22.2...) :.2- tee se ae ol eet eee A. James Wagner

EELS SUCTENP C PAY ETS C1019 (071 Tia ee ge ea Ae Albert B. DeMilo

Peembated Society of America, Washington Chapter. ..:.....-...5..252---205ee- eee Richard K. Cook

Peemeecmnumcicar society, Washington Section... 2... ie ceed ba dence ee eee ke cee. Paul Theiss

eer ood Technologists, Washinston Section ... 22 ..0.. s6e eee ee eee cee ee ee Elvira L. Paz

American Ceramic Society, Baltimore-Washington Section.....................:- Joseph H. Simmons

RMON MASAI SICTE IM A Ore, Soe Cos Gk es une eet clei eee gene tAtale Ueki Sy ae Alayne A. Adams

Pen MEL MSE IE SCIENCE CONUD) <2) Stee ac) oie ge Se cited cia Soe hein oi Aeld a Bebe Albert Gluckman

American Association of Physics Teachers, Chesapeake Section ..................... Peggy A. Dixon

memea society of America, National Capital Section..-..........-....526..-02-- William R. Graver

American Society of Plant Physiologists, Washington Area Section.............. Walter Shropshire, Jr.

Washington Operations Research/Management Science Council ...................... John G. Honig

memenesmricty Of America, Washington Section:. ....2.2...26 6.0 sce eed ese dee et aws Carl Zeller

American Institute of Mining, Metallurgical and Petroleum Engineers,

0 UE EET SSE TRU Io soo et Seed en eee re ee ear ee Ronald Munson

SME ARTEL NST OMOMICTS ho ener on Se lta ee le oe eee eed Robert H. McCracken

Mathematics Association of America, MD-DC-VA Section..................0.00-. Alfred B. Willcox

PEIN STERPTSE TA MIE TICHIISTS 20 88 oe es el oe aie ke ory Se te a ee Miloslav Rechcigl, Jr.

PPPMERENAER CAH ASSOCIANONG 66. Oe ie tn ee on ace Sie eae ahaa we a cee Jane Flinn

ee een nL AIEMECOMMIC AL (LOU). ok kw 2S a kis os oo ase wi ys Seles Bae Cee Robert F. Brady

mmctican Phytopatholopical Society, Potomac Division................2.2.+..-/50--% Deborah Fravel

Society for General Systems Research, Metropolitan Washington Chapter .... Ronald W. Manderscheid

PP MePMCIONS SOCIeIY. FOtGmac (uapter -.),.0 52. 21636 225-6: «Ss ees piles epee eae Stanley Deutsch

DAE MUSCiIeS: SOCIEhY PT OLOMmaG Claplen 60. ..ccce sls ohn cs ee eee sth cael eyes Robert J. Sousa

Bescon tor science, Lechnology and Innovation..-.......5+.2:.02-22-+es-eee ee eee Ralph I. Cole

ee MARSOC SCE SMT ER oreo. os arcing 6s Bsn ee ess wove we Sea wag oe Ronald W. Manderscheid

Institute of Electrical and Electronics Engineers, Northern Virginia Section............. Ralph I. Cole

Association for Computing Machinery, Washington Chapter.................-----2--- Zalman Shavell

A PMAES EES CAMS OCAE TYE ore Seco ban ie Se a oes Sse aS ie goes Carl Pierchala

Society of Manufacturing Engineers, Washington, DC Chapter ...................-.. James E. Spates

Seaweed iudusiiial encancers. Chapter 14)... 5.62.56. bese sso bees nods oon eeendee John L. Baer

Delegates continue in office until new selections are made by the representative societies.