Interview with Dr. Kelum Pelpola. MBBS (Colombo), MRCP (UK), MRCP (Geriatric Medicine), FRCP (London)
In this interview, Dr. Kelum Pelpola, a leading expert in Geriatric Medicine, explains why the field of geriatric care is unique, compared to other specialties and highlights the importance of holistic, tailored care for elderly patients. From managing multi-morbidities to ensuring quality of life at the end of life, Dr. Pelpola shares key insights into what sets Geriatric Medicine apart and the profound benefits it offers to older adults.
Q: Dr. Pelpola, can you start by explaining what Geriatric Medicine is and how it differs from other medical specialties?
Dr. Pelpola: Geriatric Medicine is a specialized branch of healthcare focused on the care of elderly patients, typically aged 65 and older. What makes Geriatric Medicine different is that it doesn't just treat isolated conditions in specific systems of the body, such as other medical specialties ( such as Cardiology, Respiratory Medicine, Nephrology or Rheumatology) would. Instead, we look at the entire person, considering all their health issues as a whole. Older adults often have multiple chronic conditions that impact different body systems simultaneously. For example, someone might have heart disease, diabetes, arthritis, and dementia all at once.
In other specialties, a cardiologist focuses on heart health, a rheumatologist on joints, or a gastroenterologist on the digestive system. But in Geriatrics, we have to consider how different conditions interact with each other and how treatment for one issue might affect others. This requires a more complex, integrated approach to care, where we aim to balance the needs of all systems in the body, rather than just optimizing one.
Q: Could you elaborate on the challenges of managing patients with multiple health conditions, also known as multi-morbidity?
Dr. Pelpola: Multi-morbidity is extremely common in older adults. It's a term we use when someone has two or more chronic conditions that impact different systems of the body. For example, a person might have heart failure, chronic kidney disease, arthritis, and memory problems. The treatments for these conditions often interact with each other, so treatments must be carefully tailored.
Imagine trying to treat someone with both heart disease and kidney disease. If we focus on optimizing heart function with certain medications, it could potentially worsen kidney function. On the other hand, treatments for kidney disease might negatively affect heart function. As Geriatricians, we have to weigh these factors carefully, taking the patient's overall well-being and quality of life into account. Sometimes, the treatment regimen becomes very complex, but it's crucial to balance all their conditions in a way that improves their quality of life without making one problem worse.
Q: You mentioned the importance of a multidisciplinary team in Geriatric Care. Could you explain what that entails?
Dr. Pelpola: Geriatric care involves a team of healthcare professionals working together to address all aspects of a person's health. This is known as a multidisciplinary approach. For instance, we may have doctors, nurses, physiotherapists, occupational therapists, dietitians, speech therapists, and social workers all involved in the care of a single patient.
Let's say an elderly person has difficulty swallowing, a common issue among older adults. We would consult a speech and language therapist to assess their swallowing ability and recommend exercises or dietary modifications. If they're also having trouble walking, a physiotherapist might be involved to assess their mobility and suggest ways to improve strength and balance, perhaps recommending walking aids if needed.
This team-based approach ensures that all of a patient's needs are addressed — physical, mental, and social — leading to more comprehensive care and a better quality of life.
Q: Can you tell us more about the practice of de-prescribing in geriatric care and why it's so important?
Dr. Pelpola: De-prescribing is a important concept in Geriatrics. As people age, they often accumulate a variety of medications for different conditions. While these drugs may have been necessary at some point in life, they may no longer be appropriate or beneficial as people get older. In fact, some medications can cause adverse side effects, interactions, or even worsen certain conditions.
For example, a frail person with both dementia and high blood pressure might be prescribed medications for both conditions, but some blood pressure medications could exacerbate the risk of falls, in such an individual. As Geriatricians, we review the medications a patient is on and determine which ones are still necessary. We may reduce or stop medications that no longer serve the patient’s best interests. The goal is to minimize unnecessary drug use, reduce side effects, and improve overall health and well-being.
Q: You mentioned the importance of a holistic view in geriatric care. Could you explain what that means?
Dr. Pelpola: A holistic approach means looking at the whole person, not just their physical health. In Geriatrics, we consider all aspects of a patient’s life — their mental state, emotional well-being, mobility, social factors, and lifestyle — because these all play a crucial role in health outcomes.
For example, a patient may have physical symptoms such as pain or difficulty walking, but they might also be dealing with depression or loneliness, which can exacerbate physical symptoms. By taking a holistic view, we ensure that we're addressing not just the medical conditions, emotional well-being, mobility, social factors, and lifestyle — because these all play a crucial role in health outcomes.
For example, a patient may have physical symptoms such as pain or difficulty walking, but they might also be dealing with depression or loneliness, which can exacerbate physical symptoms. By taking a holistic view, we ensure that we're addressing not just the medical conditions, but also the emotional and social factors that affect the patient’s health. It’s about providing care that’s personalized to the individual, taking into account their unique circumstances and preferences.
Q: How does Geriatric Medicine approach end-of-life care and decision-making?
Dr. Pelpola: End-of-life care is an important aspect of Geriatric Medicine. As patients approach the final stages of life, the focus shifts from curative treatment to ensuring comfort and dignity. In Geriatric Care, we often discuss quality of life rather than quantity of life. This can mean different things for different patients — for some, it might involve palliative care to manage pain and symptoms; for others, it could mean making decisions about whether or not to undergo aggressive treatments.
We also engage in advanced care planning with patients and their families, helping them make decisions about their care preferences. This could include decisions about resuscitation, whether the patient wants to remain at home or be in a care facility, and what kind of interventions they wish to pursue. For patients who can’t make decisions themselves, we work with their family members to ensure that the care aligns with the patient’s values and wishes.
Q: Finally, what role does "capacity" play in Geriatric Care, especially when it comes to decision-making?
Dr. Pelpola: Capacity refers to a patient's ability to make informed decisions about their own care. In Geriatrics, we often assess capacity to ensure that patients can understand the information given to them, retain it, weigh the options, and communicate their decision. It’s important to recognize that capacity is decision-specific — someone may have the capacity to make decisions about their finances but not about their medical care, particularly if they have dementia or other cognitive impairments.
If a patient lacks capacity, we work with their family or legal representatives to make decisions in the patient's best interest, ensuring that their care aligns with their wishes and values.
Q: In conclusion, what are the key benefits of Geriatric Medicine for older adults?
Dr. Pelpola: The primary benefit of Geriatric Medicine is that it focuses on improving the quality of life for older adults, not just treating individual diseases. By taking a holistic, multidisciplinary approach and addressing the complexities of multi-morbidity, we provide care that is tailored to the individual. This comprehensive approach helps elderly patients live with greater comfort, dignity, and a sense of well-being, even in the face of multiple health challenges. Ultimately, Geriatric Medicine emphasizes not only how long a person lives, but how well they live.
Geriatric Medicine is a vital, specialized field that addresses the unique needs of aging populations. By considering the whole person and involving a multidisciplinary team, geriatricians provide individualized care that optimizes health, reduces unnecessary treatments, and enhances the quality of life. As the global population ages, the importance of geriatric care will only continue to grow, offering great benefits to older adults in maintaining health and dignity in their later years.
KINGS HOSPITAL
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•Naleef Kitchil
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