In geriatrics, we are at the very roots of medicine

Prof. MUDr. Eva Topinková, CSc., who had recently received the František Běhounek Prize for promotion and popularisation of Czech science in the European research area (ERA), has been at the helm of the Department of Geriatrics of the First Faculty of Medicine Charles University and General University Hospital in Prague since 2001. She emphasises that geriatrics is an immensely broad area with many so far unexplored corners, which includes topics ranging from epidemiology and preventive programmes of public healthcare though clinical practice all the way to experimental biogerontology.

The Department of Geriatrics at the First Faculty of Medicine and General University Hospital was created as the first of its kind in Prague. Is it still the only one?

Yes, our department was the first geriatric clinic in Prague but although that made it in a sense ‘unique’, we took no joy in that. There are three faculties of medicine in Prague and development of this area and training of medical students requires that a department specialising in geriatrics be established at each of them. That is why I was very pleased that last year, a Department of Internal Geriatric Medicine was created at the Second Faculty of Medicine in Motol. This is needed not only for patients – it is also necessary for successful further functioning of ‘academic geriatrics’ which enables a methodical development of this field and its scientific potential, including publication activity. It is the only way how we can implement geriatric knowhow also into other areas of medicine. Academic geriatrics needs the creation of further centres, scientifically erudite leaders, clinical studies, and projects that will produce more scientific results.

In one of the texts in our Number One you wrote that the First Faculty is freeing itself from traditionalism and is modernising in line with European trends. Does that also apply to the teaching of geriatric medicine here at your department?

Yes, but personally, I am no enemy of traditions. They are important: they facilitate continuity, stability, and feeling of security given by repeating things that worked well in the past. On the other hand, traditions actually do not allow change. I believe that it is necessary to follow up on the traditions of academic teaching, develop them, and adjust them in view of current needs, the needs of students, clinical practice, but also the needs of teachers. At the department, when developing new curricula, we took as our starting point the recommendations for Europe issued by UEMS, a geriatrics section for undergraduate teaching. As a representative of the Czech Republic, I participated in their development. We also published these recommendations in the journal of our association, just as we published an overview of contents of our specialisation training programme. Geriatrics is now included among the basic specialisations and the Geriatrics Department trains interns preparing for attestation and specialisation courses.

For some years now, the basics of geriatric medicine are included in the curriculum of medical and even of the majority of non-medical fields. What further changes to the better would you like to see in the training of future healthcare professionals?

I believe we managed to reach the goal we set ourselves almost twenty years ago together with the first head of our department, doc. Jiří Neuwirth. We wanted all students of medicine, physical, occupational, and nutritional therapy, as well as nursing students, to encounter in their studies something like ‘geriatrics 101’. And this we managed, including the creation of instruction aids in Moodle. We would certainly welcome a return to full, in-person teaching without any Coved-related restrictions, a broader use of teaching materials from abroad – we are only just learning the Amboss program – and perhaps also a greater inclusion of the subject of aging into instruction in other fields taught here. It would be great to for instance include instruction in communication with older patients. To better understand geriatric diagnoses, one can also use the simulation centre – where students should try out for instance the weighted suits – to find for oneself how age changes the organism, its abilities, and its appearance. I find it surprising that for instance in pharmacology, students do not learn much about the notion of medications unsuitable in advanced age, that is, about the classes of medications which due to their pharmacokinetic or pharmacodynamic properties are not safe for older patients. these are for instance medications which significantly increase the risk of falling or those which have an anticholinergic effect. Those are not suitable for older people at all, because in advanced age the brain has low neurocognitive reserves, and the use of such drugs can have a negative impact on cognitive functioning or even cause a delirium.

How do you motivate medics to work in the area of geriatric medicine?

Our experience as well as one older questionnaire survey had shown that among students, only several percent are interested in working in geriatric medicine. This is caused by the not very positive attitude of current society to old people as well as by the still low prestige of this field, which tends to be viewed as uninteresting, lacking in action, and it is often misunderstood as amounting to long-term care for helpless seniors. We are trying to change this perception and show students that knowledge of geriatric medicine will help them take better care of patients in higher age groups even if they work in a different medical field. Perioperative care, safe prescription practices, comprehensive assessment of comorbidities, evaluation of cognitive abilities, and preventive geriatric medicine are areas where geriatric knowledge enables qualitatively better medical care.

What convinced you to choose geriatric medicine?

I must admit that I did not actually choose it. I was ‘left’ with a spot in the gerontologic group of Professor Pacovský at the Third Department of Internal Medicine of the Faculty of General Medicine (now the First Faculty of Medicine, note of the editor). But it turned out that there is much that is still unexplored and interesting in both gerontology and geriatrics, that it is an immensely broad field ranging from epidemiology and preventive programmes of public healthcare through clinical practice all the way to experimental biogerontology. Why is why I have been finding geriatrics so amazing for all those years. And another thing I find amazing is the fact that in caring for old people, we are at the very roots of medicine: helping, humane, and charitable.

Do you have some idea how many young physicians, now graduates from the medical faculties, want to focus on geriatric medicine?

Yes, in our professional association we keep track of the numbers of physicians who signed up for geriatrics and we follow them through their specialisation pre-attestation training. Our Department of Geriatric Medicine also serves as the clinical part of the Subdepartment of Geriatric Medicine of the Institute of Postgraduate Medical Education and holds accreditation for geriatrics.

In the Czech Republic, about ten physicians a year finish their specialised training in geriatric medicine, so that now there is over 200 of them working in Czechia. Should there be more?

The goal of our efforts is not to attract as many physicians into our specialisation as possible. Geriatric medicine is not for everyone. As a field, it belongs to the large family of internal medicine but has overlaps into other areas as well: it touches for instance upon orthopaedics (in other countries, this subspecialisation is called orthogeriatrics), but also post-operative care and rehabilitation, specialisations in the area of disorders of vision and hearing, neurology, and psychiatry (states of deliria, dementia, disorders of behaviour in old age). That is why we do not want to educate just specialised geriatric physicians but also train specialists in other fields who will, based on some foundations in geriatrics, take better care of older patients. Each clinical area should cultivate its methods and specifics of treatment of older population. Right now, only a few recommended procedures take into account the specific aspects of aging and the fact that old patients have other comorbidities. The test of doctor’s skill is to find, together with the patient, the patient’s priorities and suitably modify the treatment, or, as we would nowadays rather say, individualise it.

The Department of Geriatric Medicine also functions as a guarantor of a non-professional study for students of the University of Third Age. What does this study involve?

The University of Third Age (U3V) opened at the First Faculty of Medicine in 1987, so this year we celebrate 35 years of activity. Right now, we have over 200 students who follow a four-term course in Human Biology and can also attend a course News in Medicine, in which we – thanks to help from the individual departments at the faculty – introduce each semester a different field. This academic year, we introduce new findings from oncology and addictology. And on a general level, how does education of in the ‘third age’ benefit its students? Studying in advanced age clearly has an important psychological effect. Some of our students are over eighty and many have been attending the course News in Medicine for over 10 years. Mental activity and the social nature of meeting in classes (recently unfortunately limited by the pandemic) have a favourable effect on the overall feeling of health and satisfaction with life. There are scientific studies which describe the positive impact of such activities on cognitive health.

Speaking of studies, your department has become, over the past twenty years, a renowned scientific partner of dozens of large European projects. Which of those resulted in key contributions to your field?

It is difficult to select just one or two projects. I remember the first project of the 5^th framework programme of research and development of the European Commission AD HOC (2001–2004), which was I think also the very first large European project our faculty had acquired as part of this programme. It dealt with the issue of seniors in home care, clinical indicators of patients, indicators of quality of care, and the extent of care and services. Our department analysed pharmacotherapy and patients’ adherence with treatment, and we published the results in JAMA, a highly prestigious journal. In 2005, we were the first in the Czech Republic to draw attention to the concept of unsuitable medications which carry increased risks for older patients. We are still active in researching this subject. I also remember the PREDICT project, which drew attention to the low representation of older persons in clinical studies and investigated barriers and ways of increasing their representation in clinical research. The results contributed to the creation of an expert groups for geriatric medicine adjoined to the European Medicines Agency. Scientifically most productive project with over 30 publication outputs in journals with impact factor was the SHELTER project of the 7^th framework programme of the European Commission, which at that time followed the largest cohort of 5,000 patients in long-term care in eight European countries. From the past five years, I’d mention three large European projects focused on the study of seniors’ frailty and sarcopenia. The SPRINTT project had proven the beneficial effect of directed physical activity and nutritional interventions in frail seniors and the MIDFRAIL project had shown improvements in physical fitness in older diabetics. The publication European consensus on the definition and diagnostics of sarcopenia has, as of today, 5,871 citations. Interesting were also the results of MPI–AGE project. It confirmed the contribution of MPI index to evaluation of frailty and prediction of mortality in a prospective study of hospitalised seniors and effectivity of interventions given their degree of frailty.

In your current scientific work also related to the Covid-19 pandemic?

Yes, we are now analysing the results of an international multicentric observational study MPI-COVID-19. It is a prognostic stratification of patients 65+ hospitalised with Covid-19 and an evaluation of effectiveness of intensive interventions using the MPI index. We are now also following, within the framework of international study EU-COGER, the effectiveness of post-Covid rehabilitation in geriatric patients.

You have recently received from the Ministry of Education the František Běhounek Prize for promotion and popularisation of Czech science in European research space. Which particular study or initiative in this area deserves, in your view, some special appreciation?

I am most honoured by this prize. It is an award not only for popularisation and promotion of Czech science but in effect a symbol of appreciation of the entire research field of gerontology and geriatric medicine. In addition to the abovementioned international research projects and grants, I have also been active in various international organisations for many years. For two terms, that is, eight years, I served as the general secretary of the International Association for Gerontology and Geriatrics IAGG for the European region and subsequently I was for four years president of the clinical section of IAGG-ER. I have also worked in the European Geriatric Medicine Society (EUGMS) and member of its academic board, and I have been serving for many years as a representative of the Czech Republic in the UEMS-Geriatric Medicine. I very much appreciate the opportunity of collaborating within the expert community with outstanding and important European geriatrists and gerontologists, and I value the support we receive in realisation of projects and educational activities from the faculty and the hospital. And I am most grateful to all my collaborators at the department and at other cooperation institutions, everyone who participates with me in promoting and developing geriatric medicine in our country and abroad.

Dr. Richter, head of the department, told me about you that you create at the department for your collaborators an ‘anti-stress’ environment. How do you do it?

Our aim is to make sure that people like working at our department and want to participate in its smooth operation. That is not a matter of course and I am trying to make sure that my colleagues know that I appreciate their work and respect them. I also honour the diversity of the team, where everyone can work on what they are interested in and what they find satisfying. I believe that it is important for the leader of a team to be authentic, so that the employees believe that what the leader does is seriously meant and that they are actually considered in the team leader’s decisions.

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