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Coming Home to Geriatric Medicine

Dr Munirah Alhamid

‘Home’, can be defined as a dwelling for refuge; it is distinctly different from ‘house’, which denotes a physical space for habitation. For many, “home” conjures up a familiar, much-loved place that evokes a general sense of comfort and well-being. Retaining this sense of home is especially important in Geriatric Medicine. Elderly patients, having been thrust into a cold and sterile medical environment, might be feeling scared and disoriented. We speak to Dr Munirah Alhamid, a Year 2 Senior Resident with SingHealth Residency’s Geriatric Medicine Programme who shared her views and passion for Geriatric Medicine.

Dr Munirah, who was the recipient of the Australian and New Zealand Society for Geriatric Medicine Prize in 2008, had her interest sown early in medical school, when she was studying in Melbourne. She visited a nursing home regularly as part of a community placement program. She recalls fondly one particular resident named Gladys, who had Alzheimer’s disease. “I spent quite a lot of time with the residents, most of whom had dementia. Gladys would sing her heart out during the music therapy sessions, especially when her favourite song, ‘Swing Low, Sweet Chariot’ came on. Many patients with dementia are able to remember very old memories, especially lyrics of childhood songs, and this song brought much joy and comfort to her. ” Gladys, like the other residents, was encouraged to personalise her bedroom with photos of her family and even had a cosy patchwork quilt as her duvet. A true-blue Australian, she included pictures of her favourite Australian Football League team, the ‘Geelong Cats’, Dr Munirah recounts with a laugh. Most importantly, the nursing home felt like a true home which embodied true patient-centred care, Dr Munirah reflected. “I really admired this nursing home’s deeply-rooted ethos of upholding personhood and dignity for their residents,” she added.

Dr Munirah, who completed postings in several medical departments as a Medical Officer (MO) before joining the SingHealth Geriatric Medicine Residency Programme, also witnessed a few instances that made her want to do more, such as when frail and elderly patients were restrained to their beds, due to delirium, which worsened their confusion. They often went home worse than when they came in. “Many lost their ‘spark’. I felt that we could and should do better by them,” says Dr Munirah firmly. As a Medical Officer, Dr Munirah spent seven months in Geriatric Medicine and this valuable experience cemented her passion for this field. “I spent a lot of time talking to my patients and their families to assess their needs and concerns as part of the comprehensive geriatric assessment. My seniors taught me how to motivate my patients and get them out of their beds safely. Assessing their ability to walk became part of the daily physical assessment.”

“It is very important to understand a patient’s medical history and then come to your own understanding of the diagnoses made. ‘What were the patient’s initial symptoms?’, ‘What were the criteria that made the diagnoses?’, ‘Were the medications prescribed indicated and were they still indicated?’ Concise and accurate medical summaries are very important in Geriatrics,” says Dr Munirah.

She learnt this important lesson while working for a Geriatrician who had a penchant for keeping comprehensive notes. Dr Munirah recalls a time when she was tasked with going through the medical records of a patient with a history of recurrent falls and who had become bedridden, “The patient had recurrent admissions and had different providers each time. I unearthed a prescribing cascade that had ultimately contributed to her falls. Medications had brought on more harm for this patient,” she says soberly. After discussion with her consultant and the patient’s family, medications that were deemed inappropriate were stopped. The patient eventually walked again, though not at her previous baseline. Dr Munirah says this encounter helped shaped her future practice; “It was challenging, because as an MO then, I was not confident enough to stop the medications. But I learnt from my consultant how to make patient-centred decisions and reason out the relevant benefits and harms of treatment. It was very rewarding as there is this sense of ‘ownership’ of the patient; the feeling that you knew the patient very well, not just medically.”

The principles of good geriatric care should be an integral part of routine care for any elderly person, regardless of the care setting. “We need to shift the way we approach the provision of care for the elderly. The elderly often display multiple morbidities with complex aetiologies. This means that we should adopt a clinical approach that is patient-centred, and cultivate a healthy appreciation of the limitations of current evidence and its consequent applicability to everyday care. More medicine is not necessarily always good. Recently new trials have been carried out to study the effect of discontinuing drugs in the elderly. This reflects a new paradigm shift in research.”

Dr Munirah mulls, “I suppose what we need is a cultural shift in our society too. I was quite sad to read in the news about protests being lodged against the building of nursing homes in our HDB neighbourhoods a few years back. There is a growing development in the US and Japan, where childcare centres are being merged with nursing homes. This helps to bridge the intergenerational gap and helps children foster empathy for the elderly and familiarises them to the ageing process. I believe the nursing home residents also benefit from the cognitive and social interaction. We should also be encouraging the same for our young here. Our frail elderly should not be forgotten and should not be segregated from the general community.”

Dr Munirah notes that Geriatric Medicine is considered relatively new in Singapore, its fledging status can be translated into more opportunities to push the boundaries in acute hospitals, in the community and in preventive care. Geriatric research is a ripe area to be explored, especially with research institutes focusing on Geriatrics being established recently. For those inclined, health policy-making for the elderly population is another area, where more improvement is needed. “We anticipate that the ageing population in Singapore will continue to rise with more entering the oldest-old range (≥ 85 years old),” says Dr Munirah. “It is to be expected because the medical advances we pursue also increase life expectancies. Our resources are limited so we must innovate. The solution is not necessarily just to build more hospitals and train more healthcare professionals, but to streamline and enhance our current processes to make it as seamless and integrated, and patient-centred as possible.”