Geriatric Medicine - Section of UEMS

Demography
Bulgaria has a population of 7,204,687 (July 2009 est.).

The age structure of the population is:
0-14 years: 13.8% (male 509,544/female 484,816)
15-64 years: 68.5% (male 2,426,060/female 2,508,772)
65 years and over: 17.7% (male 518,711/female 756,784) (2009 est.)

Life expectancy at birth:
total population: 73.09 years
male: 69.48 years
female: 76.91 years (2009 est.)
As in many central and eastern European countries, in Bulgaria the ageing of the population is more significant for rural areas.

The average health-adjusted life expectancy (HALE) for males was 63 years compared to 67 years for women in 2002. Relative to those at the age of 60, the estimated HALE for men was 11.5 years and 13.9 years for women. The estimated disability-free life expectancy (DFLE) was 62.5 years for men and 66.8 years for women in 2002.

Bulgaria’s health expenditure as a percentage of GDP has been among the lowest in central and eastern Europe during the transition period, and is at present well below the EU average. In accordance with WHO estimates in 2004 total health expenditure in Bulgaria accounted for 7.7% of GDP in 2004.

In 2004 Bulgaria had 306 hospitals with 43 597 beds according to the National Centre Health Informatics.

Geriatric medicine

Background
In 1963 The Institute for Gerontology was founded in Bulgaria. In its centre of interest were aging process research and the effects of physical exercise to delay aging. Other topics of interest were demographic studies of aging, psychological and social issues etc. The Institute attracted many from the medical profession to work, do research and specialize in the field. In 1972 the Institute was transferred under the auspices of the Medical Academy of Sofia and was merged into the Institute of Endocrinology and Gerontology with a gradual wearing off of its activities as a result.

A significant number of doctors and therapists, who were involved at the Institute, have acquired solid knowledge and experience in the field of physical rehabilitation of the aging patient. Other postgraduate doctors, who have been involved in gerontology, state that they are trained in geriatric medicine. The difference between Aging research and Clinical geriatric medicine is unclear to most medics and so are the principles of Geriatric medicine altogether.

Teaching
The Chair of Endocrinology and Gerontology has not been active in any sort of geriatric teaching, neither on the undergraduate, nor on the postgraduate level. The farthest it has gone is to state that it offers non-obligatory courses in geriatric medicine for undergraduate students, which have remained unattended. The Institute of Gerontology has not groomed geriatricians, trained by modern standards and with relevant clinical experience, who would be able to teach students or postgraduate doctors.

There is no undergraduate teaching of medical students in the 5 medical universities in Bulgaria, as there are no teachers and as geriatrics is not included in the national curriculum. (TeGeMe study).

The postgraduate curriculum in Geriatric Medicine had to be written and presented to the European Union at the end of 2006 for the purposes of the acceptance of Bulgaria in the EU. Although the curriculum fulfills the requirement for a 4 year duration of training, its content does not fulfill the requirements of the internationally accepted definition of geriatric medicine. The Bulgarian training curriculum is organ based, emphasizes on studies of age related changes and misses out on the comprehensive geriatric assessment, the common geriatric syndromes, multidisciplinary team approach and other vital aspects of the specialty. It refers mainly to Bulgarian geriatric texts, two of which date back to 1966 and 1976 and it lacks internationally recognized text books as references altogether. Some universities have decided to attempt to offer the above training program to postgraduate doctors, it remains to be seen what will happen.

Some of the nursing schools have teaching in geriatric topics however.

In reality there are no geriatric beds for clinical teaching either. In addition, the public health system is based on funding for single problems as defined by a limited selection of Clinical Pathways. Therefore the budget is limited to the acute care of one medical problem and does not allow for geriatric medicine to be applied according to modern standards as a specialty treating patients with multiple co-morbidities and patients with specific complex geriatric syndromes.

Facilities

Acute hospital stays are considered completed when the number of maximum bed days as specified in the Clinical Pathway is reached (and this is usually very short). Many elderly patients are then discharged home in a state requiring major care input from family and additional paid medical consultations at home. This reflects on the health and functional outcomes and puts a huge burden on society in terms of time off work and large expenses for family members.

Post-acute and intermediate care facilities are exceptionally limited in numbers and do not offer a holistic approach to rehabilitation.

Public Long Term Care Facilities (LTCF) are limited in numbers and majorly underfunded. While most of them offer facilities and physical therapy staff for rehabilitation, they lack:

• Consistent criteria for admission (don’t exist)
• System of categorization for level of care (doesn’t exist)
• Sufficient staffing for nursing care (no set criteria for safe staffing levels)
• Medical care plans (GPs struggle due to lack of standardized approach to care plans)
• Nursing care plans (nursing diagnoses and care plans are not taught at nursing school)
• Specific training for nurses and caregivers
• Quality measures (no transparent system of quality assurance)

Private LTCF have started to emerge as the demand is huge, but in addition to not being affordable for the majority of the needy elderly, they have the same above listed problems as the public LTCF. The licenses for these facilities are not subject to strict control.

In summary, in Bulgaria modern Geriatric medicine does not exist.

Since the change of government in July 2009 some of the issues have been publicly addressed. One positive development is the acknowledgement, that there is no sufficient hospital care for the elderly and the strategy to develop post-acute and intermediate care in the public hospitals. The recent health service provider contract has for the first time included funding for a small number of post-acute diagnoses. The political momentum allows discussions about training and the need for criteria for rehabilitation, criteria for long-term care and quality indicators.

Politicians are also willing to accept new suggestions for introduction of internationally recognized teaching programs for doctors, nurses and caregivers.

Bulgaria cannot develop the specialty of geriatric medicine up to international standards without international help. It is obvious that the first step towards training should be to identify programs, by which the future teachers in Bulgaria will be trained and the respective funding for that. The UEMS is very supportive of these efforts and offers to guide the country through the process. The political environment is ready for this step.

Toni Staykova
FRACP, Geriatrician

MD, FRACP

Toni Staykova

Krasimir Vizev