Current Geriatric Diagnosis & Treatment, 1st Edition
Section I - Approach to the Geriatric Patient
1. The Need for Expertise in Geriatric Medicine in the Care of Older Patients
William L. Lyons MD
- Seth Landefeld MD
The discipline of geriatric medicine arose in part because aged patients are more complex than they were in middle age, with some extra decades under their belt. Many persons who live long enough become as qualitatively different from younger adults as children are. Yet most health care providers are not taught the principles and perspectives that come into play when caring for the aged.
DIMINISHED PHYSIOLOGICAL RESERVE
The connection between old age and frailty—in its popularly understood sense—is ancient. Older people are predisposed to suffering bad health outcomes, including bothersome symptoms, diminished ability to perform desired tasks and roles, and death. For some, these outcomes result from recurrences or exacerbations of diseases that plagued them earlier in life. For others, they result from serious diseases, such as cancer or cardiovascular disease, which increase in incidence with age. For many older people, the years take a more global toll in reduced vitality and resilience. This reduction in vitality and resilience results in part from a gradual diminution in the maximum capacity of physiological systems: cardiovascular, pulmonary, renal, musculoskeletal, neurological, endocrine, and immune. The rate of decrease in physiological capacity and its time of onset differ among persons, but a decrease is universal at some point after the age of 30. The decrease in physiological capacity may be imperceptible throughout life, but often physiological capacity falls below a threshold that is noticed. As a result, simple activities of everyday living, such as walking to mail a letter or shopping for groceries, may slow, then become difficult, and eventually require assistance of a device or another person.
One common manifestation of this diminished reserve is the appearance of well-described geriatric syndromes. Because many elders are operating near the capacity of one or more of their weakened physiological systems, even a small event (such as initiation of a new medication or an otherwise mild illness or injury) can generate a system failure. A number of such failures seem to be particularly prevalent—syncope, falls, delirium—perhaps reflecting the systems (cardiovascular, musculoskeletal, and cerebral, respectively) in which humans most commonly run out of reserve.
There are several clinically important consequences of geriatric patients' diminished physiological reserve.
- Disease presentation in older persons is often atypical. Whereas a 45-year-old with pneumococcal pneumonia may present with complaints of fever, productive cough, and pleurisy, an 85-year-old may, with the same infection, present with acute confusion, or light-headedness and new urinary incontinence.
- Occam's razor, or the law of diagnostic parsimony, may not apply. The old adage that a single unifying diagnosis will explain all of a patient's clinical findings works much better in the care of
young or middle-aged patients than in the care of frail elders. With many older patients, symptoms and findings precede the crisis that leads to the physician's visit or they coincide in time and are unrelated. Often a crisis is precipitated by an event largely because of the context of contributing comorbid conditions and diminished physiological capacity; for example, a viral upper respiratory infection that would hardly slow a 30-year-old might precipitate ventilatory failure and delirium in an 80-year-old with chronic obstructive pulmonary disease and mild cognitive impairment who lives alone. Clinicians treating elders need to become comfortable with the notion of not “making the diagnosis” and selecting a single therapeutic “magic bullet.” Often, when a reasonable search for a single cause has not turned up a clear cause for a new illness episode, it is necessary instead to direct attention and treatment to multiple potential contributing factors. At the risk of overgeneralizing, a provider caring for an elder with syncope is more likely to benefit her by attending to issues of dehydration, polypharmacy, and posture (patterns of assuming upright position) than by ruling out the elusive pulmonary embolus and failing to consider these common issues.
- Diminished physiological reserve produces weakened compensatory mechanisms, which may otherwise allow a disease to present at an earlier, less severe stage in elders. A case of Graves' disease, which would have produced only mild nervousness in a middle-aged woman, may cause an 80-year-old to become profoundly confused and incapable of caring for herself.
- Weakened compensatory mechanisms contribute to the slowed recovery from illness seen in many elders.
- Certain preventive measures (eg, vaccines for influenza or pneumococcal pneumonia or exercise training to prevent falls) are beneficial in many elders because they support focal areas of diminished reserve.
- Beyond the fact that older patients have more interactions with the health care system (more drugs, more procedures), their weakened reserve puts them at greater risk of iatrogenic injury.
NEUROPSYCHIATRIC CHANGES & THE MIND–BODY INTERACTION
Aging is associated with an increase in the prevalence of serious brain diseases, such as dementia and stroke. More subtle changes in cognition, personality, or mood also seem to occur with the passage of time. Taken together, all of these effects mean the elderly population has a broad spectrum in intellect, outlook, and vitality. The interaction between neuropsychiatric deficits and physical health and function is intrinsic to geriatric practice and is an area of intense gerontological research. A few phenomena seem to be clear. Neuropsychiatric problems are generally associated with (and are probable contributors to) both physical frailty and social isolation, and neuropsychiatric deficits and medical comorbidities have a potent, negative interaction. A demented elder with pneumonia has a far graver prognosis than one with either dementia or pneumonia alone. A reciprocal dynamic of body-mind frailty is at play as well. Mood and cognition are both influenced by physical illness (eg, depression arises commonly in the wake of myocardial infarction), and the strength of the interaction may be greater in the older population.
CLOSER TO THE END THAN THE BEGINNING
The fact that elderly persons are closer to the end of life than are the young has several implications for providers of geriatric care. At a practical level, this influences medical decisions, such as whether to replace a native cardiac valve with a bioprosthetic or a longer lived mechanical valve and when to cease screening for colon cancer. More broadly, the later stages of life may bring with them a change in a patient's goals for health care. Younger patients usually seek cure of disease and prolongation of life. Many elders seek the same, but a substantial number place greater emphasis on comfort, function, and the ability to live independently. Experienced providers of geriatric care learn to engage their patients in goals-of-care discussions, a skill less called for in the care of younger individuals.
MULTIPLE VENUES OF HEALTH CARE
Because of the great variety of elders' health needs, functional deficits, social supports, and goals of care, professional services for this group are provided in more settings than with any other population. Familiarity with the capabilities, characteristics, strengths, and weaknesses of local clinics, acute hospitals, rehabilitation hospitals, skilled nursing facilities, residential care facilities, geropsychiatric units, hospices, and home care agencies will assist the clinician in caring for older patients. It is not unusual for a frail elder to pass through a number of these venues during a single illness episode. Negotiating the transitions between venues of care is an essential part of geriatric health care.
THE IMPORTANCE OF MONEY & FAMILY
Finally, although everybody needs financial reserves and a loving family or friends, these are particularly precious resources for the health of elders. Many elders come to medical attention because of some combination of economic constraints and social isolation. The cost of medications, professional services, and personal help increases with age for many people, whereas incomes do not, leading to a financial imbalance that impoverishes some older persons and forces many to neglect some needs to pay for others. Without assistance from concerned others, getting to grocery stores, pharmacies, and physician appointments may become impossible. With older patients, the key to diagnosis and treatment in a difficult situation often lies in the social history.
Covinsky KE et al: Relation between symptoms of depression and health status outcomes in acutely ill hospitalized older persons. Ann Intern Med 1997;126:417. [PMID: 9072926] (Depressive symptoms slowed functional recovery from an acute illness, illustrating the synergistic effects of neuropsychiatric impairment and medical illness.)
Mahoney JE et al: Problems of older adults living alone after hospitalization. J Gen Intern Med 2000;15:611. [PMID: 11029674] (Older persons who live alone and receive home nursing after hospitalization were less likely to improve in function, and more likely to be institutionalized, than those who live with others.)
Resnick NM, Marcantonio ER: How should clinical care of the aged differ? Lancet 1997;350:1157. [PMID: 9343575] (Overview of differences required in approaching the elderly patient.)
Rosenfeld KE et al: End-of-life decision making: A qualitative study of elderly individuals. J Gen Intern Med 2000;15:620. [PMID: not available] (Discussions with elderly about advance directives and goals of care should focus on valued life activities and acceptable health status rather than specific medical interventions.)
Sands LP et al: Cognitive screening identifies trajectories of functional recovery from admission to three months after discharge in hospitalized elders. J Gerontol A Biol Sci Med Sci 2003;58:37. [PMID: 12560409] (Cognitive impairment slowed functional recovery from an acute illness, illustrating the synergistic effects of neuropsychiatric impairment and medical illness.)
Tinetti ME et al: Dizziness among older patients: A possible geriatric syndrome. Ann Intern Med 2000;132:337. [PMID: 10691583] (Dizziness was associated with predisposing characteristics and precipitating situational factors and is illustrative of other multifactorial geriatric syndromes.)