Robert M. Palmer MD, MPH
The plan of care provided by primary care physicians and practitioners (PCPs) is becoming more challenging as the population ages and patients move across living situations, ranging from independent living to nursing home residence. Currently, about 13% of the American population is 65 years of age and older. By 2030 that percentage is expected to approach 22%. Primary care practice will be increasingly geriatric practice.
By convention, elderly is defined as being 65 years of age or older. However, this definition encompasses a range of ages spanning 5 decades and fails to consider the heterogeneity in the rate of aging and the incidence of chronic age-related diseases in the elderly population. PCPs who guide older patients through the process of care need to appreciate the differences in goals of medical therapy as elderly patients age and their site of care changes. Even as patients receive the medical care of specialists in outpatient or hospital settings, the PCP remains at the center of the care plan, helping to coordinate the complex, often conflicting recommendations of medical and other health professionals. The PCP helps sort out the major issues confronting the patient, helps the patient and family make important decisions about the scope and aggressiveness of medical care, and offers supportive reassurance to patients and their families through frequent office or hospital visits or telephone communication.
THE CARE PROCESS
The care process begins with the first encounter between the PCP and the older patient, most often in the outpatient setting. The first encounter establishes the rapport between physician and patient, creating a sense of trust and confidence on the part of the patient. That rapport is strengthened by the continuity of care provided by the PCP, who helps the older patient adapt to chronic illness, recover from acute and curable diseases, or move to a new living situation.
Manton KG, Gu X: Changes in the prevalence of chronic disability in the United States black and nonblack population above age 65 from 1982 to 1999. Proc Natl Acad Sci USA 2001;98:6354. [PMID: 11344275] (National surveys conducted over the past 3 decades show that the rate of physical disability measured in terms of independent performance of ADL is gradually decreasing.)
HEALTH CARE-RELATED CHOICES
As patients age, there is a transition in the health care, from primary prevention and curative interventions to secondary prevention and chronic disease management. However, the opportunities to delay or prevent physical disability, illness, and functional decline (loss of independent performance of ADLs), through detection of risk and implementation of effective interventions, never cease. Greater collaboration with allied health professionals and family caregivers is justified.
To establish goals of medical care with older patients, PCPs should understand the patient's personal values, health care expectations, and priorities. Discussions with family members, at the discretion of the patient, can be the source of substantial enlightenment regarding the patient's values.
Although the fear of death may be great, some older persons have a greater fear of loss of autonomy resulting from physical disability and of becoming a financial, emotional, or physical burden to their families. Others, however, may value life extension at any cost, even over quality of life and degree of suffering. Insight into the patients' values is gained through discussion regarding patients' perceptions about the quality of life they have and seek. For example, what priorities do they hold most dear? How important are religious beliefs in the decision to pursue or forgo medical care? How important are the wishes and interests of family members or close friends? Older patients will often define their values primarily in the context of what is perceived to be the best decisions for their family members, especially when issues of finances or caregiving are involved.
Values change over time, so periodic discussions with the patient are advisable. Even when it appears that patients lack specific goals for medical care, they can be asked what events or activities make living important or worthwhile, thereby serving as incentives for recovery and living.
Patients' values extend to their expectations for each health care encounter. Open-ended questions directed to patients give them license to discuss nonmedical issues such as personal losses or worries that might be of a sensitive nature and otherwise left unrevealed.
The PCP needs to update medical information to make the most accurate diagnoses and to offer the soundest advice. Laboratory and diagnostic studies are obtained and reviewed, and recommendations made in the context of each patient's value system.
A geriatric assessment should be performed so that the physician can objectively evaluate the patient. A geriatric assessment helps to catalogue the medical, psychosocial, and environmental factors that affect health and level of functioning. Medical diagnoses are catalogued and updated on the patient's problem list.
In the care process, periodic review of the patient's functional status is useful, with a focus on changes in domains of health: performance of basic ADLs and IADLs; cognition; gait and mobility, including recent falls; nutritional status (weight loss of>10 lb in 6 mo); social supports; and living situation. A change in functional status indicates a significant decline in general health or the potential for further decline and signifies the need for further investigation and perhaps closer medical follow-up. Diagnostic investigations must be undertaken in consideration of the patient's ability and willingness to undergo difficult or discomforting diagnostic studies. For example, in pursuing a workup for gastrointestinal bleeding, the patient might be too physically frail to undergo colonoscopy. A more cautious course of evaluation is justified. In contrast, when an otherwise high-functioning patient expresses a desire for an aggressive evaluation, the PCP again serves as a patient advocate to pursue the subspecialty consultation.
Patients' judgments regarding whether to proceed with interventions are based on the degree of accurate information they receive and are often influenced by the opinions of their family members. Differences in opinions among patients, families, and physicians are common and can be resolved through a process of negotiation. Contingencies are created with explicit time frames for assessing the patient's decision. For example, if the patient refuses colonoscopy for evaluation of occult blood loss, the option of a less invasive procedure is given (eg, checking for occult blood on several more samples of stool and performing frequent blood counts to detect anemia). The overall strategy is reviewed and modified. If the reluctant patient continues to have occult gastrointestinal bleeding, the contingency plan might change to include colonoscopy without proceeding to more invasive therapies unless there is a risk of bowel obstruction resulting from carcinoma. This decision is documented in the PCP's record and is transmitted to specialists involved in the patient's care. The outcome (eg, a negative colonoscopy) is reviewed and issues of further evaluation (upper endoscopy) are considered. Although this process of recommending a course of diagnosis, negotiation, and agreement on strategy is lengthy, it can be carried out over the course of several office visits and reviewed and updated during office visits scheduled for other purposes (eg, blood pressure checks or immunizations).
CHANGING GOALS & OBJECTIVES
The goal of patient care is to prevent disease and disability and help aging patients enjoy optimal quality of life. The objectives of patient care change with advancing age. In part, they are influenced by the patient's additional years of life expectancy, functional status and level of physical disability, and presence of ultimately fatal diseases.
For the young–old, the goals of therapy are somewhat similar to those for middle-aged patients. For example, the average 65-year-old American woman has an additional life expectancy of about 19 years, thereby justifying a medical approach that focuses on primary prevention of diseases, screening, and detection of diseases in early and treatable stages. Because the young–old have a low rate of disability, the preservation of physical independence is given a high priority. Hence, medical priorities include weight loss for overweight patients, especially those with cardiovascular risk factors, and regular and sustained programs of endurance and resistive exercises. Aggressive diagnostic investigations and interventions are offered to older patients as they would be to middle-aged patients.
As patients' age, additional years of life expectancy decline and influence the degree of aggressiveness of diagnostic and therapeutic actions and hence the goals of therapy. For the old–old, the goals of therapy become influenced by the occurrence of chronic and ultimately disabling or fatal diseases, such as Alzheimer's disease. Increasingly, more consideration is given to quality of life issues (largely determined by functional status) in the finite remaining years. However, aggressive efforts are warranted to prevent functional disability and treat chronic diseases. Evidence is growing that the old–old benefit from medical treatments for hypertension, coronary artery disease, and osteoporosis. Falls are potentially preventable for these at-risk patients.
For the very old, a more cautious approach is best considered before embarking on extensive testing or aggressive interventions. Decisions must weigh the benefits against the discomforts or harm of diagnostic studies and therapies. For example, chronic hemodialysis and renal transplantation are increasingly being offered to elderly patients. These approaches might be appropriate for older patients whose functional status would be greatly improved with the therapy but not for those with a guarded prognosis as a result of severe comorbid conditions (eg, advanced Alzheimer's disease). By age 85 the average woman has an additional life expectancy of ~6 more years, the average man 5 years. It becomes more difficult for the PCP to justify screening tests and therapeutic interventions that might have limited use. One analysis that examined the role of cancer screening in older patients found substantial variability in the likelihood of benefit for patients of similar ages with varying life expectancies. Those with life expectancies of<5 years are unlikely to derive any survival benefit from cancer screening. In fact, there is a likelihood of potential harm (ie, by detecting cancers that would never have become clinically significant and implementing treatment).
Walter LC, Covinsky KE: Cancer screening in elderly patients:A framework for individualized decision making. JAMA 2001; 285:2750. [PMID: 11386931] (Framework for guiding physicians and elderly patients to more informed cancer screening decisions by detailing the benefits and harms that need to be weighed when making screening decisions.)
ADVANCE CARE PLANNING
The PCP is in the pivotal position of helping patients plan their future care. In particular, physicians can promote earlier patient–physician discussions about end-of-life care preferences and the completion of advance directives. The discussions, often held before or during a patient's transition in living situation or general health, include sensitive issues such as the patient's wishes for end-of-life care (eg, cardiopulmonary resuscitation, intensive care, ventilator support) and nutritional support during acute or end-stage illness. In the event of end-of-life care, one should review the goals of continuing care, including palliation, comfort measures, and the role of hospice.
Advance directives, health care proxies, and living wills permit patients to make decisions regarding their health care, to be implemented when the patient becomes incapacitated. A living will explicitly addresses the actual treatment preferences of a competent adult. It specifies the use, withholding, or withdrawal of life-sustaining treatments if the individual loses the capacity to make such decisions because of terminal illness or permanently unconscious state. Comfort care measures are continued in these states. The durable power of attorney for health care designates surrogate health care decision-makers if the person becomes incapacitated. The designated agent is allowed to act on the person's behalf in making decisions regarding medical care, including the withdrawal of nutritional support or other treatments in the event of a terminal illness or permanently unconscious state. State laws vary in terms of content and portability of the durable power of attorney for health care. Incompetent patients who lack next of kin or power of attorney for health care require guardianship.
Advance directives, although desirable, do not always reflect the wishes of the patient during a moment of crisis. Even in the face of terminal illness, many patients, their families, or physicians insist on aggressive interventions for critical illness, suggesting that these decisions need to be decided before the incident critical illness or at least early in the course of the illness.
Miller DL, Bolla LR: Patient values: the guide to medical decision making. Clin Geriatr Med 1998;14:813. [PMID: 9799481] (Advance directives express a patient's preferences regarding end-of-life care and are used to guide medical treatment. Patients who lack decision-making capacity require appropriate surrogate involvement.)
Crawley LM et al: Strategies for culturally effective end-of-life care. Ann Intern Med 2002;136:673. [PMID: 11992303] (Physicians should assess the cultural background of each patient and inquire about values that may affect end-of-life care.)
Hruby M et al: How do patients view the role of the primary care physician in inpatient care? Am J Med 2001;111:21S. [PMID: 11790364] (Patients under the care of an inpatient physician desire contact with their PCP and good communication between the PCP and hospital physicians.)
RELEVANT WORLD WIDE WEB SITES
Alzheimer's Association: http://www.alz.org
Caregiver resources: http://www.caregiver911.com
National Association of Area Agency on Aging: http://www.n4a.org
National Family Caregivers Association: http://www.nfcacares.org
National Safety Council: http://www.nsc.org
Senior Scope: http://www.seniorscope.com
U.S. Department of Health and Human Services, Administration on Aging: http://www.aoa.dhhs.gov