Geriatric Care: General Principles



“First do no harm”; many well-intended diagnostic and therapeutic interventions (with efficacy established in younger patients) may not benefit the elder. Geriatric care, more than many other medical specialties, focuses on preserving and improving function and comfort, rather than on life extension.


The percentage of the U.S. population anticipated to be >65 years old by the year 2050 exceeds 20%, and the percentage of those who are >85 years old may reach 24%.

Etiology and Pathophysiology

Physiology of aging

  • The aging process is not pathologic but part of the developmental continuum. However, physiologic changes associated with aging tend to diminish the body’s compensatory reserve and increase susceptibility to disease.
    • Aging increases body fat and decreases total body water and lean body mass. This results in hydrophilic drugs having a smaller apparent volume of distribution. Lipophilic drugs will have an increased volume of distribution and longer half-life.
    • Aging decreases renal elimination of drugs.
    • Declines in lung capacity, oxygen uptake, cardiac output, muscle mass, glomerular filtration rate as well as blood flow to the brain, liver, and kidneys are associated with aging and must be considered in the diagnosis and treatment of elderly patients.

Risk Factors

Access to care

  • Despite Medicare, persistent barriers to care include but not limited to lack of provider responsiveness, medical bills, and transportation.
  • Barriers tend to be more prevalent in the female population and with increasing age.
  • Alternatives to the traditional face-to-face visit have become more possible since the COVID-19 pandemic. These could enhance access to care, and these include:
    • Encrypted email or home telehealth for those who are technologically equipped
    • Phone visits for those with adequate hearing
    • Nurse visits at home to evaluate and plan care by reporting to provider

General Prevention

Completion of an advanced directive is critically important.
  • Definition: Advanced directives are documents a person completes while still in possession of decisional capacity to ensure their values are reflected when considering how treatment decisions should be made on her or his behalf in the event she or he loses the capacity to make such decisions.
  • Instruments:
    • Durable power of attorney: Patient (called the principal) appoints an agent to handle specific health, legal, and financial responsibilities.
    • Health care proxy: a durable power of attorney specifically for health care decisions; their role is to express the patient’s wishes and make health care decisions if the patient cannot speak for themselves.
    • Living will: a legal document that allows patients to express their wishes for end-of-life medical care, in case they become unable to communicate their decisions
    • Discussions and completion of orders pertaining to end of life care, referred to as physician order for life-sustaining treatment (POLST) in most states and medical orders for life-sustaining treatment (MOLST) in some northeastern states

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