Description

The optimal approach to caring for our elderly patient population requires an understanding of the physiology of normal aging as well as unique geriatric considerations for access to care, diagnosis, treatment, and ongoing care. “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.

Epidemiology

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

Etiology and Pathophysiology

Physiology of aging

• Although patients age ≥65 years are typically considered elderly, there is variability in the rate of decline in organ function associated with aging dependent on genetic, environmental, socioeconomic factors as well as disease burden.
• 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:
  • A lack of provider responsiveness to patient concerns
  • Mounting medical bills
  • Transportation challenges
• Barriers tend to be more prevalent in the female population and with increasing age.
• Alternatives to the traditional face-to-face visit should be considered to enhance access to care:
  • 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

• Vaccination schedule for seniors: https://www.vaccines.gov/who_and_when/seniors/index.html
• Function is the heart of geriatric care. Assess and promote function at each encounter as changes in functional independence are common. Assess: activities of daily living (ADLs), instrumental ADLs (IADLs) (ability to use equipment such as a phone)
• Hearing assessment via hearing
  • Handicapped inventory
• Depression via:
  • Geriatric Depression Scale: https://consultgeri.org/try-this/general-assessment/issue-4.pdf
• Cognition via Mini Cognitive Assessment Instrument https://www.alz.org/media/Documents/mini-cog.pdf and Montreal Cognitive Assessment https://www.mocatest.org/
• Falls: Those with two or more falls in the past year, fall with injury requiring medical treatment, or fear of falling due to difficulty with gait or balance require a full fall risk assessment: https://www.cdc.gov/steadi/pdf/STEADI-Algorithm-508.pdf and https://www.cdc.gov/steadi/materials.html
• Urinary incontinence: Inquire if patient has lost urine >5 times in past year.
• Polypharmacy
  • Use pill bottles, pharmacy records, patient and caregiver input to reconcile medication lists.
  • Ask about use of over-the-counter and alternative medications.
  • Reconcile medications at each visit
  • Make an attempt to simplify medications at each encounter.
  • Engage patients and their caregivers in discussions regarding prescribing cascade and polypharmacy disadvantages
• Substance use: CAGE criteria: https://www.mdcalc.com/cage-questions-alcohol-use
• Advanced care planning
  ALERT
  Completion of an advanced directive among most important interventions
• 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 POLST (physician order for life-sustaining treatment) in most states and MOLST (medical orders for life sustaining treatment) in some northeastern states