Geriatric Care: General Principles

Description

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

Epidemiology

By 2050, the U.S. population anticipated to be >65 years old will be 22%, and those >85 years old may reach 4.5%. The geriatric population is projected to be 83.7 million.

Etiology and Pathophysiology

Physiology of aging

• The aging process is not pathologic but part of the developmental continuum. 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.
  • Declining 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 more prevalent in female population and with increasing age
• Telemedicine could enhance access to care via the following:
  • 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.cdc.gov/vaccines/hcp/imz-schedules/adult-age.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/
• Urinary incontinence: Inquire if patient has lost urine >5 times in past year.
• Polypharmacy (≥5 medications)
  • Use pill bottles, pharmacy records, and patient and caregiver input to reconcile medication lists.
  • Query OTC and CAM medications.
  • Reconcile medications at each visit
  • Attempt to simplify medications at each encounter.
• Substance use: CAGE criteria: https://www.mdcalc.com/cage-questions-alcohol-use
• Advanced care planning
  ALERT
  
  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 POLST (physician order for life-sustaining treatment) in most states and MOLST (medical orders for life-sustaining treatment) in some northeastern states