Geriatrics Aphorisms
James R. Webster Jr., M.S., M.D.
The aging process is not
a disease, does not cause symptoms and is generally benign. The
hallmark of normal aging is loss of physiologic organ reserves
that place an older individual at risk of developing certain diseases
and syndromes. This risk can be significantly modified by behavioral
and life style interventions at almost any age.
The overwhelming majority
of older adults are active, independent and mentally intact. Physiologic
changes that occur with aging and the co-morbidity of multiple
illnesses result in atypical presentation of diseases in the elderly.
Serious illness can be present despite non-specific symptoms and
findings. These factors make the history and physical examination
especially challenging in the older adult. Physicians err both
in presupposing disability without reason and in overlooking the
risk of frailty in healthy, functional older adults.
The elderly have been found to have more undiagnosed disease than
other groups, suffer greater morbidity and mortality and require
prolonged recovery times. Special skills are required. Geriatric
care emphasizes total medical, social, psychological, and functional
assessment for comprehensive diagnosis and the determination of
patient needs. The functional impact of illnesses, rather than
their names or total number, guide diagnostic intervention and
treatment planning. Optimum recovery of function is the goal of
therapy.
Physicians caring for
the elderly must:
- Practice optimum interviewing
(history taking) and physical examination skills, taking into
account sensory and cognitive slowing. Develop comprehensive
care plans.
- Integrate the vastly
increased risk of iatrogenesis from drugs and procedures among
older patients into informed decision analysis for treatment
planning.
- Involve other health
professionals in the care of patients within formal or informal
interdisciplinary teams to meet the comprehensive needs of the
elderly.
- Apply primary care principles
and practice to an especially challenging age cohort.
- Utilize principles of
geropharmacology to: 1) avoid adverse reactions, and 2) provide
therapeutic advances.
- Consider the special
ethical challenges that elderly persons present, in order to
assure sensitive and appropriate decision making.
- Use "high-tech"
interventions based on the findings of geriatric assessment,
with informed decision analysis in a selective and efficient
manner. The elderly should not be deprived of new, effective
therapies that will improve their functional status. Neither
should they be subjected to impressive technologies that do not
support the care plan goals.
- Understand the specifics
of common geriatric syndromes and their frequently atypical presentations
which may be due to chronic cognitive impairment (which distorts
the history), hypophysiologic findings (e.g., blunted febrile
and cardiovascular responses), delirium as a non-specific initial
symptom, unusual etiologies (e.g., unexpected bacteria), and
confounding chronic illness.
- Emphasize primary, secondary,
and tertiary prevention: e.g., diet, exercise, immunizations
(flu/pneumonia vaccine), accident/injury prevention (esp. falls
prevention), vision and hearing evaluation, blood pressure control,
driver training/seat belts, dental health care, caregiver support,
specific disease screening programs, ASA therapy, estrogen therapy,
cigarette smoking and alcohol cessation, and possibly antioxidants.
- The I's of Geriatrics:
Health problems of the elderly which most commonly present with
interactive multiple causes:
Iatrogenesis, Immobility, Immune deficiency,
Impairment of vision/hearing, Impotence, Impoverishment,
Inanition (malnutrition), Incoherence, Incontinence,
Infection, Insomnia, Instability, Institutionalization,
Intellectual impairment, Isolation