Medicine in old age

Medicine in old age - technical.

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Essentials

Frailty

Frailty occurs in a mainly older or geriatric population, is linked to the accumulation of a number of different health-related problems, and may influence disease presentation. A frequently used clinical definition recognizes presentations comprising weight loss, exhaustion, slow movement, a low level of physical activity, and weakness. It can also be graded by degree of disability: (1) very mild frailty describes someone who has given up complex hobbies; (2) mild frailty implies some dependence on ‘instrumental activities of daily living’; (3) moderate frailty involves intermediate self-care activities; and (4) severe frailty requires personal-care dependence. The complexity of frailty underlies the difficulties that often arise when managing the care of an older person. Understanding the concept and consequences of frailty is essential to the problems of and successful management of many older people.

Falls

Falls occur frequently in older people, especially women. Prevention, unfortunately often secondary prevention, is as important as managing the consequences of the fall that has brought someone to medical notice. A careful history should be taken from everyone who has fallen, and they should be carefully examined, including detailed examination of the central nervous system (CNS), rather than the frequently entered single comments ‘CNS normal’ or ‘CNS NAD (no abnormality detected)’. Falls clinics make an important contribution both to the long-term well-being of patients and also to reducing hospital referral and the consequent costs. Helping patients overcome the fear of falling is often an important contribution to their well-being, as is teaching them how to get up after a fall. Careful assessment with appropriate management will often reduce the frequency of the falls, and also their consequences. Prognosis for many people who have been falling is good.

Pressure sores

A patient in hospital should never be allowed to develop a pressure sore. Those at risk should be carefully monitored and predisposing factors carefully managed. Most are multifactorial in aetiology, with important factors being pressure shearing forces, friction, and maceration from prolonged contact with moisture. Careful nursing, the use of risk-factor scoring systems, and—where appropriate—pressure-relieving devices, will minimize their development. Once established, treatment should be directed not only at the pressure sore itself, but also to nutrition, fluid intake and predisposing factors such as incontinence and comorbidity that may impair healing. Infected and difficult pressure sores will often require expert advice from a microbiologist and/or plastic surgeon.

Delirium

Delirium is defined as a disturbance of consciousness and a change in cognition that develops acutely. It is common among older people, in whom it is a sensitive but nonspecific sign of illness, especially in older people who are frail. The American Psychiatric Association has developed widely used diagnostic criteria, emphasizing that delirium should be classified by its presumed cause.

Urinary incontinence

This is a frequent problem that is often under-reported. It can usually be classified into one of a number of causes, including (1) overflow incontinence, (2) stress incontinence, (3) urge incontinence and—probably most commonly—(4) mixed incontinence. Treatment depends upon the underlying cause or causes, and the ability to influence these. In many cases it will be possible to improve or resolve the incontinence, so improving the patient’s quality of life. Long-term indwelling catheters always lead to infection and should be used only as a last resort.

Faecal incontinence

Faecal incontinence is much commoner than appreciated because people are reluctant to discuss an embarrassing condition. It can have a major effect on the quality of life of both patients and their relatives, and many can be helped by simple interventions, hence it is a symptom that should be sought directly during history taking in those particularly at risk, including (1) frail women who have had obstetric damage; (2) people with loose stools or diarrhoea (whatever the aetiology); (3) people with dementia or some neurological conditions; and (4) people with chronic constipation or faecal impaction. Management includes identifying and treating the underlying cause, but at the same time preserving the patient’s dignity and offering appropriate psychological support.

Prescribing for older people

Dosing schedules of many drugs frequently prescribed for frail older patients are based on data obtained mainly from trials in younger patients. However, aside from issues of the effect of possibly impaired hepatic and renal function, older people often have comorbidities that are also treated with drugs, which may affect results of subsequent prescribing, and the tendency to do so without regular review is probably a significant cause of both morbidity and mortality. When a new drug is being prescribed, all existing treatments should be reviewed, and in most situations it is advisable to start with a low dose that is increased cautiously, monitoring the emergence of unwanted effects very carefully. Compliance is often a problem, for many reasons, and also needs careful monitoring.

Surgery and the older patient

Chronological age alone should never be considered a contraindication to surgical procedures. Careful preoperative assessment and evaluation of the relative fitness and frailty of patients will direct surgery towards improving the quality of life of many older people. Assessment requires a careful history and examination, also appropriate investigations, to identify the presence and extent of comorbidities (particularly cardiopulmonary) that may complicate the surgery and postsurgical recovery, with particular note taken of the patient’s nutritional state. It is vitally important to have a careful understanding of the patient’s prior state of function, and to assess both the patient’s (and family’s) and the surgeon’s understanding of how the current level of function is likely to improve (or is threatened) by a given procedure. Making explicit the supposed goals of surgery also allows the patient and their family to have a role in making any decision about the appropriateness of surgical intervention.

Older people and driving

Driving skills decline in many older people, and in many countries this is taken into account when motor vehicle insurance and/or driving licences are renewed. However, the notion that older people are at greater risk on the road is not generally true, with the higher numbers of crashes per mile driven by older people being related more to their lower mileage than to age itself.

In many countries the driving licence authority must be notified, usually by self report, of the development of any condition that may affect driving skills, for some of which very definite guidelines have been formulated, e.g. cerebrovascular disease, seizures. Most people with early dementia can probably drive safely for the first 3 years after their diagnosis, but there is considerable variation between people and so assessment should be individualized. In the United Kingdom, the Driver and Vehicle Licensing Agency must be notified of all new diagnoses of dementia, usually by self report, but if necessary by the clinician involved. Cognitive testing in itself is not a good basis for judging driving skills, but identifies those who require formal on-the-road assessment. If the latter is not immediately available, a decision has to be made about whether the patient should continue to drive while awaiting their assessment.

Introduction 

In the Western world, most people who are ill enough to be admitted to hospital are old, so it is natural to ask what makes a patient (or a clinical service) ‘geriatric’. Just as there is much local variation in how specialized geriatric medicine services are labelled (e.g. ‘clinical gerontology’, ‘elderly medicine’, ‘geriatric medicine’), the question of who or what is ‘geriatric’ is answered differently in different places.

Depending on local history and circumstances, some places run ‘age-defined’ specialized geriatric services, where chronological age, typically 70 or 75 years, makes someone ‘geriatric’. Other specialized geriatric medicine services target certain conditions, such as delirium, falls, or functional decline. Elsewhere, the geriatric medicine service focuses more on rehabilitation, although this in turn prompts questions about what makes a patient suitable for ‘geriatric rehabilitation’ and not for the ‘rehabilitation medicine’ service. Others offer very little acute care, finding that the mandate of geriatric medicine in their area is best employed by focusing on patients who receive institutional long-term care. Wherever geriatric medicine is employed, however, patients tend to have in common their multiple, interacting medical and social problems that adversely affect their prognosis: worse health, impaired functional ability, and death.

The case for geriatric medicine can be restated as the care of elderly people who are frail. Above all, it is their complexity that justifies a separate speciality to care for frail elderly people. For many elderly people, the management of their medical conditions should be subject to the same principles as those applied in younger people, as described elsewhere in this textbook, but modified by the age-related principles discussed in the following paragraphs. Older people are prone to many diseases, few of which are specific to ageing although some occur more commonly in later life. It is the interaction of a number of factors, including multiple pathology, age-related changes in physiology, greater sensitivity to the effects of many drugs, often combined with an elderly person’s social situation, that determines the presentation of illness. This chapter emphasizes the concept of frailty in older people, and some of the major problems that often lead to older people being admitted to hospital rather than specific medical conditions.

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Conclusions

The care of elderly people, especially those who are frail, offers rewarding personal and professional opportunities for physicians who like complexity, who can handle uncertainty, who are interested in an approach to the whole patient, and who enjoy (or are at least skilled at) dealing with families. Good geriatric medicine is practised by balancing an understanding of the individual ailments faced by an older person with a sense of their overall needs. Geriatricians embrace the complexity of their patients through an approach rooted in comprehensive geriatric assessment, and by the evaluation of high-order, integrative activities such as cognition, function, mobility and balance, and drug handling. Societies’ compelling need for geriatric medicine, and the considerable opportunities to make care better through a better understanding of what elderly people need, and what works best for them, will make this an exciting area of human endeavour for the foreseeable future.

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