Geriatrics is a branch of the biomedical sciences devoted to helping the elderly (over 65 years old) deal with the effects of age. The geriatric approach does not try to reverse the aging process but rather to minimize its consequences by reducing or inhibiting the progression to disability. This effort, conducted in hospitals, clinics, and nursing homes, is based on a broad range of therapies that are grounded in the biological, psychological, and social sciences.
Treating and caring for the elderly is a complex endeavor. Because of their age, older people are usually suffering from several simultaneous disorders that cannot be treated with the drugs or therapies that are routine for younger individuals. Drug therapies assume a clearance time (physiological deactivation of the drug) provided by a healthy liver, which may not be found in an older patient. For example, drugs that are safely used to treat depression or cardiovascular disease in young patients can have devastating effects on the elderly. In addition, accurate medical histories are often difficult to obtain from elderly patients, either because of poor memory, or because of psychological compensation by which the patient ignores and minimizes danger signs and symptoms. Growing old is a time of loss: An elderly patient may have lost her husband, friends, physical abilities, and her family home may have been given up for a room in a nursing home or hospital ward. All of these elements complicate the diagnosis and the prognosis for a geriatrics patient.
The focus of this topic is clinical geriatrics, which covers the many problems associated with the care and treatment of the elderly. The discussion begins with the demographics of North American society with respect to age distributions, epidemiology, and the capacity of health-care providers to deal with the ever-expanding geriatrics population.
Our aging society
Between 1900 and 1990 the total U.S. population increased threefold, while the number of elderly people increased tenfold. In 1990 more than 35 million Americans were over the age of 65, nearly twice as many as in 1960. This number reached 38 million in 2007 (10 percent of the population) and is expected to increase further to 88 million by 2050 (20 percent of the population). There are currently more than 5 million people who are among the very old (85 or older) and 96,548 centenarians (100 years or older), a number that is expected to increase to 600,000 by 2050. Women tend to live longer than men, so that among the very old, for every 100 woman there are only 41 men. Before the age of 85, the elderly usually live with relatives or a spouse, but after 85, 18 percent of men and 28 percent of women live in nursing homes or hospital wards.
Per capita costs for acute and long-term (chronic) health-care services are highest for the very old, so the growth of this group will have a profound affect on health-care costs. People over 65 currently represent just more than one in three of the patients seen by a primary care physician, and over the next 20 years this ratio is expected to increase to one in two. While the costs of caring for the elderly is expected to rise, this is due not just to the patient’s age, but also to a general increase in the complexity and expense of diagnostic procedures and equipment. It is expected that as the proportion of older to younger people increases, less financial and social support will be available for the elderly. Medicare and Medicaid cover much of the financial burden of caring for the elderly in the United States. But even with these public services, the elderly still bear a considerable share of the expenses. Currently, geriatrics patients can expect to pay as much as 25 percent of their income for medical care.
Evaluating the geriatric patient
Evaluation of a geriatrics patient is much different from that of a younger individual. Young patients generally have a single complaint that the physician can focus on, and there is usually no reference to the patient’s socioeconomic environment. But the approach to a geriatrics patient usually begins with the physician asking the patient to describe a typical day in his or her life. In this way the physician can best assess the elderly person’s overall quality of life, liveliness of thought, and physical independence. This approach also helps develop a good patient-physician rapport, something that is especially important to elderly patients, who often take longer to answer questions, and may be shy because of it. In the initial interview, geriatricians are especially careful not to infantilize the patient by asking an attending relative questions pertaining to the patient’s history or medical status. It is for this reason that geriatrics patients, unless suffering from dementia, are interviewed alone. During the initial evaluation and interview, the physician attempts to gather information about the patient’s medical, drug, nutrition, and psychiatric histories.
Medical History
With an elderly patient the medical history may extend back to a time when society’s disease profile was different than it is today. For example, rheumatic fever and tuberculosis were much more common in the mid 1900s than they are today. Consequently, the physician will ask about diseases that were common when the patient was young. The patient will also be asked about outdated treatments, such as mercury for syphilis or pneumothorax therapy for tuberculosis. Elderly people tend to underreport symptoms out of denial or a fear of illness, disability, and the dependence these conditions may bring. Aging can also alter the individual’s response to certain diseases, such as a painless myocardial infarction or pneumonia without a cough.
Drug History
Although the physician will ask the patient, and the patient’s relatives, about prescription drugs, some geriatricians have suggested that the best approach is the "brown bag" technique, whereby the patient is asked to empty his or her medicine cabinet into a brown paper bag and then to bring it to the evaluation interview. Often the complaints of older patients are traced to a drug or combination of drugs they have been taking. The drug history includes determining which drugs are used, at what dose, how often they are taken, who prescribed them, and for what reason. Topical drugs are included, such as eye drops for treating glaucoma, because there is the possibility that systemic absorption may cause unexpected side effects in the elderly. Over-the-counter drugs must be included because their overuse can have serious consequences, such as constipation from laxative use or salicylism from aspirin use. Patients are also asked to demonstrate their ability to read the labels (often printed in very small type) and to open the container, which may contain a child-resistant lid. Because older patients are often treated with multiple medications, they are at risk of noncompliance and adverse effects.
Nutrition History
The physician tries to determine the type, quantity, and frequency of food eaten, including the number of hot meals per week. Special diets, self-prescribed fad diets, alcohol consumption, over-the-counter vitamins, and dietary fiber are also determined. For the elderly, it is very important to determine the amount of money the patient has to spend on food each week, and whether suitable cooking facilities are available. The patient’s ability to eat is assessed by examining the mouth and the condition of the teeth or dentures, if fitted. Poor vision, arthritis, immobility, or tremors may affect an old person’s ability to prepare food. A patient who suffers from urinary incontinence may reduce fluid intake, which could also lead to poor food intake.
Managing age-related disorders
The most common disorders of the elderly are dementia, cardiovascular disease, osteoporosis, and incontinence. It is not unusual for elderly patients to suffer from all of these disorders simultaneously.
Dementia
Nearly half of all elderly patients suffer from various degrees of dementia. Two-thirds are caused by Alzheimer’s disease (AD) and are currently irreversible. Reversible dementias are caused by strokes, neoplasms, or toxins such as alcohol, or those produced by infections. Although a complete cure for most dementias is not possible, optimal management can improve the ability of these patients to cope with basic tasks. In many cases, dementia is the result of one or more small strokes caused by hypertension. Thus the first step in managing dementia is aggressive treatment for high blood pressure. This is followed with pharmacological agents that enhance cognition and function, and treat associated problems, such as depression, paranoia, delusions, agitation, and even psychoses.
Where AD is suspected, the patient may be treated with cholin-esterase inhibitors to maximize the half-life of brain neurotrans-mitters. There are three such drugs available: donepezil, rivastig-mine, and galantamine. Clinical trials have shown that these drugs can improve cognitive function. But side effects, including nausea, vomiting, and diarrhea can lead to serious complications. Other drugs, such as estrogen (for women), vitamin E, ginkgo biloba, and nonsteroidal anti-inflammatory agents, are also used but their effectiveness is in doubt. While these agents may be ineffective as a treatment for advanced dementia, they may be useful in treating milder cases.
Cardiovascular Disease
Cardiac output and the response of the heart to exercise decreases with age. Ventricular contractions become weaker with each decade, a problem that is compounded by the age-related reduction in blood vessel elasticity. Hardening of the arteries is the prime cause of hypertension in the elderly, but it is not an unavoidable consequence of aging. The first stage in managing hypertension and cardiovascular disease is a change in lifestyle. Clinical trials have shown that even the very old can benefit by this approach, which involves maintaining an ideal body weight, no smoking, regular aerobic exercises, and a diet consisting of fruits, vegetables, and low-fat dairy products (all of which are rich in essential potassium, calcium, and magnesium). If these procedures fail to reduce blood pressure, drugs such as thiazide, beta-blockers, or calcium channel blockers may be used, but the diet and exercise regimen should be maintained.
Osteoporosis
Diminished bone mass can be determined most conveniently with special X-ray machines (dual energy X-ray absorptiometry) or with ultrasound densitometry. Both procedures determine the density as g/cm2, which is compared to normal values from a younger population and is used to estimate the likelihood of fracture. The first attempts to manage this disease involve a diet rich in calcium and vitamin D, along with regular weight-bearing exercises. Hormone replacement therapy has also been recommended, for men and women, but as discussed in a previous topic, this approach can lead to dangerous side effects. An alternative drug therapy involves the use of bisphosphonates, antiresorptive drugs that are known to increase bone mass. The bisphosphonate, alendronate, was shown to decrease the incidence of vertebral and nonvertebral fractures by more than 50 percent in postmenopausal women. The major side effects are gastrointestinal, and the drug must be taken on an empty stomach in an upright position.
Incontinence
Incontinence, or the involuntary loss of urine or stool, is very common in the geriatric population. About 33 percent of elderly women and 20 percent of elderly men suffer from this disorder. The prevalence may be as high as 80 percent in nursing homes or long-term care institutions. Incontinence may develop because of neurological damage sustained after a stroke, or it may be traced to age-related changes in the urinary system, in particular, the integrity of the urethra, and the holding volume of the bladder, which decreases with age. Delirium and the stress of being exposed to a new environment, such as recent admission to hospital or nursing home, can also lead to incontinence in the elderly. Simply modifying the patient’s fluid intake and eliminating diuretics such as coffee or tea can often treat transient incontinence.
Persistent or acute incontinence is managed initially by ensuring the patient can reach a toilet quickly. It may also be necessary to provide the patient with incontinence undergarments and pads. Often with special care and training the problem can be resolved. In other cases it may be necessary to resort to drug therapy. A commonly used drug is a bladder relaxant, tolterodine, which is available in long-acting preparations. In severe cases surgery may be required to repair damaged sphincters that normally regulated urine flow through the urethra. It may also be necessary to fit the patient with a catheter that continually drains the bladder into a plastic bag. Chronic indwelling catherization is not advised, however, as it is associated with a high risk of developing urinary system infections.
Drug therapy
Geriatric patients are often prescribed a large number of drugs to deal with the many disorders they suffer from. In many cases, there are effective nonpharmacological therapies available that should be attempted before resorting to drugs. All geriatric patients need a careful and thorough review of the drugs they are prescribed to ensure they are necessary and that there is no change of potentially dangerous drug interactions. Effective drug therapy is often hampered by faulty diagnosis. Older patients may underreport symptoms, or their complaints may be vague and multiple. In addition, symptoms of physical diseases may overlap with psychological illness. Consequently, making the correct diagnosis and prescribing the appropriate drugs is a very difficult task in geriatric medicine. Finally, the aging process alters the elderly patient’s ability to deal with drugs physiologically. This deficit occurs primarily at the liver and at the kidneys.
The liver contains about 30 enzymes that are involved in the degradation of a wide variety of compounds that are consumed in an average diet. These enzymes can also handle more exotic compounds such as alcohol or pharmaceutical drugs. Age-related, or even alcohol-induced, deterioration of these enzymes make a safe drug dangerous when given to a geriatrics patient. Potentially fatal ventricular arrthymias have been caused by certain antihistamines when given to older patients with defective liver enzymes. The situation, however, is too complex for a physician to assume that an elderly patient with normal liver function tests will be able to metabolize a given drug as efficiently as a younger patient.
The kidneys also play an important role in ridding the body of foreign or unwanted chemicals and drugs. Drugs given to older patients are cleared more slowly by the kidneys and thus have a tendency to accumulate to high, possibly toxic, levels over the time-course of treatment. Thus drugs that have not been specifically tested for use on older subjects must be used with extreme caution. Medical servicing centers and pharmaceutical companies have developed computer algorithms and databases to help evaluate drug usage and to detect possibly dangerous drug combinations that are prescribed for geriatrics patients.
Nursing homes
The poor quality of care provided in nursing homes has been known for decades. There has been some improvement since the Institute of Medicine (IOM) released a critical report in 2000, but a recent report by congressional investigators shows that serious problems still exist. Quality of care is still generally poor in U.S. nursing homes. Chronic problems concerning residents’ pain, pressure sores, malnutrition, and urinary incontinence have not been resolved.
Nursing homes are intended as places where the elderly can be cared for in their final years by a team of medical professionals who specialize in geriatric medicine. In many cases, however, logistic and economic restraints make this a very difficult goal to realize. Physician involvement in nursing home care is often limited to telephone conversations with the nursing staff. Restrictive Medicare and Medicaid reimbursement policies do not encourage physicians to make more than the required monthly or 60-day visits. Physician involvement in such essential services as attendance at the medical team conferences, family meetings, and counseling residents and surrogate decision makers on treatment plans in the event of terminal illness are usually not reimbursable at all. In addition, most nursing homes lack expensive diagnostic equipment, and thus many of the residents are sent to hospital emergency rooms, where they are evaluated by staff who lack training and interest in the care of frail elderly patients.
Despite these many problems, the effectiveness of nursing homes can be improved with more attention paid to the documentation of the resident’s illness and treatment history, as well as the introduction of nurse practitioners and physician assistants. These medical practitioners could be very helpful in implementing some of the screening and monitoring that is needed to ensure proper care of the residents, and to this extent would function as an independent patient advocate. They could also have an important role in communicating with the staff, residents, and families when the physician is not in the facility.
The problems facing nursing homes over the next 40 years are tremendous. In a recent report the IOM noted the urgent need for research and data collection to obtain a better understanding and description of the various long-term-care arrangements throughout the country, including their size, the services provided and staffing levels and training, the characteristics of those receiving care, and the staffing and quality of care provided in the different settings and services. They also called for increased funding, concluding that "the amounts and ways we pay for long-term care are probably inadequate to support a workforce sufficient in numbers, skills, stability, and commitment to provide adequate clinical and personal services for the increasingly frail or complex populations using long-term care."
Ethical issues
The basic ethical principles governing the care of the elderly were established in the 1970s in response to allegations that human subjects in biomedical clinical trials were poorly treated. Principles of respect for persons, beneficence, and informed consent apply equally well to elderly patients in a nursing home, or hospital ward, as they do to human subjects involved in clinical trials.
Respect for persons
Respect for persons, in the context of clinical trials, demands that subjects enter into research voluntarily and with adequate information. This assumes the individuals are autonomous agents, that is, are competent to make up their own minds. There are, however, many instances of potential research subjects not really being autonomous: prisoners, patients in a mental institution, children, the elderly, and the infirm. All of these people require special protection to ensure they are not being coerced or fooled into volunteering as research subjects. Geriatrics patients are especially vulnerable because of their many medical disorders, which often affect their ability to understand what is being done to them.
Beneficence
It is not enough to respect a potential subject’s decisions and to protect them from harm, but in addition it is necessary to do all that is possible to ensure their well-being. Beneficence is generally regarded as acts of kindness or charity, but in the case of geriatrics patients, weakened by illness and age, it is an obligation. In this sense, it is the natural extension of the Hippocratic oath that all physicians are expected to adhere to: I will give no deadly medicine to anyone if asked, nor suggest any such counsel. In other words, do no harm, and for those involved in biomedical research, never injure one person to benefit another. This is particularly relevant to prescribing drugs for the elderly, who are especially sensitive to this type of therapy.
Informed consent
All participants in clinical trials must provide informed consent in writing. Moreover, steps must be taken to ensure the consent is, in fact, informed. This might involve an independent assessment of the individual’s ability to understand the language on the consent form and any instructions or explanations the investigators have given. Geriatrics patients, many of whom suffer from dementia, cannot be expected to give informed consent under many circumstances. Consequently, it is necessary to proceed with extreme caution in such cases and to ensure that an action taken, such as moving an elderly person out of his or her home and into an institution, is really in their best interest and not simply a convenience.
