Improve five functional domains of disability

  1. Physical ADLs include activities such as bathing, dressing, eating, and walking.

  2. Instrumental ADLs are home management tasks such as shopping, meal preparation, money management, using the telephone, and performing light housework.

  3. Cognitive functioning is particularly important in the elderly. Dementia is one of the four leading causes of disability in the elderly and a principal reason for institutionalization.

  4. Affective function is important. Secondary depressions are common in the elderly, and suicide is a more frequent cause of death in the elderly than in the young.

  5. Social functioning is less of a problem. Only 1% of the elderly rate their social interactions as inadequate.

Disability in basic ADLs is common among community-dwelling older persons, with prevalence rates ranging from 7% in those 65–74 years of age to 24% in those 85 years of age or older. Restricted activity, defined as staying in bed for at least half a day and/or cutting down on usual activities because of an illness, injury, or other problem, is common among community-living older persons, regardless of risk for disability, and it is usually attributable to several concurrent health-related problems. Although disability in older persons is often thought to be progressive or permanent, previous research shows it is a dynamic process, with individuals moving in and out of states of disability. To set realistic goals and plan for appropriate care, disabled older persons, along with their families and clinicians, need accurate information about the likelihood and time course of recovery. Prevention of functional decline and disability includes not only management of acute episodes of disability and promotion of recovery, but also ongoing evaluation and management of key risk factors for disability and use of preventive interventions. The high likelihood of recurrent disability among older persons suggests that those who recently recovered from an episode of disability are an important target population for preventive interventions. Although some interventions designed to prevent recurrent disability may be disease specific (eg, anticoagulation after embolic stroke), others may be broadly applicable regardless of the specific precipitant of disability (eg, exercise-based programs).

 

 

    1. Gerontology (both basic and applied)
      1. The presentation of disease is often different in older persons because the response to stress is different. A hallmark of aging is a decreased ability to respond to stress. The body's stress response is what typically generates the symptoms of an illness. Older people fail to respond as actively. Hence, they may not have spiking fevers or elevated white blood cell counts in the face of an infection. Heart disease may be silent.
    2. Chronic disease management, especially multimorbidities
    3. End-of-life care

 

Chronic disease management is difficult on its own. It is much more difficult when an older patient suffers from multiple simultaneous diseases. Basic care guidelines may not work. Indeed, they may pose a threat (Boyd et al., 2005).

Much of the emphasis in care planning is directed at containing disease and maintaining function and improving quality of life. Death is a part of old age. Geriatrics must deal with that reality and help patients and families deal with end of life, helping them to make informed decisions that reflect their goals and priorities. But geriatrics cannot focus exclusively on end-of-life care. One compromise has been the evolution of palliative care (discussed in Chapter 18). To this triad, some might also add a role for advocating reasonable preventive actions (see Chapter 5).

The care of older patients differs from that of younger patients for a number of reasons. While there continues to be a debate about the cause of these differences, it is likely that they are a combination of biological changes that occur during the course of aging, associated diseases, and attitudes and beliefs of older adults and their caregivers. Aging is defined as the time-sequential deterioration that occurs in most living beings, including weakness, increased susceptibility to disease and adverse environmental conditions, loss of mobility and agility, and age-related physiological changes (Goldsmith, 2006). At least in vitro, it is clear that the “aging clock” can be reset (reviewed in Rando and Chang, 2012). Somatic cell nuclear transfer of the nucleus of a mature somatic cell into an enucleated oocyte can give rise to mature, fertile animals.

It is important to distinguish life expectancy from life span. The former refers to what proportion of the possible maximum age a person may live. The latter suggests a biological limit to how many years a species can expect to survive. In general, geriatrics has the most to contribute to improving life expectancy, but new genetic breakthroughs may ultimately affect life span as well. Another helpful distinction is between chronological aging and gerontological aging. The latter is calculated on the basis of the risk of dying, the so-called force of mortality. Thus, two people of the same chronological age may have biologically very different ages depending on their health state. Some of that propensity for death is malleable; some is simply predictable.

Perhaps one of the most intriguing challenges in medicine is to unravel the process of aging. From a medical perspective, the question continues to haunt us as to whether aging is a feature of an organism's design that has evolved over time and is beneficial to the survival of species, or aging is a disease or defect that confers no survival benefit. Even more important to medical management of aging is the question of whether there are medically treatable factors that are common to the various manifestations of aging we see. Could aging treatments delay the signs and symptoms of aging such as sensory changes, musculoskeletal problems, or skin-related changes?

Nonetheless, the distinction between so-called normal aging and pathologic changes is critical to the care of older people. We wish to avoid both dismissing treatable pathology as simply a concomitant of old age and treating natural aging processes as though they were diseases. The latter is particularly dangerous because older adults are so vulnerable to iatrogenic effects.

There is growing appreciation that everyone does not age in the same way or at the same rate. The changing composition of today's older adults compared with that of a generation ago may actually reflect a bimodal shift wherein there are both more disabled people and more healthy older people. We continue to learn more and more about healthy or successful aging through hearing the stories of the growing number of centenarians. Generally the consensus is that moderation in all areas (eg, food intake, alcohol intake), regular physical activity, and an engaging social life are critical to successful aging. A recent large actuarial study (Gavrilova and Gavrilov, 2005) further suggested that environmental factors may also be relevant. Social factors can also play a strong role (Banks et al., 2006). The challenge is to recognize and appreciate aging changes while using resources to prevent or halt further changes and overcome aging challenges.

 

 

transitions in medical care, medication prescribing practices, fall reduction, pain and symptom control, and decreasing caregiver burden

Disconnect often remains between what happens in clinicians’ offices and what patients and their caregivers need at home. Although the principles of geriatric medicine aim to bridge such gaps, many clinicians leave their training ill-equipped to incorporate the fundamental principles of geriatric medicine into their care of older adults.

Decreased Physiologic Reserve

Older adults have lower physiologic reserve in each organ system when compared with younger adults, placing them at risk for more rapid decline when faced with acute or chronic illness. Some contributors to decreased physiologic reserve may include decreases in muscle mass and strength, bone density, exercise capacity, respiratory function, thirst and nutrition, or ability to mount effective immune responses. For these reasons, older adults are often more vulnerable, for example, to periods of bedrest and inactivity, external temperature fluctuations, illnesses that are otherwise self-limited in younger adults, and complications from common infectious diseases.

Decreased physiologic reserve may also impair older adults’ ability to mount an effective immune response to vaccines. These processes can also delay or impair recovery from serious events or illnesses such as hip fractures or pneumonia. As a result of the interplay of multiple medical conditions in the context of decreased physiologic reserve, older adults are prone to developing complex geriatric syndromes, such as frequent falls.

Functional and Cognitive Status

In older adults, cognitive and physical functional status are often more accurate predictors of health, morbidity, mortality, and health care utilization than are individual diseases. Cognitive status includes domains of executive function, memory, mental status, and clinical decision-making ability. Functional status includes the physical requirements necessary to maintain independence in one’s own environment, often assessed using activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Decreased cognitive abilities put older adults at risk (eg, for medication errors caused by an inability to follow instructions about complex medication regimens), can create significant stress on caregivers, and increase the possibility of elder abuse (eg, financial abuse). If cognitive disorders such as dementia are present, relying solely on patient history may result in inaccurate diagnosis and treatment. Functional status can also strongly affect health outcomes. Decreased functional status in the hospital setting, for example, increases the likelihood of nursing home placement and death after discharge. Thus, a comprehensive understanding of cognitive and functional status is critical to providing care to the older adult, planning for the older adult’s future medical and social care needs, prognosticating, and providing caregiver support.

Use Goals of Care and Prognosis in Clinical Decision Making

Clinicians should begin the clinical evaluation of older adults by assessing their goals of care and decision-making capacity. This approach focuses the clinical encounter on targeting diagnostic and therapeutic plans based on the stated needs and goals of the patient and the patient’s caregivers, and identifying the patient who needs the help of surrogate decision makers. Experts in geriatrics and palliative medicine have developed tools and approaches to explore patients’ and their caregivers’ goals of care as an important starting place in the clinical encounter. To further enhance individualized decision making, geriatrics applies a consideration of prognosis to assess benefits and harms of proposed evaluations and interventions. While the science of prognostication is still catching up to clinical need, prognostication models based on more than age alone can be used to determine more accurate estimates of life expectancy. Considering such estimates in the context of patients’ goals of care represents an appropriate starting place for guiding decisions and treatment plans.

The Social Context of Care

Caring for the older adult is most effective when the broader context of the older adult’s family, friends, and community is taken into account. The social network of an older person’s life plays a significant role in identifying the individual’s preferences, resources, and support infrastructure in times of need. While younger adults may thrive with relative independence in accessing resources, older adults may rely more on their social network to provide care during episodes of acute illness or exacerbations of chronic illness. In managing a complex therapeutic plan at home (eg, one that involves managing multiple medications, dressing changes), effective compliance with therapy may hinge on the availability of financial resources, the ability of the patient to remain mobile in the residence and in the community, and the helping hands of family or friends. In the setting of acute unexpected events, an older adult’s survival may depend on having maintained routine contact with a social network. In addition, meeting the needs of the older adult is often contingent upon adequate care and support for caregivers who often suffer from caregiver burden, stress, and health effects of their own, particularly when caring for an older adult with advanced cognitive impairment. Thus, planning effective medical care of the older adult is inseparable from the thorough consideration of his or her social context.

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The Impact of Multiple Conditions, Medications, and Settings of Care
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Because of the complex interactions between physiologic reserve, functional and cognitive status, and social and/or caregiver support, older adults are particularly vulnerable when faced with multiple chronic conditions, many medications, and transitions across settings of care. When treating multiple conditions, the clinician caring for the older adult will be challenged by conflicting clinical care guidelines, as well as by the polypharmacy that often results when following several clinical guidelines simultaneously. As a result, the older adult often experiences new symptoms that represent adverse drug effects or interactions from multiple medications. During times of transition, for example, from hospital to home or from nursing home to emergency room, the older adult is particularly at risk for poor outcomes from incomplete medication reconciliation processes, inadequate hand-off communication, and additional potential harms, such as pressure ulcers from waiting an excessive amount of time on gurneys and falls related to hazards such as intravenous tubing. When caring for an older adult, multiple dimensions of care must be taken into account, guided by the patients’ goals and prognosis.

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As older adults age, interaction with the medical system becomes, on average, a bigger part of their lives. Unfortunately, suffering amongst older adults and their caregivers remains too common. Because of older adults’ significant medical and social complexities, the typical medical encounter may be insufficient to identify or address the etiology of this suffering. In an increasingly global community, now is the time to learn from models of care that have been tried in different communities, populations, and countries. It is essential that clinicians are adept at applying and integrating the proven principles of geriatrics—accounting for decreases in physiologic reserve and cognitive and functional abilities, considering prognosis and goals of care, understanding the social context of the patient, and responding to the complex needs of patients with multiple conditions and medications across diverse care settings—to optimize the health of an aging society.

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Landefeld  C, Winker  MA, Chernof  B Clinical care in the aging century—announcing “Care of the Aging Patient: From Evidence to Action.” JAMA. 2009;302(24):2703-–2704.
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[JAMA and JAMA Network Journals Full Text]
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Reuben  DB Medical care for the final years of life: “when you’re 83, it’s not going to be 20 years.” JAMA. 2009;302(24):2686-–2694.
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[JAMA and JAMA Network Journals Full Text]

 

The aged body is different physiologically from the younger adult body, and during old age, the decline of various organ systems becomes manifest. The appearance of symptoms depends on the remaining healthy reserves in the organs.

Geriatricians distinguish between diseases and the effects of normal aging. For example, renal impairment may be a part of aging, but renal failure and urinary incontinence are not. Geriatricians aim to treat diseases that are present and achieve healthy aging.

Increased complexity

The decline in physiological reserve in organs makes the elderly develop some kinds of diseases and have more complications from mild problems (such as dehydration from a mild gastroenteritis). Multiple problems may compound: A mild fever in elderly persons may cause confusion, which may lead to a fall and to a fracture of the neck of the femur ("broken hip").

Elderly people require specific attention to medications. Elderly people particularly are subjected to polypharmacy (taking multiple medications). Some elderly people have multiple medical disorders; some have self-prescribed many herbal medications and over-the-counter drugs. This polypharmacy may increase the risk of drug interactions or adverse drug reactions. In one study, it was found that prescription and nonprescription medications were commonly used together among older adults, with nearly 1 in 25 individuals potentially at risk for a major drug-drug interaction.[4] Drugs metabolites are excreted mostly by the kidneys or the liver, which may be impaired in the elderly, necessitating medication adjustment.

The presentation of disease in elderly persons may be vague and non-specific, or it may include delirium or falls. (Pneumonia, for example, may present with low-grade fever and confusion, rather than the high fever and cough seen in younger people.) Some elderly people may find it hard to describe their symptoms in words, especially if the disease is causing confusion, or if they havecognitive impairment. Delirium in the elderly may be caused by a minor problem such as constipation or by something as serious and life-threatening as a heart attack. Many of these problems are treatable, if the root cause can be discovered.

Geriatric giants

The so-called geriatric giants are the major categories of impairment that appear in elderly people, especially as they begin to fail. These include immobility, instability, incontinence and impaired intellect/memory.

Impaired vision and hearing loss are common chronic problems among older people. Hearing problems can lead to social isolation, depression, and dependence as the person can no longer talk to other people, receive information over the telephone, or engage in simple transactions, such as talking to a person at a bank or store. Vision problems lead to falls from tripping over unseen objects, medicine being taken incorrectly because the written instructions could not be read, and finances being mismanaged.

Practical concerns

Functional abilities, independence and quality of life issues are of great concern to geriatricians and their patients. Elderly people generally want to live independently as long as possible, which requires them to be able to engage in self-care and other activities of daily living. A geriatrician may be able to provide information about elder care options, and refers people to home care services,skilled nursing facilitiesassisted living facilities, and hospice as appropriate.

Frail elderly people may choose to decline some kinds of medical care, because the risk-benefit ratio is different. For example, frail elderly women routinely stop screening mammograms, because breast cancer is typically a slowly growing disease that would cause them no pain, impairment, or loss of life before they would die of other causes. Frail people are also at significant risk of post-surgical complications and the need for extended care, and an accurate prediction—based on validated measures, rather than how old the patient's face looks—can help older patients make fully informed choices about their options. Assessment of older patients before elective surgeries can accurately predict the patients' recovery trajectories.[5] One frailty scale uses five items: unintentional weight loss, muscle weakness, exhaustion, low physical activity, and slowed walking speed. A healthy person scores 0; a very frail person scores 5. Compared to non-frail elderly people, people with intermediate frailty scores (2 or 3) are twice as likely to have post-surgical complications, spend 50% more time in the hospital, and are three times as likely to be discharged to a skilled nursing facility instead of to their own homes.[5] Frail elderly patients (score of 4 or 5) who were living at home before the surgery have even worse outcomes, with the risk of being discharged to a nursing home rising to twenty times the rate for non-frail elderly people.

01. Cell and Tissue Changes Associated with Aging