Geriatrics is a sub-specialty of internal medicine and family medicine that focuses on health care of elderly people. It aims to promote health by preventing and treating diseases and disabilities in older adults. There is no set age at which patients may be under the care of a geriatrician, or physician who specializes in the care of elderly people. Rather, this decision is determined by the individual patient’s needs, and the availability of a specialist.
Geriatrics, the care of aged people, differs from gerontology, which is the study of the aging process itself. The termgeriatrics comes from the Greek γέρων geron meaning “old man” and ιατρός iatros meaning “healer”. However, geriatrics is sometimes called medical gerontology.
Differences between adult and geriatric medicine
Geriatrics differs from standard adult medicine because it focuses on the unique needs of the elderly person. The aged body is different physiologically from the younger adult body, and during old age, the decline of various organ systems becomes manifest. Previous health issues and lifestyle choices produce a different constellation of diseases and symptoms in different people. The appearance of symptoms depends on the remaining healthy reserves in theorgans. Smokers, for example, consume their respiratory system reserve early and rapidly.
Geriatricians distinguish between diseases and the effects of normal ageing. For example, renal impairment may be a part of ageing, but renal failure and urinary incontinence are not. Geriatricians aim to treat any diseases that are present and to decrease the effects of aging on the body.
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 (“breaking her/his 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; some adult physicians prescribe medications to their specialty without reviewing other medications used by the elder patient. This polypharmacy may result in many drug interactions and may cause some 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. Drugs are excreted mostly by the kidneys or the liver, either of which may be impaired in the elderly, and as a result the medication might need adjustment to avoid overwhelming the kidneys or liver.
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, dehydration, confusion or falls, rather than the high fever and cough seen in middle-aged adults.) Some elderly people may find it hard to describe their symptoms in words, especially if the disease is causing confusion, or if they have cognitive 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.
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 is no longer able to 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.
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 inself-care and other activities of daily living. A geriatrician may be able to provide information about elder careoptions, and refers people to home care services, skilled nursing facilities, assisted 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. 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. 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.
Subspecialties and related services
Some diseases commonly seen in elderly are rare in adults, e.g., dementia, delirium, falls. As societies aged, many specialized geriatric- and geriatrics-related services emerged including:
The Hospital Elder Life Program (HELP) is an innovative model of hospital care created by Sharon Inouye, MD, MPH and her colleagues at the Yale University School of Medicine. It is designed to prevent delirium and functional decline among elderly individuals in the hospital inpatient setting. HELP uses a core team of interdisciplinary staff and targeted intervention protocols to improve patients’ outcomes and to provide cost-effective care. Unique to the program is the use of specially trained volunteers who carry out the majority of the non-clinical interventions.
In up to 40% of the cases, incident delirium can be prevented. To that end, HELP promotes interventions designed to maintain cognitive and physical functioning of older adults throughout the hospitalization, maximize patients’ independence at discharge, assist with the transition from hospital to home and prevent unplanned hospital readmissions. Customized interventions include daily visitors; therapeutic activities to provide mental stimulation; daily exercise and walking assistance; sleep enhancement; nutritional support and hearing and vision protocols.
HELP has been replicated in over 63 hospitals across the world. Although the majority of the sites are based in the United States located in 25 different states, there is a growing international presence. International sites include: Australia, Canada, the Netherlands, Taiwan and the United Kingdom. HELP is protected by copyright held by Sharon Inouye MD, MPH. The Dissemination Team including Dr. Inouye are located at Hebrew SeniorLife at the Institute for Aging Research in Boston, MA.
Pharmacological constitution and regimen for older people is an important topic, one that is related to changing and differing physiology and psychology.
Changes in physiology with aging may alter the absorption, the effectiveness and the side effect profile of many drugs. These changes may occur in oral protective reflexes (dryness of the mouth caused by diminished salivary glands), in the gastrointestinal system (such as with delayed emptying of solids and liquids possibly restricting speed of absorption), and in the distribution of drugs with changes in body fat and muscle and drug elimination.
Psychological considerations include the fact that elderly persons (in particular, those experiencing substantial memory loss or other types of cognitive impairment) are unlikely to be able to adequately monitor and adhere to their own scheduled pharmacological administration. One study (Hutchinson et al., 2006) found that 25% of participants studied admitted to skipping doses or cutting them in half. Self-reported noncompliance with adherence to a medication schedule was reported by a striking one-third of the participants. Further development of methods that might possibly help monitor and regulate dosage administration and scheduling is an area that deserves attention.
Another important area is the potential for improper administration and use of potentially inappropriate medications, and the possibility of errors that could result in dangerous drug interactions. Polypharmacy is often a predictive factor (Cannon et al., 2006). Research done on home/community health care found that “nearly 1 of 3 medical regimens contain a potential medication error” (Choi et al., 2006).
Ethical and medico-legal issues
Elderly persons sometimes cannot make decisions for themselves. They may have previously prepared a power of attorney and advance directives to provide guidance if they are unable to understand what is happening to them, whether this is due to long-term dementia or to a short-term, correctable problem, such as delirium from a fever.
Geriatricians must respect the patients’ privacy while seeing that they receive appropriate and necessary services. More than most specialties, they must consider whether the patient has the legal responsibility and competence to understand the facts and make decisions. They must support informed consent and resist the temptation to manipulate the patient by withholding information, such as the dismal prognosis for a condition or the likelihood of recovering from surgery at home.
Elder abuse is the physical, financial, emotional, sexual, or other type of abuse of an older dependent abuse. Adequate training, services, and support can reduce the likelihood of elder abuse, and proper attention can often identify it. For elderly people who are unable to care for themselves, geriatricians may recommend legal guardianship orconservatorship to care for the person or the estate.