Chapter Outline
Common Problems in Geriatric Care
Unique Issues in Geriatric Care
Community Resources and Services
Information and Referral Services
Case Management or Care Coordination
Day Care and Day Health Care Programs
This chapter provides an overview of geriatric medicine oriented to beginning clinicians, including basic information and clinical perspectives that are useful to health care providers (HCPs) in approaching the social and medical complexities associated with care of older persons. The health care of older adults in the United States presents clinicians with numerous challenges. In addition to complex medical conditions, many older patients present with social, spiritual, economic, and political challenges. When these challenges are successfully met, however, PAs caring for older patients in any setting can experience enormous satisfaction and provide an important contribution to the well-being of both patients and society.
Our society is growing older just as our medical care has become more sophisticated at an ever-increasing cost. By the year 2030, projections are that one in five Americans will be 65 years of age or older, and there will be twice as many people 65 years of age and older as there were in 2000. This huge increase began in 2011 when the first cohort of baby boomers reached age 65 years. These older Americans will also be increasingly diverse, with 40% of them belonging to one of the minority populations by midcentury. Medical practices are experiencing the effects of this increase in the older population just as many also experience a changing medical reimbursement system and uncertainty about the structure of medical care in the future. Physician assistants (PAs) are providing an increasingly important role in general geriatric care, specialty care, and long-term care. The challenge to all PAs is to provide competent, cost-effective, functionally oriented, ethnically competent health care to each older person in their practice.
Geriatric Care
Chronic Conditions
There are some significant differences in providing appropriate geriatric care that require PAs to make a clear shift in the goals they usually have in patient care. Because most of the health conditions older adults present with are likely to be chronic rather than acute, it requires the provider to concentrate on management in most cases rather than treatment in the expectation that the condition will be cured. Because the chronic conditions are not time limited and additional chronic diseases are frequently added, geriatric clinicians are most often faced with trying to manage a patient’s multiple conditions, which usually entail multiple medications as well. Fig. 19.1 illustrates the most common chronic diseases experienced by older adults in the United States. The goal is to help older adults maintain the highest possible function to maximize their quality of life in the context of their chronic conditions.
Functional Status
This emphasis on functional status is a critical component of good geriatric care and requires the clinician to use the measure of function as a constant tool. The two principal methods of functional assessment are determining the level of independence or dependence in performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs). See Box 19.1 for a list of ADLs and IADLs and Fig. 19.2 for the profile of Medicare enrollees who have limitations in either measure.
Dependence on ADLs is commonly used as a measure of eligibility for services such as nursing homes, adult day health care, or in-home support services. There are several different versions of the lists of ADLs and IADLs, but they all contain the basic activities. Scoring schemes vary from yes/no answers to questions such as, “Do you need help performing the following activities?” to five categories of dependence for each activity.
In the routine clinical encounter, function needs to be a constant concern. Can a patient with diabetes see well enough to be able to self-administer insulin? Can a patient easily swallow antibiotics for pneumonia or would a liquid be easier and promote compliance? Can a patient limited by arthritis remove the cap from the medication bottle or easily remove the tablets from the office samples given him or her? The question that should always underlie any change of condition or new diagnosis is, “How does this affect the person’s ability to manage the activities of daily living?”
Time and Perspective
Geriatric practice often differs in time and perspective in that PAs working with geriatric patients frequently need to spend more time learning and understanding their patients’ medical status and personal preferences. In many cases, care of older adults includes working with family members or other caregivers, which involves additional time and a unique set of skills. Time is often the critical factor in eliciting a thoughtful and comprehensive history, especially in patients with multiple chronic conditions. Many older patients need more time to disrobe and dress again. The PA may have to work into his or her schedule driving time to a patient in a nursing home whose condition has changed or for a routine continuity-of-care visit. When an older patient who is chronically ill develops an acute condition, a prior therapeutic relationship with the patient and a clear sense of the patient’s baseline are extremely important because they enable the provider to identify the subtle signs (e.g., confusion, decreased appetite, listlessness) that may often be the only clues of a new underlying disease process. Although initially the PA may need to spend more time getting to know an elderly patient, he or she will find it easier to spot acute or chronic change and be able to preempt the problem. After such a meaningful therapeutic patient–PA relationship has been established, the PA will be of enormous help in that he or she will be able to establish the contextual framework for the patient’s illness, thereby significantly increasing the overall efficacy of the practice ( Table 19.1 ).
| Problem | Screening Measure | Positive Screen |
|---|---|---|
| Vision | Two parts:
| Yes to question and inability to read >20/40 on Snellen chart |
| Hearing | Use audioscope set at 40 dB; test hearing using 1000 and 2000 Hz | Inability to hear 1000 and 2000 Hz in both ears or inability to hear frequencies in either ear |
| Leg mobility | Time the patient after asking: “Rise from the chair. Walk 10 feet, turn, walk back to the chair, and sit down.” | Unable to complete task in 10 sec |
| Urinary | Two parts: | Yes to both questions |
| incontinence | Ask: “In the past year, have you ever lost your urine and gotten wet?” | |
| If yes, then ask: “Have you lost your urine on at least 7 separate days?” | ||
| Nutrition, weight loss | Two parts: | Yes to the question or weight <100 lb |
| Ask: “Have you lost 10 lb over the past 6 months without trying to do so?” Weigh the patient. | ||
| Memory | Three-item recall | Unable to recall all items after 1 minute |
| Depression | Ask: “Do you often feel sad or depressed?” | Yes to the question |
| Physical disability | Six questions“Are you able to do strenuous activities such as fast walking or bicycling?” “… do heavy work around the house, such as washing windows, walls, or floors?” “… go shopping for groceries or clothes?” “… get to places out of walking distance?” “… bathe, using a sponge bath, a tub bath, or a shower?” “… dress, including putting on a shirt, buttoning and zipping, and putting on shoes?” | No to any of the questions |
Normal Age-Related Changes
Aging is commonly viewed as the gradual loss of function and independence with increasing years. Successful aging is remaining active and functional in the physical, cognitive, and emotional realms until death. The aging process depends on the complex interaction of genetics, disease, health habits (e.g., smoking and alcohol consumption), diet, and exercise over the life course. In differentiating disease from aging, it is important for PAs to have an understanding of important age-related changes that tend to occur even in those who have an active and healthy lifestyle. Common age-related changes are summarized by system in the sections that follow.
Sensory Changes
With older age, there is an increased incidence of cataracts (gradual density and clouding of the lens in the eye) and a consequent decrease in visual acuity resulting in, among other risks, an increased incidence of falls; most often, the visual acuity can be restored by surgical replacement of the affected lens. There is an age-related reduction in the ability to hear higher frequencies (presbycusis), resulting in communication difficulties if not corrected by hearing aids. When one is communicating with an older person who is known to have sensory impairment, it is important to speak slowly and clearly, sit close to the person, and make sure one’s face is well lit. These simple measures can reduce confusion and anxiety and make for a more successful clinical encounter.
There also appears to be a decrease in acuity of taste with increasing age, so food tends to be perceived as bland. The clinical consequences can be a decreased appreciation for food and a loss of appetite, which can lead to significant weight loss and nutrition deficiency, and increased use of seasoning to enhance taste, such as salt or sugar, which can exacerbate underlying medical conditions and their treatment (e.g., hypertension, heart failure, diabetes). The aging skin has thinner epidermis and subcutaneous fat layers and reduced oil production. The result is increased risk with ambient temperature changes for hypothermia and hyperthermia among older adults and a propensity for dry skin (xerosis), skin breakdown, and ulcerations.
Cardiovascular Changes
The resting cardiac output does not change with age. However, there are a slight decrease in the heart rate and a compensatory increase in stroke volume. Heart rate response to exercise is decreased in older adults secondary to a decrease in the β-adrenergic response. Also, diastolic dysfunction may be seen during both rest and exercise in older adults. Systolic blood pressure tends to rise with age more than diastolic, and sustained elevations (hypertension) in either one or both increase the risk for stroke and heart disease. Decreases in vascular compliance with age contribute to positional changes in blood pressure (orthostatic hypotension), which can lead to increased complaints of dizziness, imbalance, and risk for falls.
Coronary artery disease is the most common cause of death among those 65 years and older. A well-balanced healthy diet and regular exercise have a tremendous positive impact on the cardiovascular changes associated with aging. A reasonable diet and exercise program should be strongly encouraged for persons in their advanced years. They can increase their stamina and aerobic fitness level if they exercise regularly.
Endocrine Changes
Aging is associated with deteriorating glucose tolerance changes, and peripheral glucose utilization is thought to be the major factor in this phenomenon. Thyroid function is generally normal in physiologic aging, although older patients tend to have low triiodothyronine (T 3 ) levels. There is an increase of 2% to 5% in the prevalence of hypothyroidism in those older than age 65 years, and the prevalence continues to rise with age. The clinician should consider hypothyroidism when confronted with complaints of fatigue, depression, loss of initiative, confusion, dry skin, and constipation in an older patient. Serum parathyroid hormone (PTH) increases in older adults, and this increase correlates with a decline in vitamin D levels; treatment with 1,25-(OH) 2 -D 3 results in a decrease in PTH levels. Age-related increases in PTH are thought to be a major factor accounting for age-related bone loss, which for postmenopausal women is estimated to be 1% per year if untreated.
Immunologic Changes
There is an overall decrease in immunity with age, resulting in a greater prevalence of infections (e.g., pneumonia and urinary tract infections [UTIs]), shingles, gram-negative bacteremia, and severe episodes of influenza. Aging is accompanied by changes in both cellular and humoral immunity. The function of lymphocytes is altered with decreased proliferative capacity of T lymphocytes. Macrophage function is altered, and delayed-type skin hypersensitivity (DTH) declines. Older adults often present an atypical clinical picture, with absence of fevers, presence of hypothermia, altered eating patterns, delirium, and agitation in response to infection. They may also fail to mount a leukocytosis in response to an infection but will frequently have a left shift in the face of a normal leukocyte count. The clinical implication is that even simple illnesses in older adults need to be monitored closely and treated aggressively as indicated.
Renal Function
There is an overall decrease in kidney mass and loss of parenchymal mass over time. The total number of glomeruli decreases with age, and the renal vasculature undergoes sclerotic changes. All of these changes result in a progressively decreasing glomerular filtration rate (GFR). Concomitantly, with increasing age, there is a reduction in lean body mass, which results in decreased creatinine production. Therefore, the creatinine can continue to remain falsely low or “normal,” even in the face of decreasing GFR and compromised renal function. Even the commonly used Cockcroft and Gault equation can lead to a mean underestimation of the measured creatinine clearance of 12.1 mL/min in a group of healthy patients. Therefore, calculated creatinine clearances should be avoided in older adults in favor of short-duration, timed urine collections to measure the actual creatinine clearance. To avoid overmedication, any medicine excreted by the kidneys must be carefully considered for dosing and closely monitored.
Creatinine clearance = ( 140 − age ) × Body weight in kilograms/ ( 72 × Serum creatinine )
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