General Considerations

The geriatric patient is an individual 65 years of age or older. Among such individuals, there is considerable variation in general health, mental status, functional ability, personal and social resources, marital status, living arrangements, creativity, and social integration. The age range of this rapidly growing population spans more than 40 years. The world’s geriatric population is currently increasing at a rate of 2.5% per year—significantly faster than the total population. Between 1900 and 2000, the number of Americans older than 65 years increased from a little more than 3 million to 35 million. Since 1960, the geriatric population has grown 107%, in comparison with 50% for the U.S. population as a whole. From 2000 to 2040, in the United States, the number of people 65 years of age or older is projected to increase from 34.8 million to 77.2 million. It is estimated that in the developed nations of the world, there are 146 million people 65 years of age and older. This group will increase to 232 million by the year 2020.

A decreasing rate of mortality, especially from heart disease and stroke, and a reduction in risk factors such as smoking, high blood pressure, and high serum cholesterol levels have contributed to this increased survival.

The population older than 85 years of age represents the fastest-growing segment of the U.S. population. This “graying of America” is expected to continue. By the year 2020, one fifth of the population will be older than 65 years of age. These statistics are extremely important in view of the cost of medical care for this population. Currently, 32% of all health care dollars is spent on the geriatric population, which constitutes only 12% of the total population.

Some other statistics are important. Eighty-nine percent of older adults are white. Older adult women outnumber older men 1.5 : 1 overall and 3 : 1 among individuals 95 years of age and older. African Americans constitute 12% of the total U.S. population but only 8% of the older age groups. In 1986, most older men (77%) were married, whereas most older women (52%) were widows. Fifteen percent of older men live alone, in comparison with 40% of women. Nursing home residents account for 5% of the population older than 65 years. Approximately 12% of the population older than 65 years of age continue to work; 25% are self-employed, in comparison with 10% of the total population. Five percent of the geriatric population—nearly 1 million individuals—are victimized by abuse or neglect. The U.S. Bureau of the Census estimates that 1 million Americans will be 100 years of age or older by the year 2050 and that nearly 2 million will be that age by the year 2080.

Structure and Physiologic Characteristics

This section covers some of the anatomic and physiologic changes attributed to aging, as well as some of the physical findings that result.

Basic Principles of Geriatric Medicine

Whereas in the younger population the goal of medicine is to cure, the ultimate goal in the geriatric population is to preserve the patient’s quality of life. The health care professional must strive to maintain function and relieve the symptoms that can be relieved. This often involves moving from a doctor-patient relationship alone to a doctor-family or doctor-caregiver relationship. In the event of terminal illness, you should ensure as little mental and physical distress as possible and provide appropriate emotional support to the patient and family. There are a few basic principles of geriatric medicine.

First, there is an altered manifestation of disease. The actual symptom may not be a symptom of the organ system involved with the disease. For example, if a person in his or her 50s were to have a heart attack, the individual, unless diabetic, would usually suffer from chest pain. This is not the case in the geriatric age group. It is well documented that 70% of nondiabetic individuals older than 70 years of age do not have chest pain with a myocardial infarction. Such patients may present instead with breathlessness, falling, confusion, or palpitations.

Another illustration of this alteration in symptoms is the geriatric patient with diabetes mellitus. Ordinarily, because of lack of insulin, younger patients become acidotic and ketotic, with a smell of ketones on their breath. They may also exhibit shallow, rapid respirations. Older patients with uncontrolled diabetes mellitus may not become ketotic and acidotic. Instead, the syndrome of hyperosmolar, nonketotic coma may ensue. These patients, who do not have the smell of ketones on their breath and are not acidotic, are hyperosmolar and may have serum glucose levels in excess of 600 to 700 mg/dL. They may even present in coma.

A third example is a patient with hyperthyroidism. A geriatric patient with hyperthyroidism might not present with the tachycardia, sweats, or anxiety states that are seen in younger individuals with increased thyroid activity. The geriatric patient may instead appear depressed and apathetic.

An older patient with acute appendicitis might not suffer from abdominal pain, and an older patient with pneumonia might not have shortness of breath; confusion may be the only symptom.

A second principle in geriatric medicine is the nonspecific manifestation of disease. When an older person becomes ill, a family member commonly reports that the patient “just hasn’t gotten out of bed.” The patient may go to bed and stay there. The patient may not want to eat and may have only nonspecific complaints.

A fourth principle is the recognition that multiple pathologic conditions may be present in a geriatric patient. Such a patient may have been given multiple medications or therapies. One medicine may have deleterious effects on a patient if some other condition exists. Of course, this can occur with any patient, but it is more likely to occur in older patients who probably have several pathologic conditions.

A fifth principle is polypharmacy, which is defined as the administration of three or more medicines. It is critical that the interviewer see and know about all the medications being taken by the patient. Instruct the patient or family to bring in all medications, both prescription and nonprescription, and ask the patient how he or she is taking them. There is commonly a significant discrepancy between the written prescription and the dosage that the patient actually takes.

Americans older than 65 years of age use approximately 25% of all prescription medications consumed in the United States, and at any one time, the average geriatric patient uses 4.5 prescription medications. The average nursing home resident consumes the most medications, averaging 8 medications at any one time. The use of mood-altering drugs is common in the geriatric population. Approximately 7% of nursing home residents are taking 3 or more psychoactive drugs.

Finally, what is the patient’s chief complaint? This is sometimes referred to as “the myth of the chief complaint.” Many geriatric patients do not have a single complaint. There may be several problems related to their many conditions. In fact, as already discussed, if a chief complaint is given, it may bear no relationship to the organ system involved. Be careful in the evaluation of the chief complaint when dealing with older patients.