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Geriatric Care: General Principles

BASICS

  • "First do no harm" principle: interventions effective in younger patients may not benefit elders.
  • Focus on preserving function and comfort rather than solely extending life.

EPIDEMIOLOGY

  • By 2050, >20% of U.S. population projected to be >65 years old.
  • Those >85 years old may reach 24% of elderly population.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Aging is developmental, not pathological.
  • Physiologic changes decrease compensatory reserve and increase disease susceptibility.
  • Changes include increased body fat, decreased total body water and lean mass.
  • Hydrophilic drugs: smaller volume of distribution.
  • Lipophilic drugs: increased volume of distribution, longer half-life.
  • Decline in renal elimination.
  • Decreased lung capacity, oxygen uptake, cardiac output, muscle mass, GFR, blood flow to brain/liver/kidneys.

RISK FACTORS

  • Access barriers: provider responsiveness, medical bills, transportation.
  • More prevalent with female gender and increasing age.
  • COVID-19 pandemic enabled alternatives such as telehealth, phone visits, home nurse visits.

GENERAL PREVENTION

  • Follow recommended vaccination schedules for seniors.
  • Assess and promote function at each visit (ADLs, IADLs).
  • Hearing assessments and depression screening tools (Geriatric Depression Scale).
  • Cognitive screening: MiniCog, Montreal Cognitive Assessment (MoCA).
  • Falls: full risk assessment if ≥2 falls/year or fear of falling.
  • Urinary incontinence: inquire about urine loss frequency.
  • Polypharmacy: defined as use of ≥5 medications; reconcile meds at every visit; engage patients/caregivers.
  • Substance use: screen with CAGE.
  • Advanced care planning: encourage advance directives, durable power of attorney, health care proxy, living wills, POLST/MOLST.

DIAGNOSIS

HISTORY

  • Speak directly to patient; adjust communication to health literacy and emotional state.
  • Assess social and financial support.
  • Establish values, preferences, goals of care.

PHYSICAL EXAM

  • Check orthostatic hypotension.
  • Assess temperature regulation (hypo/hyperthermia).
  • Evaluate weight loss causes.
  • Hearing tests (e.g., Whisper Test).
  • Assess gait, balance, muscle strength (Timed Up and Go, Tinetti test).

DIFFERENTIAL DIAGNOSIS

  • Atypical presentations common (e.g., silent MI with dyspnea).
  • Common conditions: constipation, delirium, UTI, depression, insomnia, hearing/vision impairment.

DIAGNOSTIC TESTS & INTERPRETATION

  • Evaluate decision-making capacity.
  • Identify surrogate decision-makers.
  • Avoid unnecessary testing causing burden.
  • Adjust interpretation of labs for age-specific norms.

TREATMENT

GENERAL MEASURES

  • Prioritize nonpharmacologic interventions.
  • Align treatment with patient goals and feasibility.
  • Address compliance and polypharmacy risks (Beers criteria).
  • Deprescribing recommendations: avoid feeding tubes in dementia, cautious antipsychotic use, avoid sedative hypnotics, careful diabetes management prioritizing hypoglycemia prevention.
  • Pain management: start with nonpharmacologic, then acetaminophen (<3 g/day), cautiously use tramadol, narcotics, NSAIDs with GI and renal protective measures.

MEDICATION

  • First line: acetaminophen.
  • Second line: caution with opioids, tramadol, NSAIDs.

ADMISSION AND INPATIENT CONSIDERATIONS

  • Prevent falls, delirium, skin breakdown, infection, and manage pain.

ONGOING CARE

  • Review and discontinue unnecessary medications regularly.
  • Use interdisciplinary teams (home health, social services).

DIET

  • Encourage balanced diet and optimal caloric intake.

PATIENT EDUCATION

  • Provide caregiver resources (Alzheimer’s Association, respite care).
  • Screen for elder mistreatment (Bruises, malnutrition, abuse).
  • Consider referral for palliative and hospice care.

CLINICAL PEARLS

  • Establish and align care with patient goals.
  • Use interdisciplinary approach for holistic elder care.

REFERENCES

  1. Abraha I, Cruz-Jentoft A, Soiza RL, et al. Evidence of and recommendations for non-pharmacological interventions for common geriatric conditions: the SENATOR-ONTOP systematic review protocol. BMJ Open. 2015;5(1):e007488.

CODES

  • ICD10: Z71.89 Other specified counseling