Geriatric Gems

1939 Advice from the “Point of View of a Clinician”

In medicine, we shall require an increasing number of men (so-called “gerontologists”) who will specialize in geriatrics but their number need not be nearly so large as those who specialize in pediatrics. But every student in the medical schools should attend at least a short course in geriatrics and in this he should be taught to train his patients of middle age to prepare themselves for later life so that in old age they can be contentedly occupied themselves and, as far as possible also continue to be socially useful. He should be told to point out to them the growing tendency of elderly to live apart from their children, either in homes of their own or in homes for the aged, and that people should therefore make timely provision for their later lives by the establishment of trust funds or the purchase of annuities. The old age security laws are unlikely soon to make adequate provision for the majority of elderly people, though they may be expected to mitigate the hardships now suffered by the aged poor. Each physician should, from the time of his graduation onward, keep in mind the nature of the problems that are associated with old age, and should do everything in his power to aid in their solution from the biological as well as from the social-cultural side.

Barker, LF in Problems of Aging edited by EV Cowdry, Baltimore Wilkins and Wilkins Co.1939. Chapter 25, p 741.

Approaching the Geriatric Patient

A Summary

1. Chronological age alone should not determine the intensity of care.
   Biologic age does not always coincide with chronology. We all know 60 year olds who are "old" and 90 year olds who are "young." Life expectancy for a 65-year-old white woman is about 20 years and for a 90-year-old woman about 4 years.
2. The primary goal in geriatric medicine is to maximize function using as a guide the ability to carry out Activities of Daily Living (ADL’s) and Instrumental Activities of Daily (IADL’s). CARE as a goal of therapy overrides CURE. Think Quality of Life as a primary driver of care. Respect the patients' autonomy and desires.
3. Emphasis on preventive medicine, starting long before the individual is elderly, may delay the aging process and shorten the morbid period at the end of life. Physiologic changes are the least contributor to the aging process and can often be mitigated by life-style modifications. Intervening in the more likely causes of the aging process, ie., the accumulation of chronic diseases and self-abuse (tobacco, alcohol, etc) can be most beneficial.
4. Communication by the physician with the family and other caregivers is essential in assuring that appropriate care is provided in the appropriate environment. The art of medicine is nowhere better applied than in the frail elderly when addressing significant issues, including support systems, safety issues, financial concerns, and legal needs.
5. Multidisciplinary involvement may be essential. Because the breadth of care is often beyond the purview of the physician alone, nurses, social workers, agency personnel, physical medicine, etc. may all contribute in major ways to enhancement of quality of life.
6. The presentation of significant medical conditions can be subtle and atypical. For example the lack of pain with myocardial infarction or with penetrating duodenal ulcers’, there may be absence of fever and leukocytosis in the presence of infection. Often a simple "change of behavior" (new falls or incontinence or confusion) is the hallmark of significant new disease.
7. Reversible and overlooked diseases must be sought. The responsibility of physicians to seek out curable conditions is not abrogated in the elderly. Some diseases, such as hypo- and hyperthyroidism, are clinically difficult to recognize but easily treated.
8. Iatrogenesis/over-treatment can be hazardous. There is significant potential for harm in those patients with limited reserve and depleted immune functions. Avoid invasive procedures except when essential. Provide least amount of medications in lowest effective dosage.
9. Cognitive decline should not be discounted because the patient is alert, social, and responsive. It is common that dementia is masked or concealed and not recognized by the physician which gives way to the strong argument that the individual should be accompanied at the medical evaluation by a caregiver.
10. Sensory deficits should be recognized and "corrected". Their presence must be factored into the medical assessment. Both visual and auditory impairment may be a cause of decline/depression and thus may mimic the dementing state.
11. Depression may masquerade as organic disease; somatization syndromes are common. Losses accompanying old age are responsible for a high prevalence of depression in the elderly.
12. Time expenditure increases when caring for the older patient. Histories can be extensive, as there are more diseases and conditions to address. Elderly patients tend to move slowly, notable in walking, dressing and undressing. Recovery from disease and the healing process are also prolonged.

E. Gordon Margolin, MD
Professor of Internal Medicine
Department of Internal Medicine