Older Patients Require a Comprehensive, Coordinated Approach to Healthcare
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Addressing the healthcare needs of older adults demands a comprehensive, coordinated approach that balances their medical needs with the circumstances of their lives. A majority of older persons have at least one chronic disease, making management of such conditions as heart failure, hypertension,osteoarthritis and diabetes a key component of care, says Sonja Rosen, M.D., a geriatric specialist at UCLA Medical Center, Santa Monica. At the same time, a substantial numbers of older patients also have difficulty performing basic and more advanced activities of daily living, complicating matters.
"If, for example, you give a prescription to a patient who can't manage medications because he or she is cognitively impaired, that prescription does no good," Dr. Rosen notes. "Geriatricians take care of the whole patient, not just the disease, and part of that is understanding what's going on in the patient's home and community."
It is important for physicians to understand a patient's goals for care. "The goals of someone who is highly functional and maybe even working part-time into their 80s or 90s are likely to be very different from the person who is wheelchair- or bed-bound and dependent in their activities for daily living, or from someone with dementia," Dr. Rosen says.
When what a patient wants can't be achieved, "we need to bring the medical realities into the discussion. But when patients have identified realistic goals, it is our responsibility to be their advocates in achieving them," says David Reuben, M.D., chief of the UCLA Division of Geriatrics.
A comprehensive patient history is important and enables the physician to focus on answering the patient's questions, addressing concerns and going over areas that need further exploration. An initial outpatient visit may also include an assessment of the patient's medical and cognitive status; an exam to gauge depression and anxiety; and an analysis of functional and physical abilities, social and caregiver support, spirituality issues economic factors, environmental issues and quality-of-life/well-being. Advance directives may also be discussed.
A comprehensive assessment also should include a full gait and balance evaluation. If a patient is at risk for falls, physical therapy or use of an assisted walking device may be recommended, Dr. Rosen says, as well as a home visit from an occupational therapist to ensure the home environment is free of hazards.
If the patient appears to have one or more geriatric syndromes — complex conditions that typically involve multiple body systems — referral to a geriatrician with special training in diagnosing and managing these syndromes may be indicated. Common geriatric syndromes include dementia, delirium, incontinence, sensory impairment, malnutrition, osteoporosis, social isolation, falls, immobility, pressure ulcers and problems caused by being on many interacting medications.
Many acute conditions present differently in older patients, Dr. Rosen notes, particularly if there are comorbidities. An older patient with an infection, for example, may not have a fever or an elevated white blood cell count. A patient who is cognitively impaired might seem only lethargic when he or she is experiencing a stroke or heart attack.
It is important for older patients to have a physician who looks at the big picture. "Sometimes a patient will go from one specialist to another, without one person who is monitoring everything," Dr. Rosen says. "Someone has to be the quarterback, helping to decide what is necessary and making sure all aspects of the patient's health and wellbeing are addressed in a coordinated way."