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Physicians Update

 
Winter 2012

Older Patients Require a Comprehensive, Coordinated Approach to Healthcare

The complexity of older patients' conditions and needs demands a comprehensive, coordinated approach that recognizes the interdependence of medical, social and mental health issues in the overall health and healthcare of these patients, says Sonja Rosen, M.D., a geriatric specialist at UCLA Medical Center, Santa Monica.

Given that a majority of older persons have at least one chronic disease, management of chronic conditions such as heart failure, hypertension, osteoarthritis and diabetes is a key component of care, Dr. Rosen notes. Complicating matters is that substantial numbers of older patients have impairments in their ability to perform basic and more advanced activities of daily living. Thus, more than younger patients, geriatric patients benefit from multidisciplinary care that looks at all aspects of their lives - not just how they present in the doctor's office.

"If you give a drug prescription to a patient who has no way to get to the pharmacy or can't manage medications because he or she is cognitively impaired, that prescription does no good," Dr. Rosen says. "Geriatricians take care of the whole patient, not just the disease, and part of that is understanding what's going on at home and in the community."

The mission of geriatric care should be to maintain and improve the health, functioning and well-being of older persons, Dr. Rosen says. Ensuring that patients' needs are met often means coordinating with other professionals across healthcare and community-based settings.

To meet patients' needs, it's important to understand their goals of care. "Some patients want to stay in their home and remain as pain-free as possible, while others prefer to work everything up and treat any problems even when they're into their 90s," Dr. Rosen says. "There's a huge spectrum, and much depends on functional status. 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 someone with dementia."

When Dr. Rosen sees new patients, a key part of the first visit is an extensive questionnaire that the patient is asked to complete prior to the appointment. "The physician reviews all of this information before entering the room, so that the time with the patient can be spent answering the patient's questions, addressing concerns and going over areas that need to be further explored," she says.

Depending on the patient, the initial outpatient visit may include an assessment of the patient's medical and cognitive status; an affective exam (depression and anxiety are common in the elderly population); 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.

The physical and functional assessment looks at the older patient's ability to perform basic activities of daily living (including bathing, dressing, toileting, feeding and continence) and intermediate activities of daily living (using the telephone, shopping, preparing meals, housekeeping, using public transportation, taking medications, handling finances). "To function and be safe at home you either have to be independent in your activities of daily living or you need someone who can do those things for you," Dr. Rosen says. "If patients aren't doing these things on their own, we need to make sure they have someone helping them, and if they don't we need to connect them with a social worker or care manager, who can get them the appropriate resources."

A comprehensive assessment for older patients also includes a full gait and balance evaluation. If a patient is at risk for falls, Dr. Rosen will often recommend physical therapy or use of an assisted walking device, 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 polypharmacy (problems caused by being on many interacting medications).

Many acute conditions manifest differently in older patients, Dr. Rosen notes, particularly if there are comorbidities. An older patient with an infection, for example, may not mount a fever or show 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. "Older people have an atypical presentation of disease," Dr. Rosen says. "Heart attacks can present simply as delirium."

The likelihood that these patients are experiencing multiple chronic concerns, often necessitating multiple medications, increases the importance of having a primary care provider who is looking at the big picture. "Often these patients will go from one subspecialist 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 well-being are addressed in a coordinated way."





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