Geriatric patients and principles: a schematic overview

This is the first of a two-part series on geriatric patients, their complexities, special needs and how we can improve our care for them.

PEOPLE often say they don’t really understand what geriatricians do – although they may have a sense that we solve complicated problems in a Ghostbusters sort of way (“who ya gonna call”). Nevertheless, geriatric medicine is sometimes voted the least prestigious of specialties, and few people know exactly what the word “geriatrician” means in conversation.

Similarly, “geriatric” patients themselves may trigger negative reactions; their problems seem vast and insoluble, and the (incorrect) assertion “of course, there’s nothing you can do” is encountered regularly by geriatricians. Meanwhile, trainees sometimes express anxiety regarding the number of complex older patients they face. Hospitals may be brimming with “geriatric patients” – yet on televised medical dramas, old people comprise only 6% of depicted patients.

There is sometimes a strange duality working in geriatrics – knowing there is often low regard for the specialty, yet being inundated with requests to see complex cases inside and outside hospitals. Interestingly, this paradox is nothing new.

Geriatrics was partly founded in the 1930s and 1940s by Dr Marjory Warren – and in some ways, little has changed since. Her general medical peers noted that “chronic sick” elderly inpatients “actually fared better on the geriatric unit” (see today’s similar Cochrane evidence); they also acknowledged her ability to “clear their beds of chronics” (achieve discharges against the odds). Nevertheless, pioneer geriatricians were described as members of “a second-rate specialty, looking after third-rate patients in fourth-rate facilities”, and physicians in Marjory Warren’s hospital “saw little value in what she was doing … it was not technical or scientific in their terms”.

In this context, I wanted to share some basic non-exhaustive thoughts on the mysteries of “geriatric” patients and how they “work”. After giving an overview in this article, in the next I will illustrate what clinicians can fruitfully do with older people to realise both clinical and health-economic benefits. It is wholly untrue that “there’s nothing you can do” – there is always a great deal that can be done for geriatric patients if some key concepts are known.

Geriatric patients in a nutshell – an overview

Starting out, it is worth noting that about 80–90% of all older people are actually robust; only a small minority becomes what we may call geriatric, and they crudely have the following characteristics:

• they are typically people in the last few years of life (commonly < 10 years life expectancy);
• they often progressively deteriorate in a rather formulaic way (described shortly), ultimately becoming dependent on others;
• they are exceedingly vulnerable to acute crises. Hospitalisations endured are typically high risk, prolonged and expensive. The word “frail” is synonymous here with the word “vulnerable” in this sense – depicting that brittle geriatric patients have little reserve, decompensate readily, and teeter on the edge of adverse health outcomes (here, here, here); and
• geriatric problems take time to assess and manage. No matter how unpopular a notion in fast-paced health care, many patients with multimorbidities simply take hours to “sort”. To do the job well, which takes time, an unescapable truth is that high staffing allocation is nee
• ded (Figure 1)

[caption id="attachment_54480" align="aligncenter" width="787"] Figure 1. A truism about medical care. Geriatric specialist care must be “good” in the sense of being meticulous in the face of complexity – so it cannot be done cheaply with low levels of manpower. Geriatrician workforce adequacy is covered here.[/caption]

The “anatomy of crisis” in older people

Let’s look at a schematic formula through which some older people transition from robust to geriatric. This is depicted in Figure 2 – with a metaphorical patient sliding gradually downhill towards a precipice (ie, a crisis). I see this pattern playing out time and again in one way or another.

[caption id="attachment_54481" align="aligncenter" width="1024"] Figure 2. “Geriatrics 101”: the anatomy of crisis in some frail, older people with a disability. Many patients deteriorate along these lines, though of course it doesn’t always play out like this, and the slope can go on further (eg, many admissions and possible entry into residential aged care before death). Life expectancy after the onset of profound disability in older Australians is about 4 years. BP = blood pressure. LOS = length of stay.[/caption]

At the top of the slope is an older person from the population. Many such people have accumulated mid-life comorbidities (eg, diabetes, hypertension, gout); nonetheless, over 80% will remain lucid and independent. In the unfortunate 10–20% fated to slide downhill, the key tipping point is the insidious (commonly unrecognised) accumulation of yet further organic disease states – particularly illnesses associated with living a long time, including:

• slow-burning brain diseases — most common are progressive idiopathic neurodegenerative diseases such as Alzheimer’s or frontotemporal degeneration; however, the problem may instead be neurochemical (eg, depression, undetected schizophrenia) or myriad other central nervous system (CNS) pathologies (some of which may wreak havoc quickly as rapidly progressive dementia);
• disabling diseases associated with peripheral degeneration, or longevity — for example, older people are prone to cancers, cataracts, aortic stenosis, osteoporosis, myopathy, osteoarthritis and cervical myelopathy; and
• unintentional and insidious drug-related harms — as older people accumulate morbidity, they may see increasing numbers of organ specialists (what I call “polyspecialism”), leading to increased numbers of medications, some of which may have adverse CNS effects, exacerbating the presence of brewing dementia or Parkinsonism. Alternatively, older people may suffer undertreatment; an example may be crippling knee arthritis in need of a joint replacement, where older age means patients are deemed “unfit” for surgical treatment without formal perioperative work-up.

These organic problems tend to present to clinicians as mental and physical impairments or syndromes, including amnesia, psychosis, immobility, ataxia, pain, apathy, drowsiness, dysphagia, catatonia, Parkinsonism, incontinence, syncope, dizziness, insightlessness and impulsivity (to name a few). Importantly like “anaemia” or “chest pain”, however, these are not diagnoses (ie, not textbook diseases or drug toxidromes).

It is critical to distinguish between diseases and ageing at this point. Older people are high-risk for developing pathologies and drug toxicities – but relentless cognitive and physical decline is not part of normal ageing like, say, wrinkles or grey hair. If geriatric syndromes are viewed as reflections of old age, reversible or manageable underlying illness will never be tackled (and the downhill slide will continue unabated). It is thus important to reject the phrase age-related in favour of age-associated. As the old joke goes: an old man complains to his doctor “Doc, my left knee is killing me”, and the doctor replies, “well, you are getting old”; the old man then says “yes, but my right knee is the same age and doesn’t hurt at all”.

Right, but what next?

If the person’s physical and cognitive diseases are genuinely irreversible – or if they are simply under-recognised, misdiagnosed or undertreated – the older person will develop disability over time (this may take several months or years). The word “disability” describes inability to perform everyday tasks safely, fully, appropriately and in a manner whereby nobody watching on is concerned. It is synonymous with dependency in activities of daily living (ADLs), lest foreseeable problems arise. There are dozens of potential examples illustrating how disability, dependency and risk can manifest in real life to frighten onlookers (Figure 3):

[caption id="attachment_54482" align="aligncenter" width="1024"] Figure 3. Activities of daily living and how they can go scarily wrong in older people with a disability due to accumulated pathologies in the brain and body.[/caption]

Okay, but what happens next?

Commonly, family members and others – now fearful that the patient has become an accident waiting to happen – start to step up or intervene. Actions taken include supervising medication, greater GP input, or searching for home care packages (acknowledging that, if patients live alone, no package will watch them 24/7; night times can be especially worrisome). Irrespective, the dependent older person has now slid much closer to crisis point. Generally, all that is now holding them from an acute calamity is the ongoing support of others, and a social and home environment free of hazards (staving off social vulnerability).

With this in mind, one can then appreciate the final set of (predictable) risk factors for crisis. If the home environment falls apart for whatever reason, frail patients typically don’t take long to declare themselves and fall off the cliff into an acute hospital. There are numerous ways in which the viability of their home environment may collapse:

• behavioural change occurs in the patient – if someone with dementia becomes aggressive or apathetic towards carers, the very same people propping them up, the risk of carer withdrawal is high. A final straw behaviour can be similarly cataclysmic – such as faecal smearing, public wandering, or driving illegally;
• elder abuse – a dependent older person may be deprived of things they need (such as medicines, foods, social contacts, GP visits) if a carer controls all the finances, or is absent despite theoretical recognition as the carer;
• illness in a carer;
• some isolated older people lack any carers, or even a GP;
• in modern-day Australia, it is difficult to secure a higher level home care package (HCP) in a timely manner; long waits for appropriate HCPs to become available is a real source of vulnerability (see here, page 27); and
• the environment itself – hazards in the home (eg, ledges, squalor, strewn pills, old food).

Crisis point

At this point, patients may experience falls, long lies, fractures, burns, poisonings, sepsis or the sequelae of medication errors (including cardiac or respiratory failure, high or low bloods sugars, acute Parkinsonism, strokes, bleeds etc). Once acutely hospitalised, they are prone to both prolonged lengths of stay and poor individual outcomes. There are at least three major reasons why this is so:

• first, frail individuals are sitting ducks for nosocomial complications;
• second, older people commonly present without clear and specific symptoms. In hypoactive delirium, somnolence may be attributed to napping or depression – thereby leading to delayed diagnosis of whatever is fuelling the delirium. Atypical or vague presentations of acute illness (common in geriatric patients) are heavily associated with adverse outcomes – for example, in pneumonia, cholangitis and acute coronary syndrome. Similarly, we know when non-diagnostic labels (such as “acopia”) are used as the diagnosis, outcomes can nose-dive, again because underlying illness or drug toxicity may be missed; and
• a third reason for prolonged lengths of stay may be not knowing the real back story of the patient’s problems. Superficially, an admission might seem due to “chronic obstructive pulmonary disease (COPD) exacerbation” or “hypoglycaemia”; yet the deeper root cause may be hiding. A community patient may have quietly developed unrecognised dementia and anticholinergic toxicity, and may actually have been struggling to cope for weeks or months before the acute sentinel event. They may then be unable to understand how to take their medication, and hence their chronic illnesses decompensate (using insulin or COPD inhalers actually takes surprising cognitive skill). Nonetheless, once the acute problem settles, a second wave of murmurings commonly begin from ward visitors or others that “this person isn’t coping … they can’t really be discharged;” this is perhaps similar to the 15-minute GP consultation where the patient’s complaint was addressed and yet, in the 14th minute on walking towards the door, another (bigger) problem is brought up. The patient commonly then stays – unless the lengthy work-up of their more chronic problems has already been performed by community specialists beforehand. It can take days or weeks waiting for important information to arrive in the form of old letters, collateral history from family members, the status of guardianship arrangements, and confirming or refuting whisperings of calamities at home (eg, exploitation, neglect, squalor, evictions). It can also take days waiting for aged care assessment team evaluations, and much longer for guardianship board tribunals (if needed).

In the next article I will address how we help older patients and the health system more broadly: the benefits of geriatrics.

Dr Toby Commerford is a consultant geriatrician at Royal Adelaide Hospital, is course coordinator for geriatrics at the University of Adelaide’s Rural School, and practices remote and rural outreaches to Port Augusta and Murray Mallee. He is also the lead singer in a rock band.

 

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