AGEING AND DISEASE: FOCUS ON MANAGEMENT ISSUES
• Describe the main differences in the ways that older people may present with health problems, as compared with younger adults.
• Identify distinctive aspects of quality care in assessing and managing the health needs of older people.
• Demonstrate an understanding of several key issues in drug therapy for the older person, specifically adverse drug reactions, polypharmacy and compliance.
• Discuss a number of strategies to promote the safe use of medications.
• Recognise the main problems that older people may encounter as inpatients in hospital.
• Identify several key strategies to help older people maintain their function and independence if they are admitted to hospital.
present some of the practical implications that arise from the disease processes that may be associated with the biology of ageing. The module begins by exploring some of the important ways that health problems may be different in older people than in younger age groups. It then discusses the particular area of drug therapy in older people. It concludes by examining the special care needs of older people who require treatment in hospital.
It examines ageing from the practical viewpoint of care providers. No matter what area of gerontology you are involved in, it is certain that those you care for will be
receiving some sort of medical care. It is essential that you understand the principles governing medical care of the aged. This topic identifies how biological changes associated with age impact on the practice of geriatric medicine.
The ageing of the population has major health care implications. In Australia, half of all acute care hospital beds are occupied by people aged over 60 years. People more than 65 yrsrepresent 12% of the population but account for 35% of total health care expenditure. Expenditure per person aged 65 or more is 3.8 times higher than younger people. It is estimated that the fraction of GDP spent on health will double in 40 years as a result of ageing.
Many health care workers express difficulty with geriatric medicine because of its complexity, the chronic nature of many common conditions, and the lack of evidence to which to base decisions.
The medical assessment of older people requires special skills and attitudes. Issues that need consideration include frailty and potential difficulties in communication (e.g. deafness, dysphasia, cognitive impairment). Patience, gentleness and courtesy will be rewarded with a wealth of clinical information as well as development of a therapeutic relationship with the patient.
The following issues are important in approaching medical problems of older people.
1. Atypical presentation of disease. The typical signs and symptoms of disease (e.g. chest pain in heart attack) are not seen frequently in older people. More commonly, older people present with non-specific symptoms: confusion, incontinence, failure to cope, immobility and falls. These are sometimes called the “geriatric giants” and in some ways parallel symptoms such as failure to thrive and irritability in paediatric medicine. In the acute hospital setting, these problems are often precipitated by infection (e.g. urinary tract infection, pneumonia) or the adverse effects of drugs – so called “drugs and bugs”. However, inevitably the acute illness often has a multifactorial aetiology.
2. Comorbidity. Older people often have several acute and chronic health problems. In developed countries in people over the age of 70 years, the prevalence of common diseases include arthritis (50-60%), hypertension (40-50%), heart disease (20-25%), cancer (20%), diabetes (10-15%), dementia (5-10%). It is important to identify all underlying health problems in every patient because, in order to achieve a good functional outcome, each problem (not necessarily each disease) usually needs to be addressed and treated. Because of the high prevalence of cognitive impairment and mood disorder in older hospitalized people, every older patient should have an assessment of cognition (e.g. MMSE) and mood (e.g. Geriatric Depression Scale) performed.
3. Iatrogenic contributions to health problems. Because older people often do have multiple problems it is vital that all the issues are considered and that problems are not treated in isolation. If this happens it is very easy for one form of treatment tolead onto other – often more serious – problems. For example, a patient with dementia who has been causing carer stress because of wandering is prescribed a sedative. As a result, he aspirates and develops pneumonia. He is brought to the Emergency Department with worsening confusion.
4. Holistic assessment of the person’s situation. Assessment of the health status of the older person should not be restricted to medical problems. It is also important to get an understanding of other aspects of the person’s life such as their social support systems, financial constraints affecting their care, accommodation and transport needs.
5. The goals of therapy. Quality of life and independence are often paramount for an older person. In a study of older people in hospital, it was found that the majority had “returning to their own home” as their main goal. This often did not correlate with the wishes of family members. In general, an older person is admitted to hospital because they cannot manage independently and should be returned home once independence has been achieved. In this setting, other medical goals such as the treatment and investigation of specific diseases need to be undertaken as an outpatient or by the general practitioner.
CARE OF THE OLDER PERSON IN HOSPITAL
The greatest users of hospitals are older people. Therefore, all people working within the hospital system should have an appreciation of some of the special management issues in this age group. These include the following.
1. Team approach. Older people often have multiple problems that need to be addressed, therefore special input is required for the assessment and management of each problem.
2. Early discharge planning. Ideally, all members of the team should have a long-term plan in place from the day of admission. This is required so that all members of the team have a consistent goal and so that organizational issues (such as completion of Form 26/24 for residential care placement) can be completed ahead of time. For many older people, hospitalization is a harbinger of the need for permanent residential care. Discharge planning should involve communication with the person’s general practitioner and relevant health and support services in the community.
3. Appreciation of rehabilitation and palliative care needs. A rehabilitative approach should be undertaken from the day of admission and not left until the acute illness has been treated in order to prevent the complications of immobility. If medical treatment is futile, palliative care can be instituted. In this setting, consideration of resuscitation orders, adequate analgesia, and communication with the patient and family are important.
4. Prevention and management of iatrogenic disease. There are seven common complications of immobility and hospitalization in older people:
a. venous thrombosis,
b. pressures sores,
c. malnutrition,
d. deconditioning,
e. depression,
f. bronchopneumonia and
g. constipation.
These all contribution to morbidity, mortality and length of hospital stay, but ideally are all preventable.
DRUG THERAPY IN THE OLDER PERSON
Drug therapy is the main intervention of modern medicine. The efficacy and safety of medications are well established in younger populations with disease. Older people, who have greater susceptibility to disease, would be expected to benefit even more. However, the issue is more complex. Older people have increased risk of adverse effects and in many cases, there is limited evidence for efficacy in frail older people. In this setting, a careful risk:benefit analysis may preclude use of medications that are routine in the management of disease in younger adults.
Adverse drug reactions are a major cause of morbidity and mortality in older people. Thus, whenever an older person develops new symptoms, particularly falls or confusion, the first diagnosis to consider is an adverse drug reaction, because these are common and easy to treat.
Adverse drug reactions have taken over from syphilis and tuberculosis as the great mimic of systemic disease. As a rule of thumb, it is useful to consider adverse drug reactions for every presenting problem in older people, partly because they are common and partly because they are simple to manage (ie by ceasing the medications). Although adverse drug reactions can present with any symptoms, there are two special areas of concern in older people: falls and confusion.When making a decision to commence drug therapy, the higher prevalence of adverse drug reactions in older people needs to be considered in the risk to benefit ratio.
Polypharmacy, defined as the use of five or more medications occurs in 20-40% of older people. Part of the risk of polypharmacy may be the unintentional practice of prescribing additional drugs for the adverse effects of other drugs, the so-called ‘prescribing cascade’.
The risks and negative aspects of polypharmacy include increased risks of adverse drug reactions, drug interactions, cost and compliance errors. Medication errors can occur easily during hospitalization of older people taking complex medication regimes.
It is important to determine the potential benefits of polypharmacy before dismissing it as inappropriate. As yet, there is limited information on the usefulness of treating multiple conditions in the same patient.
Evidence based medicine The evidence base for prescribing to older people is small and clearly disproportionate to the amount of prescribing in this group. In the year
2000, only 3.45% of 8945 randomized controlled trials and 1.2% of 706 meta-analyses were for people over 65 years. Much of geriatric practice with respect to drug usage is reduced to being anecdotal, and at best based on extrapolation from studies in younger patients or healthy older people.
Pharmacodynamics and pharmacokinetics. Age related changes in liver and kidney function lead to impaired clearance of drugs from the body. This means that standard doses of drugs used in younger adults are likely to lead to increased concentrations in older people, and hence, increased risk of adverse drug reactions. Age-related changes in receptors for drugs can lead to increased or decreased drug activity.
READINGS
Assessing the health status of the older person
1. Pal SK. Katheria V. Hurria A. (2010) Evaluating the older patient with cancer: understanding frailty and the geriatric assessment. CA: a Cancer Journal for Clinicians. 60(2):120-32.
2. Inouye SK. Studenski S. Tinetti ME. Kuchel GA. (2007) Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. Journal of the American Geriatrics Society. 55(5):780-91.
Care of the older person in hospital
1. Callahan, E.H., Thomas, D.C., Goldhirsch, S.L. and Leipzig, R.M. (2002). Geriatric hospital medicine. Medical Clinics of North America, 86(4):707-29.
2. Australian and New Zealand Society for Geriatric Medicine. Position Statement No 15 Discharge Planning. http://www.anzsgm.org/documents/PositionStatement15DischargePlanningDec08.pdf
3. Rothschild, J.M., Bates, D.W., Leape, L.L. (2000) Preventable medical injuries in older patients. Archives of Internal Medicine 160(18):2717-2728
4. Wright L, Hill KM, Bernhardt J, Lindley R, Ada L, Bajorek BV, Barber PA, Beer C, Golledge J, Gustafsson L, Hersh D, Kenardy J, Perry L, Middleton S, Brauer SG, and Nelson MR (2012) Stroke management: updated recommendations for treatment along the care continuum. Internal Medicine Journal 42 562–569.
5. Kortebein, P (2009) Rehabilitation for Hospital-Associated Deconditioning. American Journal of Physical Medicine& Rehabilitation 88: 66-77.
7. Young J,Inouye SK (2007). Delirium in older people. British Medical Journal 334: 842-846.
8. Saxena S. Lawley D. (2009) Delirium in the elderly: a clinical review. Postgraduate Medical Journal. 85(1006):405-13.
9. Covinsky, KE; Pierluissi, E; Johnston, CB (2011) Hospitalization-Associated Disability “She Was Probably Able to Ambulate, but I’m Not Sure” JAMA-Journal of ohe American Medical Association. 306: 1782-1793.
10. Amador LF, Loera JA (2007) Preventing Postoperative Falls in the Older Adult. Journal of the American College of Surgeons 204: 447-453.
Pain
1. Karp JF. Shega JW. Morone NE. Weiner DK. (2008) Advances in understanding the mechanisms and management of persistent pain in older adults. British Journal of Anaesthesia. 101(1):111-20.
Drug therapy in the older person
1. Dingwall L. (2007) Medication issues for nursing older people (part 1). Nursing Older People. 19:25-9.
2. Shi, S; Morike, K; Klotz, U (2008). The clinical implications of ageing for rational drug therapy European Journal of Clinical Pharmacology, 64 (2): 183-199.
Aids
1. Thirugnanachandran T, Bateson A (2012). Seating for improving function in older people. European Geriatric Medicine 3:67–72.
2. Clegg A, Smith S (2010). Bedding aids. European Geriatric Medicine 1:385–390.
3. Stowe S, Hopes J, Mulley G (2010) Walking Aids. European Geriatric Medicine 1:122–127.
