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INTRODUCTION

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Older persons live longer and healthier lives than ever before. Persons over the age of 85 are the most rapidly growing segment of the population and those over 65 will account for 20% of the population by 2030. Most clinicians will spend half or more of their time caring for older adults. Older persons vary widely in health status, prognosis, and preferences for care. Many persons in their 60s are healthy and can expect to live another 30 years or longer. Yet, chronic diseases that will cause disability and death will develop in nearly all older persons. Therefore, clinicians caring for older adults must have skills in managing multiple comorbidities and wisely guiding the patient in both "curative" and "palliative care."

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GENERAL PRINCIPLES OF GERIATRIC CARE

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The following principles help in caring for older adults:

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  1. Many disorders are multifactorial in origin and are best managed by multifactorial interventions.

  2. Diseases often present atypically.

  3. Not all abnormalities require evaluation and treatment.

  4. Complex medication regimens, adherence problems, and polypharmacy are common challenges.

  5. Multiple chronic conditions often coexist and should be managed in concert with one another.

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Comorbidities are common in older people, and the diagnostic "law of parsimony" often does not apply. For example, fever, anemia, and a heart murmur suggest endocarditis in a younger patient; however, in an older patient, three different explanations—a viral illness, unexplained anemia of aging, and aortic sclerosis—are more likely than endocarditis alone.

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Disease presentation is often atypical in elderly patients. A disorder in one organ system may lead to symptoms in another, especially one that is compromised by preexisting disease. A limited number of presenting symptoms—ie, confusion, falling, incontinence, dizziness, and functional decline—predominate irrespective of the underlying disease. Thus, regardless of the presenting symptom in older people, the differential diagnosis is often similar. An 80-year-old person with new falls and confusion could have pneumonia, an acute myocardial infarction, a stroke, or a urinary tract infection.

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Because many geriatric syndromes have multiple causes, multiple targeted interventions may be a more realistic approach than trying to find a "cure." For example, dizziness is often multifactorial in older adults. Successful treatment may involve correcting vision, prescribing physical therapy focused on strength and balance, and reducing sedating medications, in contrast to a narrow focus on one problem.

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Many abnormal findings are relatively common in older people and may not be responsible for a particular symptom. Such findings can include asymptomatic bacteriuria, premature ventricular contractions, and slowed reaction time. In addition, many older patients with multiple comorbidities may have laboratory abnormalities that, while pathologic, may not be clinically important. A complete work-up for a mild anemia of chronic disease in a person with multiple other issues might be burdensome to the patient with little chance of improving quality of life or longevity. While abnormalities should be acknowledged in the medical record, ...

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