Principles of Geriatric Care
Key Clinical Questions
How do differences between hospitalized older adults and younger individuals alter the approach to this patient population?
What are the risk factors for functional decline and the development of geriatric syndromes during hospitalization?
What are the essential components of the initial hospital evaluation and how is this information used to trigger preventative measures? What are the essential components of daily rounds?
From 2010 to 2030, the total US population is expected to grow by 20%, while the segment of population aged 65 years and older is projected to increase by 79%. Older adults account for a disproportionate fraction of hospital discharges. In 2008, they made up 35% of hospital discharges while accounting for only 13% of the total population. As a result of aging demographics and greater utilization of hospital care by this age group, hospitalists will be caring for an increasing number of older patients.
Optimal geriatric hospital care uses a dedicated systematic approach that takes into account key differences between older and younger patients regardless of the admitting diagnosis. This chapter begins with a description of clinically significant differences between older and younger hospital patients; describes the importance of self-care function among older adults; summarizes key features of well-studied acute geriatric interventions; provides tips for care of the older patient on admission day, daily work rounds, and discharge; and finishes with information about prognosis.
DECREASED PHYSIOLOGIC RESERVE
Physiologic changes of normal aging affect all organ systems (Table 165-1). Aging is the consequence of varying genetic, environmental, and lifestyle influences, and age alone is not an accurate predictor of outcomes of hospitalization. Aging results in a loss of physiological resilience, a reduced ability of the body to maintain normal function when confronted with an external stressor.
TABLE 165-1Selected Physiological Changes That Occur with Normal Aging ||Download (.pdf) TABLE 165-1 Selected Physiological Changes That Occur with Normal Aging
|System ||Changes |
|Nervous || |
Brain perfusion shows impaired autoregulation
Slowed reaction time
Impaired balance from reduced vestibular responsiveness
|Circulatory || |
Decreased maximal HR and CO
Impaired diastolic filling, greater dependence on atrial systole
Reduced pacemaker cells in SA node
Reduced response to beta-adrenergic stimulation
Reduced elasticity of large arteries (increased systolic BP)
|Respiratory || |
Reduced FEV1 and FVC
Impaired ciliary clearance
Reduced PaO2 from V/Q mismatch
Lungs less elastic
Chest wall stiffer
|Musculoskeletal || |
Reduced muscle mass with age
Reduced bone mass
|Renal/Urinary || |
Steady drop in GFR with age
Reduced ability to concentrate or dilute urine
Reduced ability to excrete acid load
Renal perfusion more dependent on local prostaglandins
Impaired bladder emptying
|Sensory || |
Reduced contrast sensitivity (vision)
Impaired dark adaptation (vision)
Loss of high-frequency tones (hearing)
|Immune || |
Diminished cell-mediated immunity
Chronic low grade inflammation from innate immune activation
Antibodies have lower affinity
Reduced erythropoietic response to EPO...