Geriatrics’ forte is chronic disease management (Kane et al, 2005). At a time when medical care in general is awakening to the importance of good chronic disease care, geriatrics has been doing it for years. Many of the principles of geriatrics are basically those of good chronic care. Chronic disease management has two basic components. The first aims at preventing catastrophes (ie, emergency room visits and hospitalizations) by proactively monitoring patients’ conditions and intervening at the first sign of a change in the clinical course. Ideally these interventions prevent some hospitalizations, primarily by providing more effective primary care that prevents the event, but secondarily by managing crises, when they occur, without hospitalization. Figure 4-1, illustrates the paths to chronic disease catastrophe.
Paths to chronic disease catastrophe.
A growing shift in chronic disease, associated with enhanced survival and better care, is multimorbidity—the presence of multiple chronic diseases that can interact. The problems of managing chronic disease are vastly complicated by multimorbidity—a characteristic of many geriatric patients. Multimorbidity is associated with polypharmacy, which, in turn, can lead to iatrogenic complications.
Another aspect of managing chronic illness is palliative care. We tend to associate this type of care with end-of-life care, but its principles can be applied much more broadly.
Chronic disease management cannot be effectively accomplished without active central roles for patients and/or their caregivers. They live with this disease 24/7. They know its nuances. Patient-centered care has become a catchword—almost a cliché, but it lies at the heart of chronic care management.
Several models of chronic disease management have been promulgated. The popular Wagner model has spawned many variants; it envisions a productive interaction between an informed, activated patient (and caregiver) and a prepared, proactive practice team (Wagner et al, 1996). Unfortunately the current health-care system is poorly organized to facilitate such care. Fee-for-service payments, driven by in-person encounters, provide exactly the wrong climate for proactive care that uses modern communication technology to track patient status. The basic tenets of good chronic care are summarized in Table 4-1.
TABLE 4-1.Chronic Care Tenets ||Download (.pdf) TABLE 4-1. Chronic Care Tenets
|Aggressive primary care |
|Proactive monitoring |
|Early intervention to avoid catastrophes |
|Patient-centeredness, meaningful patient involvement in the care process |
|Use of information technology to track outcomes and trigger reevaluation |
|Teamwork, delegation |
|Efficient use of time |
|Benefit assessment in terms of slowing decline |
Elderly patients are in danger of being dismissed as hopeless or not worth the effort based on their age or their condition. Physicians faced with the question of how much time and resources to spend in searching for a diagnosis will undoubtedly consider the probability of benefit from the investment. Ironically, in some cases older ...