4-02: General Principles of Geriatric Care

The following principles help in caring for older adults:

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

2. Diseases often present atypically or with nonspecific symptoms (eg, confusion, functional decline).

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.

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.

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, weakness, fatigue, 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 MI, a stroke, or an adverse reaction to a medication, to list just a few possible explanations.

Because many geriatric syndromes have multiple causes, multiple targeted interventions may be a more realistic approach than trying to find a "cure." For example, the cause of 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.

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 in a person with multiple other issues might be burdensome to the patient with little chance of positively impacting any meaningful clinical outcomes. While abnormalities should be acknowledged in the medical record, they can be addressed in order of priority, with the patient's goals and preferences (eg, independence, symptom management, desire for longevity) dictating the evaluation strategy.

Many older patients must manage complex medication regimens, particularly those who have multiple comorbidities. Medication side effects can occur with low doses of medications that usually produce no side effects in younger people. For instance, a mild anticholinergic agent (eg, diphenhydramine) may cause confusion, loop diuretics may precipitate urinary incontinence, and nonprescription sympathomimetics may result in urinary retention.

Multiple chronic conditions may accumulate in older adults requiring a comprehensive approach that considers each condition in conjunction with others. This becomes particularly important when applying disease-specific guidelines that frequently do not consider ...