Clinical decision making, including diagnosis, treatment, and desired outcomes, differs between younger and older adult patients. The primary goal of medical care in younger adult patients usually is diagnosis of the disease causing the presenting symptoms, signs, and/or laboratory abnormalities. Treatment is targeted toward the pathophysiologic mechanisms deemed responsible for the disease. Relevant clinical outcomes are determined by the specific diseases and include cure if the disease is acute, and control or symptom modification if the disease is chronic.
The conventional disease-specific approach is not optimal in older patients for several reasons. First, age-related physiologic changes in most organ systems affect diagnostic test interpretation and response to treatments and may be difficult to differentiate from disease. In addition to age-related physiologic changes, the average 75-year-old suffers from 3.5 chronic diseases. With multiple coexisting chronic diseases, there is a less consistent relationship between pathology and disease or between disease and clinical manifestations. One disease may obscure or change the pathology, manifestations, or accuracy of laboratory evaluation of coexisting diseases. Treatment of one disease may increase the severity of another. With multiple coexisting diseases, it becomes difficult, and often impossible, to assess the severity or manifestations of individual diseases and to ascribe health and/or functional status to specific disease processes.
Second, many distressing symptoms or impairments among older persons, such as pain, dizziness, fatigue, sleep problems, sensory impairments, and gait disorders cannot be ascribed to a single disease; instead, they result from the accumulated effect of physical, psychological, social, environmental, and other factors. A clinical focus solely on diagnosing and treating discrete diseases may lead to expensive diagnostic testing with inconclusive results, to unnecessary, or even harmful, interventions, or, conversely, to ignoring potentially remediable symptoms. While clinicians may be reluctant to treat symptoms in younger and middle-aged patients without a specific diagnosis, treatment focused on improving symptoms in multiply ill and impaired older patients is often appropriate, because comfort and function are primary goals of health care in this population.
Third, diagnostic test characteristics may be altered by age and comorbidity, making selection and interpretation of tests more complicated than for younger patients. Furthermore, both the benefits and harms of treatment regimens may differ in the face of age-related physiologic changes and coexisting health conditions.
Fourth, older patients vary in the importance they place on potential health outcomes. When asked, older persons are able to prioritize among the often competing goals of increased survival, comfort, cognitive function, and physical function. Optimal clinical decision making in the care of older patients includes the articulation of patient preferences or goals of care; the identification of the diseases, impairments, and nondisease-specific factors affecting the attainment of these preferences and goals; and the selection of treatment options based on the modifiable impediments to individual patient goals. The multiplicity of impairments and diseases; the contribution of psychological, social, and environmental factors to health conditions; the enhanced likelihood of harm as well as ...