How do elderly patients differ from younger patients?
What are the risk factors for functional decline in the hospital?
What are the risk factors for the development of geriatric syndromes as a complication of hospitalization?
What items in the history and physical exam require customization for the geriatric patient?
What are the factors that predict higher mortality post-discharge of elderly patients?
Elderly patients differ from younger ones in many ways, including some that influence their care in the hospital. Optimal geriatric hospital care takes these special characteristics into account, and entails the use of a particular systematic approach, no matter what patients' admitting diagnoses may be. This chapter begins with a description of differences between older and younger hospital patients; describes the importance of self-care function among the elderly; 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 in this population.
One characteristic difference between older and younger patients is in how they present with common diseases. Younger patients generally present with complaints and findings that anatomically point to the diseased organ: they have productive cough and dyspnea with pneumococcal pneumonia, or chest pain with myocardial infarction. Older patients may demonstrate the same signs and symptoms, but often they present with one of two often-overlapping pictures. The first is acute functional loss—the sudden loss of self-care capability, such as independence in bathing or dressing. The other is the geriatric syndrome, which is a clinical syndrome (such as acute confusion, fall, dizziness or syncope, new-onset urinary incontinence) reflecting the presence of diminished physiological reserve. A frail elder with pneumonia may have no complaints directed at the thorax, but instead may be brought in by family because of confusion, falls, and new difficulties in the shower.
A variety of physiological changes occur as a result of normal aging in humans; Table 164-1 summarizes some of the most prominent.
Table 164-1 Selected Physiological Changes that Occur with Normal Aging ||Download (.pdf)
Table 164-1 Selected Physiological Changes that Occur with Normal Aging
- Brain perfusion shows impaired autoregulation
- Slowed reaction time
- Impaired balance from reduced vestibular responsiveness
- 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)
- Reduced FEV1 and FVC
- Impaired ciliary clearance
- Reduced PaO2 from V/Q mismatch
- Lungs less elastic
- Chest wall stiffer
- Reduced muscle mass with age
- Reduced bone mass
- Steady drop in GFR with age
- Reduced sodium conservation and excretion
- Reduced ability to concentrate or dilute urine
- Reduced ability to excrete acid load
- Renal perfusion more dependent on local prostaglandins
- Impaired bladder emptying
- Reduced contrast sensitivity (vision)
- Impaired dark adaptation (vision)
- Loss of high-frequency tones (hearing)