Geriatrics can be thought of as the intersection of gerontology and chronic disease management (Kane, Priester, and Totten, 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. Multimorbidity is associated with polypharmacy, which, in turn, can lead to iatrogenic complications. The second basic component 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.
Paths to chronic disease catastrophe.
Several models of chronic disease management have been promulgated. The most popular is the Wagner model, which envisions a productive interaction between an informed, activated patient (and caregiver) and a prepared, proactive practice team (Wagner, Austin, and Von Korff, 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
Early intervention to avoid catastrophes
Patient-centeredness, meaningful patient involvement in the care process
Use of information technology to track outcomes and trigger reevaluation
Efficient use of time
Assessing benefit in terms of slowing decline
Elderly patients are in danger of being dismissed as hopeless or not worth the effort based on their age. Physicians faced with the question of how much time and resources to spend in searching for a diagnosis will want to consider the probability of benefit from the investment. In some cases, older patients are better investments than younger ones. This apparent paradox occurs in the case of some preventive strategies when the high risk of susceptibility and the discounted benefits of future health favor older persons. But it also arises in situations where small increments of change can yield dramatic differences.
Perhaps the most striking example of the latter is found in the case of nursing home patients. Ironically, very modest changes in their routine, such as introducing a pet, giving them a plant to tend, or increasing their sense of control over ...