Populations are aging worldwide. This demographic shift will dominate the social, political and public health landscape of the 21st century. The medical and social science literature is replete with commentaries and interventions designed to address the magnitude and consequences of this phenomenon. Many of these opinions and discoveries have led to improvements in medical and social care for older adults and their caregivers. Such advances have addressed diverse areas of care, including transitions in medical care, medication prescribing practices, fall reduction, pain and symptom control, and decreasing caregiver burden, to name just a few.
Yet, as clinicians who focus on enhancing the care of older adults, we note that a disconnect often remains between what happens in clinicians’ offices and what patients and their caregivers need at home. Although the principles of geriatric medicine aim to bridge such gaps, many clinicians leave their training ill-equipped to incorporate the fundamental principles of geriatric medicine into their care of older adults.
Five principles guide the care of older adults:
The Impact of Decreased Physiologic Reserve
Older adults have lower physiologic reserve in each organ system when compared with younger adults, placing them at risk for more rapid decline when faced with acute or chronic illness. Some contributors to decreased physiologic reserve may include decreases in muscle mass and strength, bone density, exercise capacity, respiratory function, thirst and nutrition, or ability to mount effective immune responses. For these reasons, older adults are often more vulnerable, for example, to periods of bedrest and inactivity, external temperature fluctuations, illnesses that are otherwise self-limited in younger adults, and complications from common infectious diseases. Although preventive measures, such as vaccinations, may be beneficial, decreased physiologic reserve may also impair older adults’ ability to mount an effective immune response to vaccines. These processes can also delay or impair recovery from serious events or illnesses such as hip fractures or pneumonia. As a result of the interplay of multiple medical conditions in the context of decreased physiologic reserve, older adults are prone to developing complex geriatric syndromes, such as frequent falls.
The Importance of Functional and Cognitive Status
In older adults, cognitive and physical functional status are often more accurate predictors of health, morbidity, mortality, and health care utilization than are individual diseases. Cognitive status includes domains of executive function, memory, mental status, and clinical decision-making ability. Functional status includes the physical requirements necessary to maintain independence in one’s own environment, often assessed using activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Decreased cognitive abilities put older adults at risk (eg, for medication errors caused by an inability to follow instructions about complex medication regimens), can create significant stress on caregivers, and increase the possibility of elder abuse (eg, financial abuse). If cognitive disorders such as dementia ...