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 are present, relying solely on patient history may result in inaccurate diagnosis and treatment. Functional status can also strongly affect health outcomes. Decreased functional status in the hospital setting, for example, increases the likelihood of nursing home placement and death after discharge. Thus, a comprehensive understanding of cognitive and functional status is critical to providing care to the older adult, planning for the older adult’s future medical and social care needs, prognosticating, and providing caregiver support.
Using Goals of Care and Prognosis in Clinical Decision Making
Clinicians should begin the clinical evaluation of older adults by assessing their goals of care and decision-making capacity. This approach focuses the clinical encounter on targeting diagnostic and therapeutic plans based on the stated needs and goals of the patient and the patient’s caregivers, and identifying the patient who needs the help of surrogate decision makers. Experts in geriatrics and palliative medicine have developed tools and approaches to explore patients’ and their caregivers’ goals of care as an important starting place in the clinical encounter. To further enhance individualized decision making, geriatrics applies a consideration of prognosis to assess benefits and harms of proposed evaluations and interventions. While the science of prognostication is still catching up to clinical need, prognostication models based on more than age alone can be used to determine more accurate estimates of life expectancy. Considering such estimates in the context of patients’ goals of care represents an appropriate starting place for guiding decisions and treatment plans.
The Social Context of Care
Caring for the older adult is most effective when the broader context of the older adult’s family, friends, and community is taken into account. The social network of an older person’s life plays a significant role in identifying the individual’s preferences, resources, and support infrastructure in times of need. While younger adults may thrive with relative independence in accessing resources, older adults may rely more on their social network to provide care during episodes of acute illness or exacerbations of chronic illness. In managing a complex therapeutic plan at home (eg, one that involves managing multiple medications, dressing changes), effective compliance with therapy may hinge on the availability of financial resources, the ability of the patient to remain mobile in the residence and in the community, and the helping hands of family or friends. In the setting of acute unexpected events, an older adult’s survival may depend on having maintained routine contact with a social network. In addition, meeting the needs of the older adult is often contingent upon adequate care and support for caregivers who often suffer from caregiver burden, stress, and health effects of their own, particularly when caring for an older adult with advanced cognitive impairment. Thus, planning effective medical care of the older adult is inseparable from the thorough consideration of his or her social context.
The Impact of Multiple Conditions, Medications, and Settings of Care
Because of the complex interactions between physiologic reserve, functional and cognitive status, and social and/or caregiver support, older adults are particularly vulnerable when faced with multiple chronic conditions, many medications, and transitions across settings of care. When treating multiple conditions, the clinician caring for the older adult will be challenged by conflicting clinical care guidelines, as well as by the polypharmacy that often results when following several clinical guidelines simultaneously. As a result, the older adult often experiences new symptoms that represent adverse drug effects or interactions from multiple medications. During times of transition, for example, from hospital to home or from nursing home to emergency room, the older adult is particularly at risk for poor outcomes from incomplete medication reconciliation processes, inadequate hand-off communication, and additional potential harms, such as pressure ulcers from waiting an excessive amount of time on gurneys and falls related to hazards such as intravenous tubing. When caring for an older adult, multiple dimensions of care must be taken into account, guided by the patients’ goals and prognosis.
As older adults age, interaction with the medical system becomes, on average, a bigger part of their lives. Unfortunately, suffering amongst older adults and their caregivers remains too common. Because of older adults’ significant medical and social complexities, the typical medical encounter may be insufficient to identify or address the etiology of this suffering. In an increasingly global community, now is the time to learn from models of care that have been tried in different communities, populations, and countries. It is essential that clinicians are adept at applying and integrating the proven principles of geriatrics—accounting for decreases in physiologic reserve and cognitive and functional abilities, considering prognosis and goals of care, understanding the social context of the patient, and responding to the complex needs of patients with multiple conditions and medications across diverse care settings—to optimize the health of an aging society.