Older people - Clinical Tree

Introduction

‘In the end, it’s not the years in your life that count. It’s the life in your years.’ Abraham Lincoln

At the turn of the twentieth century, there were 65000 people in the UK aged 85 or older. By 2050, it is projected there will be more than 3 million. Many people still associate old age with frailty, disability and loss of independence. The positive aspects of ageing, such as sagacity, maturity and experience, are too often neglected. Society holds youthfulness in high esteem, but as the burden of morbidity is delayed by improvements in health care and economics it is hoped that these commonly held negative beliefs about growing old will gradually disappear.

Age is traditionally defined in terms of chronological age, but older people are a heterogeneous group and each old person should be respected as an individual, not merely classed according to age. Increasingly the role of ‘Frailty’ as a syndrome and a more accurate predictor of morbidity and mortality is ensuring that appropriate care and planning is provided to those who need it most, regardless of age.

People age at different rates. It is the complex interplay of environmental, psychosocial, genetic and acquired pathological processes that determines an individual’s biological age. The role of Geriatric Medicine is to take a holistic view of this process and to provide care in a way that optimizes a person’s function and health.

Presentation of disease in older people

Two major factors influence the recognition of disease processes in older people:

1.
Acceptance of ill health, with a delay in seeking help.
2.
Atypical presentation of disease processes.

The acceptance of ill health and disease as ‘ageing’, with its resultant disabilities, means that many older people expect to be frail, rarely complain and often are late seeking help. Coming to terms with some disability or change is necessary at all ages, and acceptance is part of survival. However, the tacit acceptance of inevitable deterioration, for example in vision, hearing, teeth and memory, may lead to treatable conditions being ignored and result in loss of independence. Table 7.1 illustrates what may be regarded as normal ageing and what is pathological.

Table 7.1

Normal ageing and changes in body systems

System	Normal ageing	Pathophysiological changes common in older age
Cardiovascular	Slight increase in heart size Normal stroke volume and left ventricular ejection fraction Exertional oxygen consumption declines 7.5–10% per decade; thus exercise tolerance is reduced	Ischaemic heart disease Heart failure Valvular heart disease Peripheral vascular disease Aneurysms
Respiratory	Vital capacity: 40% reduction by age 70 FEV ₁ and FVC: 30% reduction by age 80 Progressive reduction in PEFR after age 30	Haemoptysis Chronic obstructive pulmonary disease (COPD) Lung fibrosis Lung cancers
Alimentary	Reduced and abnormal peristalsis: ‘grey-oesophagus’ Slower colonic transit Reduced absorption of some nutrients; reduced energy requirements	Weight loss Dysphagia Change in bowel habits Bleeding from the upper or lower GI tract
Hepatobiliary	Reduced hepatic mass and metabolic reserve, but maintenance of normal function	Jaundice Deranged liver function tests, including abnormal clotting
Renal	Reduced GFR and numbers of functional tubules and glomeruli Reduced serum creatinine owing to loss of muscle mass	Renal impairment with raised serum creatinine Haematuria
Genitourinary	Men: Reduced testosterone Normal FSH/LH 50% of men over 70 have ‘abundant spermatogenesis’ Women: Postmenopausal low oestradiol; raised FSH and LH Loss of female reproductive capability Atrophic vaginitis owing to low oestrogen levels Loss of sexual interest may also occur, but this is complex and multifactorial	Erectile dysfunction Prostatic enlargement Bladder outflow tract symptoms Postmenopausal bleeding (PMB) Urinary incontinence Painful intercourse
Nervous system, including higher senses	High-frequency hearing loss Vision: close focusing declines from age 40 Distinguishing fine detail (reduced acuity) declines after 70 years Loss of muscle mass leads to decline in strength Reduced mental agility and minor loss of mental ability	Deafness, tinnitus and vertigo Glaucoma, macular degeneration Cataracts Dementia and delirium Hemiparesis, paraparesis Many other factors, including reduced distal sensation, vascular disease, poor balance
Endocrine	Pituitary dysfunction Abnormal thyroid function Abnormal pancreatic function Reduced adrenal response to stress	Hyponatraemia Hypothyroidism Impaired glucose tolerance and frank diabetes mellitus
Musculoskeletal	Increased body fat and loss of muscle mass (although this may be retarded with exercise)	Osteoarthritis and vertebral spondylosis Osteoporosis
Dermatological	Loss of collagen in the skin leads to thin, papyraceous skin Ecchymoses and senile purpura	Basal and squamous cell carcinoma Solar keratoses Malignant melanoma
Haematological and immune system	Loss of T-cell function with age may be associated with late-onset autoimmune disease Possible link between changes in immune system and: age-related cancers response to disease	Anaemia Myelodysplasia Haematological malignancies Chronic lymphatic lymphoma and myeloma

FEV ₁ , forced expiratory volume in 1 second; FSH, follicle stimulating hormone; FVC, forced vital capacity; GI, gastrointestinal; GFR, glomerular filtration rate; LH, luteinizing hormone; PEFR, peak expiratory flow rate.

As medicine has developed, people now survive illnesses they would previously have died from. Many patients will now present to health care settings with multiple comorbidities, which may be causally linked or not. Managing multiple conditions and pulling out the key problem at any one time is a skill that requires a combination of knowledge, an ability to manage uncertainty and close attention to detail. It is often the ‘little things’ that count the most.

Proper diagnosis and treatment in older people requires the identification and treatment of amenable clinical problems and recognition of the special needs and the specific clinical presentations of older people. The social aspects of care may be as important as the disease process itself. Understanding this encourages a patient-centred, multi-disciplinary team (MDT) approach. Caring for older people requires clinical acumen and much skill. Geriatricians not only recognize diseases and their presentations in older people but, perhaps equally importantly, act as their patients’ advocate in all areas of health care.

Frailty

In normal day-to-day circumstances, ageing organs are able to maintain normal metabolic function. However, when stressors are experienced, as in acute illness, functional capacity is exceeded and rapid clinical deterioration may occur. By definition, the frailer the person, the greater the deterioration and the more likely that deterioration will occur in the context of a relatively minor stressor. The frail person has a lower physiological reserve in response to any insult and will take longer to return to their previous level of functioning, if at all. This person may be old but younger people can be frail if they have a combination of disability and morbidity, which has an impact on their ability to live independently and lowers their physiological reserve. Frailty can be measured formally using a variety of scales, which take into account day-to-day functioning, energy levels and need for support. A clear correlation exists between increasing frailty and increasing mortality, which makes it a more useful indicator of prognosis than chronological age alone.

History

Taking a good history is always essential, but it requires particular sensitivity in older people. The practical aspects of ensuring that patients have their hearing aids and glasses and teeth in are essential to optimizing the history-taking process. Sitting on the same level as the patient will support a patient who may also lip read. Some patients may need written questions. Frailer patients may not tolerate lengthy histories or being bombarded with questions and they may tire easily.

Some patients may rely on a carer or family member to support with communication but ensure that everyone is involved in the conversation. Ask the patient’s permission to clarify something with a carer and by positioning yourself closer to the patient physically so that they feel involved. Some patients with cognitive problems may not remember much about their medical history, but they may still be able to tell you what matters most to them, how they spend their day and who is important to them.

It is useful to establish what the patient likes to be called because this is often not what is written on their record. Most of the communication skills required to support history taking in older people are transferable to ALL patients and will hone history-taking skills generally ( Boxes 7.1 and 7.2 )

Box 7.1

History taking: points to note

▪
The introduction: observation as they enter; greeting
▪
Cadence and interest
▪
Position and comfort of patient
▪
Vision, hearing, cognition
▪
Environment
▪
Autonomy and respect
▪
Use of multiple sources of information
▪
Interview versus interrogation

Box 7.2

Observations during the introduction

▪
Can the patient see and hear you?
▪
Is behaviour normal?
▪
Is language normal?
▪
Does the patient understand your role as a doctor?
▪
Is the patient at ease, or in pain?
▪
Is there evidence of support from family or friends?

Comprehensive geriatric assessment

This is an assessment tool used by the MDT to ensure that all aspects of a person’s life have been assessed and that management plans reflect the outcome of this assessment and are patient focused. Geriatricians work closely with all members of the MDT, which incorporates nurses, physiotherapists, occupational therapists, pharmacists, speech and language therapists, dieticians and social workers. The assessment may take place over a number of ward rounds or days as it involves collating a lot of information.

The comprehensive geriatric assessment (CGA) tool is an evidenced-based and well-validated intervention for older and frailer people. At its core are five main areas of focus:

1.
Physical health assessment.
2.
Mental health assessment.
3.
Functional assessment.
4.
Social assessment.
5.
Environmental assessment.

Each member of the team can contribute to any of the key areas, but doctors and nurses generally focus on the physical and mental health assessments. Physiotherapists and occupational therapists will assess the functional and environmental issues and a social worker will be involved in the social assessment. Combining information from the full team ensures that appropriate medical and social care can be implemented.

The physical and mental health assessment will need to ensure that the key ‘geriatric giants’ (immobility and falls, pressure ulcers, cognitive problems and incontinence) are assessed. Getting into the habit of doing this at an early stage in your career is essential to the future care of older and/or more frail patients ( Box 7.3 ).

Box 7.3

Comprehensive geriatric assessment

Physical and mental assessment key areas:

▪
Sleep
▪
Falls and mobility
▪
Appetite and weight
▪
Continence
▪
Skin
▪
Pain
▪
Memory
▪
Mood and energy levels
▪
Medication
▪
Vision, hearing and dentition

Older patients should be examined in the same way as younger patients, but there are some key additional areas to focus on to ensure a robust assessment has been completed and these are highlighted in each section.

Comprehensive geriatric assessment—physical health

Sleep

It is worth noting how well a patient feels he sleeps. What time does he go to sleep and how long does he sleep? Is his sleep interrupted or does he sleep ‘badly’? Does he have frequent nightmares or terrors? Is his sleep disturbed by pain or needing to go to the toilet?

Good sleep is increasingly recognized as an important contributor to optimal physical and mental wellbeing. Disturbances in sleep can have an impact on concurrent medical issues, mood, energy levels and even memory. The link between poor sleep and poor cognition is gaining evidence, but being sleep deprived will have an impact on concentration and thinking in any person.

Nightmares and night terrors may be associated with Parkinson’s disease and Lewy body dementia. Overnight pain must be explored and addressed. Frequent nocturia can be a sign of prostatism in men or may represent bladder instability, overflow or infection in either sex, all of which may be alleviated by advice around drinking habits, further physical assessment and medication, as needed. A person who gets up at night may be at increased risk of falling, so the assessment and management of simple issues like pain and continence may reduce the risk of falls and their associated complications.

Falls and bone health

Entire clinics are now devoted to assessing patients who ‘fall’, such is the impact of this seemingly simple event on morbidity and mortality. It is therefore important to ask if a person has fallen in the last year and how many times? Information about the pattern of any previous falls can be helpful: frequency, relationship to posture, activity or time of day, pre-warning and residual symptoms following the fall, and any avoiding steps taken by the patient should be ascertained. The absence of any warning implies a sudden event, usually neurological or cardiovascular in nature.

Sinister symptoms associated with falling include loss of consciousness (although, notoriously, this is poorly reported), focal neurological deficit, features of seizure, chest pain, palpitations or other cardiorespiratory symptoms. The most useful clinical investigation in ‘older fallers’ is to watch them walking; however, they may also need medical investigations to exclude cardiovascular problems such as a 24-hour ECG tape or a tilt test and brain imaging if a neurological cause is suspected.

It is also important to establish any previous injuries from a fall, especially any broken bones. Any patient who has had a previous fracture from a fall will need an assessment of bone health, including an assessment of vitamin D and calcium and potentially bone mineral density analysis.

Falls prevention programmes constitute a key part of local public health initiatives and entail education around falls, trip hazards and exercise programmes.

Key areas of examination

A focus on the cardiovascular and neurological systems and observation of the person walking are both aspects of any falls assessment ( Box 7.4 ).

Box 7.4

The causes of falls in elderly people

Premonitory

▪
Forerunner of acute, usually infectious, illness

Medication

▪
Multiple drug therapy
▪
Psychotropic drugs
▪
L-dopa
▪
Antihypertensives

Postural hypotension

▪
Drugs
▪
Alcohol
▪
Cardiac disease
▪
Autonomic failure/dysfunction

Neurological disease

▪
Neurocardiogenic syncope
▪
Multiple strokes
▪
Transient ischaemic attack
▪
Parkinson’s disease
▪
Cerebellar disease
▪
Epilepsy
▪
Age-related loss of postural reflexes
▪
Spastic paraparesis (usually owing to cervical spondylosis)
▪
Peripheral sensory or motor neuropathy
▪
Situational and postprandial syncope

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