Older people

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.

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.

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 )

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 ).

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.