Describe the main differences in the ways that older people may present with health problems as compared with younger adults.
Identify distinctive aspects of quality care in assessing and managing the health needs of older people.
Demonstrate an understanding of several key issues in drug therapy for the older person specifically adverse drug reactions polypharmacy and compliance.
Discuss a number of strategies to promote the safe use of medications.
Recognise the main problems that older people may encounter as inpatients in hospital.
Identify several key strategies to help older people maintain their function and independence if they are admitted to hospital.
present some of the practical implications that arise from the disease processes that may be associated with the biology of ageing. The module begins by exploring some of the important ways that health problems may be different in older people than in younger age groups. It then discusses the particular area of drug therapy in older people. It concludes by examining the special care needs of older people who require treatment in hospital.
It examines ageing from the practical viewpoint of care providers. No matter what area of gerontology you are involved in it is certain that those you care for will be
receiving some sort of medical care. It is essential that you understand the principles governing medical care of the aged. This topic identifies how biological changes associated with age impact on the practice of geriatric medicine.
The ageing of the population has major health care implications. In Australia half of all acute care hospital beds are occupied by people aged over 60 years. People more than 65 yrsrepresent 12% of the population but account for 35% of total health care expenditure. Expenditure per person aged 65 or more is 3.8 times higher than younger people. It is estimated that the fraction of GDP spent on health will double in 40 years as a result of ageing.
Many health care workers express difficulty with geriatric medicine because of its complexity the chronic nature of many common conditions and the lack of evidence to which to base decisions.
The medical assessment of older people requires special skills and attitudes. Issues that need consideration include frailty and potential difficulties in communication (e.g. deafness dysphasia cognitive impairment). Patience gentleness and courtesy will be rewarded with a wealth of clinical information as well as development of a therapeutic relationship with the patient.
The following issues are important in approaching medical problems of older people.
1. Atypical presentation of disease. The typical signs and symptoms of disease (e.g. chest pain in heart attack) are not seen frequently in older people. More commonly older people present with non-specific symptoms: confusion incontinence failure to cope immobility and falls. These are sometimes called the geriatric giants and in some ways parallel symptoms such as failure to thrive and irritability in paediatric medicine. In the acute hospital setting these problems are often precipitated by infection (e.g. urinary tract infection pneumonia) or the adverse effects of drugs so called drugs and bugs. However inevitably the acute illness often has a multifactorial aetiology.
2. Comorbidity. Older people often have several acute and chronic health problems. In developed countries in people over the age of 70 years the prevalence of common diseases include arthritis (50-60%) hypertension (40-50%) heart disease (20-25%) cancer (20%) diabetes (10-15%) dementia (5-10%). It is important to identify all underlying health problems in every patient because in order to achieve a good functional outcome each problem (not necessarily each disease) usually needs to be addressed and treated. Because of the high prevalence of cognitive impairment and mood disorder in older hospitalized people every older patient should have an assessment of cognition (e.g. MMSE) and mood (e.g. Geriatric Depression Scale) performed.
3. Iatrogenic contributions to health problems. Because older people often do have multiple problems it is vital that all the issues are considered and that problems are not treated in isolation. If this happens it is very easy for one form of treatment tolead onto other often more serious problems. For example a patient with dementia who has been causing carer stress because of wandering is prescribed a sedative. As a result he aspirates and develops pneumonia. He is brought to the Emergency Department with worsening confusion.
4. Holistic assessment of the persons situation. Assessment of the health status of the older person should not be restricted to medical problems. It is also important to get an understanding of other aspects of the persons life such as their social support systems financial constraints affecting their care accommodation and transport needs.
5. The goals of therapy. Quality of life and independence are often paramount for an older person. In a study of older people in hospital it was found that the majority had returning to their own home as their main goal. This often did not correlate with the wishes of family members. In general an older person is admitted to hospital because they cannot manage independently and should be returned home once independence has been achieved. In this setting other medical goals such as the treatment and investigation of specific diseases need to be undertaken as an outpatient or by the general practitioner.
CARE OF THE OLDER PERSON IN HOSPITAL
The greatest users of hospitals are older people. Therefore all people working within the hospital system should have an appreciation of some of the special management issues in this age group. These include the following.
1. Team approach. Older people often have multiple problems that need to be addressed therefore special input is required for the assessment and management of each problem.
2. Early discharge planning. Ideally all members of the team should have a long-term plan in place from the day of admission. This is required so that all members of the team have a consistent goal and so that organizational issues (such as completion of Form 26/24 for residential care placement) can be completed ahead of time. For many older people hospitalization is a harbinger of the need for permanent residential care. Discharge planning should involve communication with the persons general practitioner and relevant health and support services in the community.
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