You'll be seeing more and more elderly patients in your
practice in the coming years. By 2011 close to 15% of
Canadians will be over 65. You've probably noticed a shift
already, with fewer pediatric breaks and sprains and more
geriatric multiple aches and pains. But before you write
off their many ailments as simply part of aging, you need
to be aware of the finer points of treating the elderly.
"They're more than just old people," says Dr Howard Dombrower,
a geriatrician at the Baycrest Centre for Geriatric Care
in Toronto. "The way they present health issues is different.
It's often non-specific or presents as a functional decline."
On top of that, social issues — like whether patients
can manage on their own — must become an integral
part of properly caring for the aged.
"There's a complexity of issues
for a family physician to consider on a very practical
level," says Dr Chris Frank, vice-president of the Canadian
Geriatrics Society. To guide you in the right direction,
here's a look at some of the key health issues that
affect the elderly: cognitive impairment, fall injuries
and malnutrition. Polypharmacy and adverse events —
one of the biggest problems in geriatric medicine —
is covered separately in the article "Improper prescribing
puts seniors in peril" below.
COGNITIVE
IMPAIRMENT
Dr Frank says the public is much more educated about
cognitive impairment than they were just a few years
ago. "Patients are going to their family physicians
earlier than they used to." But that doesn't mean that
cases don't go unnoticed.
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Take-Home Tips
What to look for: Disease
presentation in the elderly is often multifactorial
and non-specific. Symptoms are often atypical.
Your best weapon: Talk
to your patient's family. Both Dr Dombrower and
Dr Frank insist they're really important in treating
and diagnosing the elderly.
Beware the 24-hour doze:
The elderly need less sleep, about six to seven
hours, notes Dr Dombrower. But seniors don't usually
sleep well. Many hit the sack because they're
bored not tired, and that throws off their sleep
cycle. Dr Dombrower's advice? Reinstruct your
patients on how to sleep: avoid naps, use an alarm
to get up at the same time each day and get to
bed at the same time every night.
Know what your patient is
taking: Have them bring all their prescription
and OTC meds to your office. Keep them on only
what's absolutely necessary and taper them off
everything else.
Prescribe with care:
Avoid the prescribing cascade by making sure new
symptoms aren't actually side effects of medications.
Consider alternative therapies whenever possible.
If medication is the only way to go, start with
the lowest possible dose.
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It's important to keep your eyes
open for some of the early warnings. "The first signs
are actually often seen in a younger patient," says
Dr Dombrower. "Someone who's having difficulty managing
a more complex situation will chalk it up to aging."
A flag should go up if any of your patients are having
difficulty functioning around the house — cooking,
cleaning, shopping or baking — or having trouble
managing their medications or remembering appointments.
"I think we've all seen some of those kinds of patients,"
Dr Frank says. "They manage their social graces for
a while."
Both Drs Dombrower and Frank agree
that family members, especially spouses, are crucial
to help diagnose cognitive problems. Look out for what
Dr Dombrower calls "turning the head to the left" —
when a patient looks to their spouse for the answers
to your questions. "The family is really important for
corroborating information," says Dr Frank. "They can
tell you if the patient is having a hard time taking
care of banking or has trouble driving." If a family
member tells you that the patient is forgetful, has
difficulty with language, problems concentrating, is
easily distractible or has constant delusions of theft,
you know there's a problem.
Dr Dombrower points to another,
often overlooked, cause of cognitive impairment —
drugs. "The most common medications prescribed to the
elderly also cause some sort of cognitive impairment,
" he says. Sedatives are prime examples.
FALLS
AND FRACTURES
Bumps, bruises and broken bones are very common in the
elderly. In fact, these kinds of injuries increase significantly
with age: from 33% at 65 to 50% by age 80, according
to the American Academy of Family Physicians. "Falls
can be related to both external or internal causes,"
says Dr Dombrower. External reasons are in the environment:
a slippery floor, improper shoes, holding onto furniture
instead of using a cane or walker. Internal reasons
include poor vision, changes in blood pressure, neurological
or musculoskeletal disorders, cardiac problems and medication.
Dr Dombrower says that benzodiazepines and antihypertensives
are often to blame.
Patients need to be educated on
how to prevent falls. Clearing cluttered rooms and exercising
to maintain strength and flexibility can help a lot.
MALNUTRITION
Weight loss, muscle atrophy, bed sores or other wounds
that aren't healing well are all signs of malnutrition,
explains Dr Dombrower. Nutritional deficiencies can
exacerbate or cause a host of health problems including
osteoporosis, constipation and iron deficiency anemia.
They're also widespread: up to 63% of people over 60
aren't getting enough iron, according to a 2003 report
published by the Canadian Task Force on Preventative
Health.
"Weighing elderly patients should
be standard procedure," says Dr Frank. "Weight should
be thought of as a vital sign, like blood pressure."
Dr Dombrower agrees. But he also believes that talking
to your patient is important. "A screening question
like 'what did you eat in the last 24 hours' isn't a
bad way to find out what's going on," he says. Talking
to patients will allow you to assess if they're able
to make a meal on their own or, more importantly, if
they're eating at all. "There are some social and some
physical explanations as to why patients might not be
eating well," he says. If the patient doesn't remember
or can't answer the question, you should look for signs
of cognitive impairment. "In either case, poor nutrition
warrants an aggressive workup," stresses Dr Dombrower.
ASK
THE RIGHT QUESTIONS
Family physicians play and will continue to play an
important role in treating the elderly. Asking the right
questions, or as Dr Dombrower says, asking the same
questions in different ways, can be key to getting the
information you need. "Instead of, 'do you have pain'
or 'do your joints hurt' ask 'is anything getting in
the way of your life?'"
One of Dr Frank's golden rules
is to take a very thorough history. "It may take a whole
lot more time," he warns. But it's also the best way
to uncover underlying health problems. Still, FPs don't
necessarily have the time to devote to dealing with
the needs of these patients. "You don't need a lot of
brain power [to treat the elderly]," says Dr Dombrower,
"you need time. Doctors need a good half hour to get
to the root of their health problems."
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