Chan KM

Introduction:

Over the years, the pattern of diseases changes from acute to chronic.  While in the past, patients often die from acute conditions, like acute myocardial infarction, now, it is not uncommon to find many survivors, perhaps, not of just one AMI, but a number, and in the process, developed chronic or even intractable heart failure.  The same goes for strokes and fractures.

With improved and safer living environment, better nutrition and medical healthcare available, the average life expectancy of the Singapore population has risen to 78 years old in males and 82 years old in women.  This increase in life expectancy also meant that whatever medical conditions that they had developed at a younger age would accumulate and carry over into old age.  Not only that, these conditions would also manifest changes associated with end organ damage as a result of years of having that condition.  For example, a person may have high blood pressure from age of 50, and by 65 years old, he would have had high blood pressure for 15 years, and may start developing end organ damage like strokes, peripheral vascular disease, heart disease and or kidney damage.  As he grows older, he may develop certain conditions that are more prone in the elderly, like diabetes (affecting eyesight, sensation and nerves), Parkinson’s disease (affecting balance and movement), enlargement of prostate (affecting urination), arthritis (pain, instability and weakness) and so forth.

At the same time, bodily and organ changes occurs due to ageing.  Atrophy of organs and tissues occurs and their functional and reserve capacity declines.  They become even more prone to further insults from trauma, infection, inflammation, toxins, chemicals and drugs.

All these meant that the older person is prone to have medical conditions and their complications affecting many organs.  Sorting out which is caused by disease, which is caused by ageing, which is acute, which is chronic or acute on chronic, becomes more complicated.  Many chronic conditions have no cure.  In the light of an elderly person with multiple and chronic medical problems intertwined with ageing issues and poor reserves, geriatric care becomes the mainstay of management.

The traditional model of medical care takes the ‘organ specific’ route.  In other words, a heart condition is managed by a cardiologist, lung condition by a respiratory physician, strokes by neurologist, dementia by psychiatrist and so on.  But from the above scenario, it would be translated to having multiple specialists managing a single elderly person with chronic diseases.  Multiple specialists, however, does not necessarily translate to better care as each look only towards their own area of specialty and this often lead to multiple doctors’ appointments and polypharmacy.  There is also no single doctor to take charge of coordinating care and medications, and this role may sometimes fall onto a caregiver who is likely to be a layperson, and sometimes, even the maid.

The elderly person also does not manifest illness in the same way as the younger population.  Neuropathy may mask the pain of a septic or gouty arthritis while dementia may cause them to forget that they had a recent fall or trauma, or some symptoms which may be useful to aid in their diagnosis.  A change in environment, such as hospitalization, could cause acute confusion in an elderly person with borderline dementia.  A chest infection, even before the first signs of cough, phlegm or fever, may manifest as a fall or incontinence.  Thus, illnesses may present as vague or totally unrelated symptoms which are peculiar yet common in the elderly:  like instability, immobility, incontinence and impaired cognition, also referred to as the Giants of Geriatric Medicine.  As in all medicine, the key to treatment is early detection.  Such vague presentations may make diagnosis difficult.  Late diagnosis lead to higher morbidity, a longer hospital stay, higher medical cost, poorer outcome and higher mortality.

Yet, with early diagnosis and appropriate treatment, outcomes in the elderly remained good, even in ICU cases.  In studies of patients admitted to the ICU, when severity of illness is controlled, differences in survival between age groups disappear.  Preadmission health status, functional status, and physiologic states were more important predictors of long-term survival after intensive care than age was.

Response to treatment by the elderly is also different from the young.  The difference in response stem from age related immune responses, changes in pharmacokinetics and pharmacodynamics.  Thus, it led Ignatz Nascher to propose that disease and medical care of the aged should be recognised as a separate specialty and invented the term “geriatrics” in 1909.   However, the growth of geriatric medicine and healthcare of the elderly is often attributed to the pioneering work of Majorie Warren who successfully treated and rehabilitated seemingly hopeless elderly patients in the UK in the 1930s.  Today, the British Geriatric Society defines Geriatric Care as that branch of general medicine concerned with the clinical, preventive, remedial and social aspects of illness in older people” and the goal of geriatric care is “to restore an ill and disabled person to a level of maximum ability and wherever possible return the person to an independent life at home.”  The wide definition necessarily implies that geriatric care must be delivered in both hospitals and community, requires a multidisciplinary approach and shares overlapping philosophies with preventive, rehabilitation, palliative and family medicine.

Principles of geriatric care

The cornerstone of geriatric care is a comprehensive geriatric assessment (CGA), where any elderly presenting to the doctor should have an opportunistic assessment – not just of the complaints which brought them, but also to ‘hidden’ conditions like incontinence, depression, dementia, osteoporosis and falls.  These ‘hidden’ problems are commonly found in chronic diseases like stroke and arthritis.  CGA is likely to identify conditions which could be treated early or potential problem areas which should be monitored closely.

The second cornerstone of geriatric care is an obsession with functional abilities (or disabilities) of the elderly person.  This obsession with function arose from the concept of ‘ageing in place’.  ‘Ageing in place’ is the concept of allowing the older person to grow old gracefully at their own home without going into a nursing home for example.  This is possible only when they have the necessary functions to do so.  Chronic diseases in the elderly very often lead to frailty of the person, and the hallmarks of frailty include weight loss, sarcopenia (loss of muscle mass), muscle weakness and instability.  Therefore, the need for geriatric rehabilitation is something that we are constantly on a look out for.  In some patients, there is only so much we can do for them.  To further optimize their independence, we need to look at the environment to make it more elderly friendly.  Hence, home modifications and use of equipment and technology may just be needed to allow the elderly person to remain at home.

The third cornerstone of geriatric care is the multidisciplinary team.  Because of the diverse nature of chronic diseases, certain aspects of care may require further attention.  The ‘usual’ multidisciplinary team would include the geriatrician as team leader, a (preferably) gerontological trained nurse, a physiotherapist, an occupational therapist, a speech therapist and a social worker.  Adhoc members of the team may include a dietitian (when nutrition is an issue), a psycho-geriatrician (or geriatric psychiatrist, when there are behavioural problems that needed attention), a pharmacist (to review the polypharmacy and reduce risk of drug interactions) and even an orthopaedic surgeon (when there are complicated bones and joints issues).

One major role of the multidisciplinary team is to manage the discharge of the elderly person.  This is called discharge planning.  This is probably the fourth cornerstone of geriatric care.  It is very important if we do not want to see the ‘revolving door syndrome’ – where because of inadequate planning, the elderly person was discharged from hospital in a suboptimal state (whether medical, physical, emotional, social or home environment) and ended up readmitted soon after the discharge.  It is not uncommon to find older patients getting in and out of hospital, like in a revolving door.

The fifth cornerstone of geriatric care is the appropriate use of community resources to assist the elderly.  Sometimes, it may be necessary to discharge the elderly to a transitional care facility between hospital and the home.  In Singapore, we have community hospitals which serve this function.

The purposes of such a facility are many folds:

1. to allow the elderly patient more time for rehabilitation so that they can be more functional at home since the acute care hospital is usually in a hurry to discharge them because of bed shortages.
2. to train the caregiver (be it the maid or a member of the family) to provide adequate and competent care,
3. to just simply wait for the arrival of a caregiver or
4. to provide respite care to the caregivers.

Respite care for the caregivers has been recognized to have an important role in ensuring continual care, better quality of care, reduction in caregiver stress and reduction in elder abuse.  In this respect, caregiver support is also a part of the total package of geriatric care.  Once the elderly person is discharged home, the appropriate use of social day centres, day care centres, dementia day centres, day rehabilitation centres, befriender services, meals services and patient escort services can lighten the load of care for them at home.

Geriatric care should also be provided where the elderly are because of their lack of mobility.  Hence, it includes home care services which comprises of home medical, home nursing and home therapy services.  Various studies have found that a targeted home-based program consisting of 6 months of physical therapy reduces the progression of functional decline, especially in the physically frail and elderly.

Conclusion

The ageing population is not unique to Singapore.  It is a worldwide phenomenon.  Doctors will have to be familiar with managing the elderly regardless of what discipline they are practicing, especially those dealing with chronic diseases.  It is also not feasible to just depend on geriatricians to handle the sick elderly.  Treating the sick elderly in the same manner like that of a younger sick person will have disastrous results.

Many laypersons and some healthcare workers confuse geriatric care with prolonging life.  Geriatric care focuses on holistic and appropriate care to the older person with the aim to achieve better quality of life for the person, and has nothing to do with the mere prolongation of life ‘at all cost.’  Part of geriatric care may involve the discussion of ‘do not resuscitate’ orders with the family and caregivers.