This is the second of a two-part series on geriatric patients, their complexities, special needs and how we can improve our care for them.
WHEN I started medicine in 1997, a song by Robbie Williams proclaimed “I hope I’m old before I die”. As a youngster celebrating life, the wish to go on forever was one I could certainly understand.
In this youthful sense, we have successfully achieved the Holy Grail – surviving longer than any previous generations. However, the hidden problem is that the “downhill slide” experienced by older people with disability is often – quantifiably and subjectively – miserable.
Studies measuring health-related quality of life (HRQOL) have shown generally linear relationships between multimorbidity, progressive neurodegenerative dementia, disability, and poor HRQOL. A poignant 2007 documentary depicted this, with older people explaining how difficult life becomes beyond a certain point – where you may outlive your children and friends, and be unable to hear music, travel, toilet in peace, sleep, or just walk outside in the sun. Australian data suggest that a slight reduction in HRQOL is normal with ageing generally, but it is clear that “geriatric” diseases and disabilities cause a further marked downturn. We also know that those with the lowest HRQOL are twice as likely to have readmission to hospitals after discharge. Essentially, living with disabling disease for prolonged periods costs us life “quality”, albeit gaining “quantity”.
In this sense, the goal of medicine for geriatric patients becomes a bit clearer. Every doctor values unambiguous clarity around the “what we are trying to achieve” with particular patients, and in most consultations, the implicit understanding is that full reversal of symptoms or diseases is the mission. However, because geriatric patients often have a tangled web of several problems, presenting with non-specific symptoms, doctors may anxiously wonder “what on earth I am supposed to be doing”.
That said, I would say there are three main inter-related aims of geriatric consultations:
- Firstly, attempting to relieve declining HRQOL – through the detection of as many reversible or modifiable drivers as possible fuelling the declining quality of life. All the while, this mandates fighting against two major barriers to success, namely time pressures and clinical reasoning “traps” to which doctors are vulnerable, and which may reduce diagnostic rigour.
- Secondly, to reduce repeated acute crises and hospitalisations (“the revolving door phenomenon”). The life expectancy of frail patients is under 5 years; accordingly, some suggest that a goal of hospital avoidance is naïve (acute illness is essentially inevitable; hospitalisations are simply deferred). This a fair point. However, identifying key contextual problems in the patient’s life means that crises become almost predictable and foreseeable. Nobody wants the final chapter of their life to be littered with repeated hospitalisations if some could – in principle – be foreseen, and thus aborted.
- A third goal is helping reduce prolonged hospital lengths of stays (pLOS). We know pLOS is dreadful for patients at risk of falls and nosocomial complications (here and here), and is expensive for administrators. Local hospital networks are paid predominantly by activity-based funding. Simplistically, this means that hospitals receive money from a large bucket of combined state and Commonwealth money for every patient-care episode completed; the amount depends on what was treated. For example, if a city hospital discharges a non-Indigenous patient whose admission is coded as complicated delirium, the hospital will receive nearly $12 000, irrespective of whether the patient stays from 3 to 31 days; please note that this reimbursement is just for the acute ward part of the patient journey. This amount of money may sound generous, but crucially, the average real-life cost of having a delirious patient in a hospital bed averages $1300 per day (here, page 65), while the average cost of acute beds in Australia nationally is $2003 per day (this figure includes more expensive admissions involving surgery and intensive care unit). Notwithstanding, this crudely means hospitals may be unfunded once a patient with complicated delirium has an acute-ward LOS exceeding 9 days. If there is a complex back story (eg, undiagnosed latent dementia, vague safety concerns), a proportion of such patients may easily stay longer than this, especially if timely transfer to subacute care is not possible. This illustrates why pLOS is economically problematic. Geriatricians can help foster appropriate (safe) discharges at both the entry and exit doors of hospitals, and within wards, if deployed. Furthermore, stationing geriatrician-led teams in the community affords hospitals a safe way of discharging patients at the exit point, maintaining patient flow via essentially a discharge to assess model (here, here and here).
Okay, but how is all this good stuff done?
If I had to sum up the core mantra of geriatrics, I’d say it is “diagnosis, diagnosis, diagnosis”. Contrary to popular opinion, geriatric medicine is intensely diagnostic – it is the opposite of the “let’s gently place unmanageable old people in care” typecast.
Clinicians managing geriatric patients need to view themselves as problem detectors – even when others resign to the mythical “there’s nothing you can do”. Physical, cognitive and behavioural impairments causing disability are like fires, but fires don’t start without a source. Our job is to detect the various sources of fuel to the fires and remove as many as possible, even if these are hiding under smokescreens (non-specific symptoms; difficulty accessing pre-morbid information; difficulty seeing the patient in their true home environment). The ability to truly help geriatric patients hinges squarely on the diagnosis of potentially reversible, manageable or modifiable precipitants of their slide downhill (please note, synonymous with diagnosis are words such as “detect”, “recognise”, “identify” and “discover”). The broad term “manageable” is deliberately used here to denote there are several endpoints through which we value-add for geriatric patients:
- reversal or cure;
- relief of distressing symptoms (ie, palliation);
- adding supports for scenarios of irreversible disability; and
- prognostication – a very under-rated clinical benefit. In the final years of life, almost everyone wants a diagnosis affording them the dignity of knowing what can be expected next (how long left, natural history, informing future generations).
Okay, but what sort of problems should we diagnose? Three is not a crowd.
First, there are pathologies – actual diseases one would find in a medical textbook. I say this to distinguish “pathologies” from descriptors sometimes mislabelled as “diagnoses” – though really just presenting complaints – including functional decline, mechanical fall, not coping, confused, back pain, dizziness and agitation, to name a few.
In this regard, I like the car analogy, shown in Figure 1; one could describe the picture vaguely as a “vehicle”, but we can do better. We all accept as students that anaemia is not a diagnosis, learning to drill further down to the true disease causing it.
Geriatric syndromes are no different (Figure 2).
Second, we need to recognise instances of unintentional iatrogenic harm (ie, medication and treatment-related problems). Some geriatricians say “it’s the drugs until proven otherwise” when discussing cognitive impairment or falls, and they have a point. Consider:
- Drugs may be prescribed for which indication is not objectively clear, so the patient inherits side effects without benefits. For example, patients may take drugs such as isosorbide mononitrate or frusemide, contributing to syncopal falls, yet without necessarily having proven coronary artery disease or cardiac failure. Patients who are dizzy may be given vestibular sedatives if dizziness remains undifferentiated, increasing sedation and the risk of falls. Some patients with crippling osteoarthritis are given pregabalin for their non-neuropathic pain. In this regard, one of the most useful steps in patient care is simple: “get the old notes, get the letters”. Unswervingly searching for previous specialist or GP documentation is high yield, hopefully revealing why medication was started. In the above case, if a private cardiology letter is suddenly found detailing a positive stress test and echocardiogram, the nitrate and diuretic suddenly warrant less scrutiny; however, the reverse is true if nobody is clear how the drugs started.
- Relatively toxic drugs can be given unknowingly, even purchased over-the-counter. Other drugs – such as antiepileptics and digoxin – have narrow therapeutic windows, and some may be taken for prolonged periods, particularly steroids. I have seen several older people on prednisolone for years, ostensibly for indications including inflammatory bowel disease and rheumatoid arthritis, resisting a shift on to steroid-sparing therapies. The risk of painful disabling osteoporotic fractures is high.
- Some regimes persist despite newer literature suggesting harm is more likely than benefit. Despite evidence suggesting “intensive” blood sugar control may be harmful in in type II diabetes, older patients are sometimes on both insulin and sulphonylureas concurrently; yet we know this dual therapy increases the risk of hypoglycaemic crises, and the combination makes little pathophysiological sense. Another example is the concept of prophylactically thinning the blood with aspirin; evidence suggests primary prevention with aspirin has a questionable risk-benefit ratio (here, here, here).
- Alongside so-called “potentially inappropriate prescribing”, undertreatment is equally important to detect. Atrial fibrillation, as one example, is often undertreated in terms of anticoagulation (though this is itself a vexed topic, depending on doctors’ past experiences). Pain and depression are similar. Part of the problem with pain, even if treated with analgesia, is that the deeper underlying pathologies may remain hidden unless specifically sought. I have seen patients for whom mechanical pains were, after assessment, shown to be due to previously unrecognised vertebral metastases, polymyositis, statin myopathy, crippling osteoarthritis, avascular necrosis of the hip (following impacted hip fracture and non-presentation to hospital), and even familial Mediterranean fever. In these cases, targeted therapies were possible – radiotherapy, immunosuppressants, statin cessation, orthopaedic surgery and colchicine, respectively.
The third category of problems ripe for detection in geriatric patients centres on the wider context of the patient’s life – perhaps best called “social, environmental and decision making problems”. Clinically, we may believe the plan for patient management is watertight – evidence-based, considered – yet in the patient’s world, it may be unaffordable or unacceptable. Accordingly, the patient may be non-adherent, and anticipated benefits never materialise. Differences between “medical theory” and “patient reality” are common:
- cost of therapies or equipment proves prohibitive in the context of a pension, or financial exploitation (eg, non-Pharmaceutical Benefits Scheme drugs; private non-Medicare Benefits Schedule appointments; incontinence pads if not subsidised);
- pending home eviction (eg, if cognition means bills are unpaid, or squalor has supervened);
- inability to actually get to outpatient clinics (perhaps licence revoked, too disabled to catch buses, unable or unwilling to afford taxis);
- real-life inability to secure a higher level home care package (common, here, page 27);
- hospitals discharge a patient with “GP to kindly follow up”, but the patient has no GP for whatever reason, and the discharge summary effectively enters the ether; and
- insightlessness, with a loss of capacity to make safe autonomous decisions in daily life, may complicate severe brain pathologies. Attempts to intervene for safety are often repeatedly thwarted by the patient. This scenario may require detailed work-up and guardianship application. Ideally, the work-up would take place while the patient is still at home (assuming care coordination puts supports in place) because hospital stays with mental incapacity can be weeks or months long.
We can help older people substantially in terms of HRQOL, crisis risk and the avoidance of repeated, prolonged hospitalisations. To do so, we need an overarching mentality of “diagnosis, diagnosis, diagnosis”, and to be stationed both inside and outside hospitals. We need to spend time with complex patients to detect manageable pathologies, drug toxicities, undertreatments, and social hazards fuelling their (expensive and distressing) slide downhill and “over the cliff”.
Dr Toby Commerford is a consultant geriatrician at Royal Adelaide Hospital, is course coordinator for geriatrics at the University of Adelaide’s Rural School, and practices remote and rural outreaches to Port Augusta and Murray Mallee. He is also the lead singer in a rock band.
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