By Andrew W. Campbell MD.
Aging is a process, not a disorder or a slow deterioration. It is very much a part of life and, although physically one may not be able to do what younger people do, intellectually the brain can be quite active and productive. Clint Eastwood was born in 1930; Senator John McCain was born in 1936; Vice President Joe Biden was born in 1942, the same year as Harrison Ford; the world’s wealthiest man, Warren Buffett, is 82; Queen Elizabeth II is 87.
The media, TV, and Hollywood are quick to depict the elderly as slow, bumbling, prone to accidents, inept, and forgetful. They take the view of Jaques in As You Like It by William Shakespeare:
All the worlds a stage,
And all the men and women merely players;
They have their exits and their entrances,
And one man in his time plays many parts,
His acts being seven ages.
Then he continues:
Last scene of all,
That ends this strange eventful history,
Is second childishness and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything.
According to the Administration on Aging of the Department of Health and Human Services, there were 40 million elderly people living in the United States as of 2011-or about 13% of the total population. Elderly is defined as anyone aged 65 or over. By 2030, the elderly will grow to about 72 million, or 20% of the population.1 According to Pew Research, approximately 10 000 Baby Boomers retire every day and will do so for the next 19 years; that translates to over 18 million people retiring in the next 5 years alone.2
The Care of the Elderly Patient
What is necessary to take care of the geriatric patient? What must we do to take good medical care of our elderly? The geriatric assessment differs from a standard medical evaluation in that it focuses on the elderly who may have complex medical issues and emphasizes functional status and quality of life. This assessment includes intellectual impairment, immobility, instability, incontinence, and iatrogenic disorders. The geriatric assessment effectively addresses these and a number of other areas that are crucial to the successful treatment and prevention of disease and disability in older people. Tufts University, in their Comprehensive Geriatric Assessment,3 lists the following items to be evaluated:
(1) Current symptoms and illnesses and their functional impact;
(2) Current medications, and their indications and effects;
(3) Relevant past illnesses;
(4) Recent and impending life changes;
(5) Objective measure of overall personal and social functionality;
(6) Current and future living environment and its appropriateness to function and prognosis;
(7) Family situation and availability;
(8) Current caregiver network including its deficiencies and potential;
(9) Objective measure of cognitive status;
(10) Objective assessment of mobility and balance;
(11) Rehabilitative status and prognosis if ill or disabled;
(12) Current emotional health and substance abuse;
(13) Nutritional status and needs; and
(14) Disease risk factors, screening status, and health promotion activities.
The medical assessment of the elderly includes functional screening for instrumental activities of daily living (IADL) which include transportation, cooking, housecleaning, shopping, taking medications, managing money, using the telephone and laundry, and activities of daily living (ADL) such as bathing, dressing, eating, continence, and moving around the house. The geriatric patient should be assessed for weight loss, falls, depressed mood, self-neglect, and impairments of hearing, vision, cognition, and mobility.
If a patient presents with dementia, defined as an acquired persistent and progressive impairment in intellectual function, with compromise of memory and at least one other cognitive area, such as difficulty with word finding, apraxia, agnosia, and impaired executive function, the evaluation should include ruling in or out Alzheimer’s disease (AD). AD is found in about two-thirds of dementia cases.4 A good neurological evaluation is essential in the elderly: This entails the history, mental status evaluation, cranial nerve examination, motor nerve examination, deep tendon reflexes, sensory evaluation, and evaluation of the cerebellum.
How long, then, does it realistically and reasonably take a doctor to complete the initial evaluation of a geriatric patient? About 1 hour to 1 hour and 15 minutes. Subsequent visits may take less time, depending on the comorbid conditions in each patient.
Current Medical Care of the Elderly
The time primary care physicians spend with their elderly patients in the United States is about 15 minutes, according to a study published in Health Services Research.5 The authors used videotapes of 392 office visits with elderly patients and determined that 5 minutes were spent on the main topic and 1 minute for each other topic. Time allocation in general was also corroborated in a more recent survey of 15 794 physicians completed in 2011 that showed that a physician will spend about 13 to 16 minutes per patient.6 Physicians, due to decreasing revenues from insurers, feel they have to see more and more patients. This leads to shorter office visits, causing ineffective care, excessive testing, and the use of the ever-present prescription pad. On the very first page of the textbook Current Medical Diagnosis and Treatment, 2013 edition, in the chapter titled “Disease Prevention and Health Promotion,” Dr Pignone and Dr Salazar state that 50% of patients fail to take their medications as directed and fully one-third never take their medicines.7 This is frequently because the patient doesn’t understand why they are being prescribed, or can’t afford them or doesn’t want them to begin with. So much for good communication and rapport with patients.
When an elderly patient presents for an office visit, there are typically five areas of concern: chronic conditions such as heart disease, hypertension, diabetes, and arthritis affect this population, leading to issues with polypharmacy. The primary care physician is often unaware of one or more of these, and a disorder in one organ system can adversely affect another organ system and result in the deterioration of the patient’s health, bringing on disability, dependence, and possibly death. Other health concerns include loss of hearing, vision problems, and dental health. These multiple disorders complicate diagnosis and treatment, which are then affected by isolation and poverty as the elderly run out of financial resources.8 How are these issues going to be addressed in about 15 minutes? All of us who went to medical school know how important a thorough history is. Today, it is basically nonexistent, especially with the electronic medical records where all the different software vendors compete by touting the simplicity and ease of use, requiring the physician to be constantly referring back and forth to a screen, rather than devoting the time to eye contact with the patient as well as for observation. Sir William Osier, the first chief of staff of the Johns Hopkins Medical School, widely regarded as the founder of modern medicine and author of the classical textbook Principles and Practice of Medicine, said in the late 1800s: “Listen to the patient, he is telling you the diagnosis.” We no longer listen as we should.
A Potential Solution
With 40 million geriatric patients currently living in the United States and 10000 more added every day, how is conventional medicine going to care for these patients? Under the current system, and even when Obamacare is fully implemented, it will not be possible to adequately and appropriately render an acceptable level of medical care to these elderly people. One possible solution is to apply the Institute for Functional Medicine’s (IFM) approach to medicine. This method is effective, efficient, and very doable. It is not the approach of giving each person with a given disease the same tests and prescription drugs but rather an individualized care based on lifestyle, genetic history, environmental issues, and treating the cause of the disease rather than the symptoms by addressing the whole person. It is patient-centered care that promotes health rather than “let’s just fix the current problem.” Functional medicine integrates Western medicine with alternative medicine and is not afraid to recommend and make part of treatment nutrition, exercise, and prescription drugs, as well as botanical medicines, supplements, and stress management.
Help In the Short Term
Is there help in treatment of dementias and AD? The news is good here too. A recent study showed it is possible to prevent atrophy of key brain regions related to cognitive decline and AD by lowering elevated plasma homocysteine using B vitamins and to slow and possibly reverse Alzheimer’s symptoms and cognitive impairment. This study was conducted at University of Oxford’s Nuffield Department of Clinical Psychology on 156 elderly patients with mild cognitive impairment who had high risk for dementia and AD. The patients were randomized and followed for 2 years, one group receiving daily supplementation with B vitamins and the other group a placebo. Before beginning and during the trial, magnetic resonance imaging was performed on all patients, which showed that the shrinkage of the grey matter was seven times less in the group that took the B vitamins. More specifically, they showed “B vitamins lower homocysteine, which directly leads to a decrease in grey matter atrophy, thereby slowing cognitive decline.” 9 The researchers also conducted neuropsychological testing on the patients and, again, those who took the B vitamins had better scores. Other studies have also made the same conclusions-for example, a study completed in Korea at Ewha Woman’s University of 321 elderly patients.10
Henry Wadsworth Longfellow once wrote:
For age is opportunity no less,
Than youth itself, though in another dress,
And as the evening twilight fades away,
The sky is filled with stars, invisible by day.
This is the attitude we should all see our elderly population with.
Source: Campbell, Andrew W, MD. Advances in Mind – Body Medicine 27.4 (Fall 2013): 4-6.
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