Care of Older Adults

This document was developed by representatives of, and has been endorsed by, the American Academy of Family Physicians and the Society of Teachers of Family Medicine.

Preamble

The ultimate concern of all physicians is the welfare of the patient. The acquisition of appropriate skills and knowledge in history taking, physical examination, and clinical and psychosocial diagnosis and management of each type of patient the family physician will encounter must be an integral part of residency training. The patient's age and background often require different approaches to care.

The percentage and number of older adults in our society is steadily increasing. Elderly persons occupy a large number of acute-care hospital beds, comprise the largest percentage of nursing home residents and make more visits to physicians' offices than any other segment of the population. Yet the health care system has become geared to acute and episodic rather than preventative, chronic and comprehensive care.

Although people do not suddenly acquire different characteristics at an arbitrarily predetermined age, there are, nonetheless, many subtle and significant differences in the approach to diagnosis and management of older as opposed to younger adults. Also, the philosophy of comprehensive, continuing care incorporates the belief that health in later years is vitally affected by lifestyle and health care patterns established throughout life. One goal of family practice is to prepare younger adult and middle-aged patients for the changes of increasing age. Another overall goal is to assist elderly persons to function independently with self-respect, preserving lifestyle as much as possible. Thus, the curriculum implies a comprehensive approach to the psychosocial and economic factors affecting the aging patient as well as the patient's family.

This curriculum guideline provides an outline of the attitudes, knowledge and skills that should be among the objectives of training programs in family practice and which will lead to optimal care of elderly patients by future family physicians.

Attitudes

The resident should develop attitudes that encompass:

An awareness of the importance of the physician's own attitudes to aging, disability and death.
Compassion and humanism, balancing realism and practicality in the consideration of inevitable decline and loss.
The promotion of dignity through self-care and self-determination.
A recognition of the importance of family and home in the overall life and health of patients.
An understanding of appropriate limitation of investigation and treatment for the benefit of the patient.
Lifelong learning and contributing to the body of knowledge about aging, health and the medical management of aging patients.
An awareness of the importance of a multi-disciplinary approach to the enhancement of individualized care.
Continuing accessibility to and accountability for his or her patients.
An awareness of the importance of cost containment.
An awareness of the benefits and limitations of advanced directives, living wills and durable powers of attorney.

Knowledge

The resident should develop knowledge of:

The underlying physiologic "normal aging" changes in the various body systems, including diminished homeostatic abilities, altered metabolism and effects of drugs, and other changes relating to the assessment and treatment of elderly patients.
The normal psychologic, social and environmental changes of aging, including reactions to common stresses such as retirement, bereavement, relocation and ill health, and the changes in family relationships that affect health care of the elderly.
The unique modes of presentation of elderly patients for care, including altered and nonspecific presentations of specific diseases.
The risks and adverse outcomes in geriatric care of polypharmacy, iatrogenic illness, immobilization and its consequences, over-dependency, inappropriate institutionalization, non-recognition of treatable illness, over-treatment, inappropriate use of high technology and the unsupported family.
The means for promoting health and health maintenance through the screening for and the assessment of risk factors.
The range of services available to promote rehabilitation or maintenance of an independent lifestyle for elderly people, increasing their ability to function as long as possible in their existing family, home and social environments.
The indications and benefits of the house call in the assessment and management of elderly patients.
The characteristics of the various types of long-term care facilities and alternative housing available to the elderly.
The specific regulations for the care of patients in long-term facilities.
The financial aspects of health care of the elderly and the way these influence health care patterns and decisions.
The means to actively promote health in the elderly through exercise, nutrition and psycho-social counseling.
The evaluation of the functional status of the elderly patient.
The following problems, which are either especially characteristic of older patients, or differ significantly in their presentation and/or management in order adults.
1. Special senses: hearing and vision loss, speech disorders, decubiti, gait disorders
2. Respiratory: pneumonia and other respiratory infections
3. Cardiovascular: hypertension, congestive heart failure, myocardial infarction, thromboembolism, temporal arteritis, cerebral vascular accident, transient ischemic attacks, postural hypotension
4. Gastrointestinal: dentition problems, acute abdomen, anorexia, constipation, fecal impaction
5. Geritourinary: incontinence, urinary tract infections, bacteriuria, sexual dysfunction
6. Musculoskeletal: degenerative joint disease, fractures, contractures, osteopenia/osteoporosis, podiatric problems, falls
7. Neurological: delirium, dementia (eg. Alzheimers), altered mental status, dizziness, tremor, memory loss, gait disorders
8. Metabolic: dehydration, diabetes, hypothyroidism, drug-induced illness, malnutrition, anemia, hypothermia, malignancies
9. Psychosocial: abuse (both physical and psychological), alcoholism and other substance abuse, grief reactions, depression, psychological effects of illness, pain, terminal care, anorexia, failure to thrive

Skills

The resident should develop skills in:

Obtaining a comprehensive history and mental status examination, utilizing all available sources of information.
Conducting an efficient comprehensive physical examination in office, hospital and nursing-home settings, mindful of the patient's modesty and mobility.
Appropriate selection, interpretation and performance of diagnostic procedures.
Performing appropriate house calls and coordinating home care.
Developing problem lists in practical, clinical, functional, psychologic and social terms.
Setting appropriate priorities and limitations for investigation and treatment.
Communicating to the patient and/or caregivers the proposed investigation and treatment plans in such a way as to promote understanding, compliance and appropriate attitudes.
Communicating hope and empathy.
Counseling about psychologic, social and physical stresses and changes of age, dying and death.
Coordinating a range of services appropriate to the patient's needs and support systems.
Integrating factors in the patient's family, home and general lifestyle into the diagnostic and therapeutic process.
Consulting with physicians and other healthcare professionals, including the critical evaluation and selective use of consultant advice and the integration of management in critical care situations.
Dealing with issues of death and dying.

Implementation

Implementation of this curriculum should include both focused and longitudinal experience throughout the residency program. Physicians who have demonstrated skills in caring for the elderly and who have a positive attitude toward the elderly should be available to act as role models to the residents and should be available to give support and advice to individual residents in the management of their own patients. A multi-disciplinary approach coordinated by the family physician, is an appropriate way of structuring teaching experiences in this area. Individual teaching and small group discussion will help promote appropriate attitudes.

The resident must have responsibility for elderly patients and be active as the decision maker and case manager. A significant number of elderly patients should be a part of each resident's family-practice panel of patients, including healthy elderly patients and those with minor health problems, the chronically ill, the critically ill, the acutely ill and the injured. The resident should have as a requirement the experience of continuing care of elderly patients in the ambulatory setting, the home, the hospital and the ambulatory facility.

Resources

Reichel, W, ed. Care of the Elderly: Clinical Aspects of Aging. 5th ed. Baltimore: Williams & Wilkins, 1999.
Ham, RJ, Sloane PD, eds. Primary Care Geriatrics: A Case-Based approach. 4th ed. St. Louis: Mosby-Year Book, 2001.
Reuben DB, Yoshikawa TT, Besdine RW, eds. Geriatrics Review Syllabus Supplement: A Core Curriculum in Geriatric Medicine. 5th ed. New York City: American Geriatrics Society, 2002.