Special note to readers:
I’m aware that if you’re reading this, you’re already dedicated to caring for elders with quality and compassion. Thank you! Consider sharing this column with colleagues and staff as a way to enhance the quality elder care in your practice setting. Let us know if there are topics you’d like to see discussed or materials that would help put to use any specialized information.

Think Like a Geriatrician

Welcome to 2015! We’ve all had experience making New Year’s resolutions to improve an aspect of our lives, but how about making resolutions that will improve the care of elders?

Resolve to learn strategies that will help you think like a geriatrician.

Here’s what I mean. These days everyone cares for large numbers of older adults. But as a geriatrician, I think about my elderly patients just a bit differently. Just as a cardiologist looks with a bit more intensity and knowledge at the same electrocardiogram we can all read, I may look differently at care decisions for elderly patients. In the coming months I will share some real-life cases that will describe how a geriatrician applies the key principles of geriatric medicine to guide clinical decision-making strategies.

Special Considerations

• Don’t assume aging is the answer. Avoid the temptation to say, “What do you expect, you’re 85?”

• Know your patient’s baseline. What is this 88-year-old’s functional status, recent hemoglobin, etc?

• Think about how your patient will use the advice or prescription you are providing. Can he or she get the prescription filled? Did he or she hear and understand the instructions you just gave? Providing high-quality care for elders requires knowing how patients will obtain the care they need.

A neighbor of mine is a remarkably vibrant 88-year-old woman. She is without any chronic illness, highly fit both cognitively and physically, and fully functional. Though widowed a few years ago, she’s continued an active and engaged lifestyle. She’d been planning to help decorate the country club for the holidays. Then quite unexpectedly she had a brief but clear syncopal episode followed by a day of extreme weakness and low appetite. The next day she could not descend her staircase, which usually posed no problem for her. Fortunately, she called me. I learned of the syncope the day earlier and knew she needed a full evaluation.

I took her to our local emergency room. A full history revealed a history of a bleeding ulcer on three occasions. The most recent was eight years ago and required a transfusion. Initial laboratory studies revealed a hemoglobin of 10, to which the examining hospitalist doctor kind of shrugged and said, “That’s not so bad at 88.” He said he wasn’t sure what had caused the fainting, but admitted her for cardiac monitoring.

I hope you are now thinking like a geriatrician. As I sat and listened and heard the report of hemoglobin of 10, I was immediately concerned. (Hemoglobin, especially in women, does not decrease to 10 due to aging alone; there must be something else going on.) The hospitalist believed anemia is OK in an 88-year-old woman and led the diagnostic evaluation in other directions. Especially in a woman with a history of bleeding ulcers, the low hemoglobin should have led to further evaluation. Knowing how the body changes with aging helps direct diagnostic evaluation.

As I heard the hemoglobin of 10, a second thought also came to mind. I immediately wondered what her hemoglobin had been in the past.

A review of the electronic records showed that three months prior, her hemoglobin had been 14. So for this 88-year-old patient, a hemoglobin of 10 was a significant change. This change from her baseline required explanation. It wasn’t OK for her to have a hemoglobin of 10. Knowing your patient’s baseline helps you assess for degree of change and the need for further evaluation.

Age is a number, and as you treat more and more elderly, you have probably come to realize that the heterogeneity of the elderly population makes it really important not to generalize based on age. At the pace of medicine today, it’s tough because in younger age groups, those generalizations work well. Think of infants and even adolescents. There are a few outliers, but for the most part the problems facing those cohorts are fairly well defined.

Once you start seeing older adults, it’s clear there is marked variability in the overall physical, cognitive, and social status of the elderly population. Age alone does predict a likelihood of certain senescent pathology or acquired illness, but is not a fully diagnostic factor. Woe to the doctor who assumes a 90-year-old has dementia and then comes to find out that the gentleman seated across from you is in the 50% of nonagenarians who do not have dementia!

The next thing that happened also highlights a difference in how geriatricians think and manage elderly patients.

As my neighbor was being prepped for discharge, she had had no further syncope and the cardiac evaluation was negative. She was told it was unclear why she had been weak, had low appetite, and fainted. The doctor told her to be careful, drink more fluids, and see her primary care provider soon. The basic discharge process was proceeding but I had concerns. I kept thinking to myself that what this 88-year-old widowed woman really needed, especially since we did not yet know why she had passed out, was either a fall-detecting personal response system or someone to be at her home with her. A request for social services quickly remedied these lapses and she was discharged more safely to her home. Knowing how your patients will get the care they need, for example, using the advice or prescriptions you are giving them, is vital to their care.

A few days later an esophagogastroduodenoscopy revealed an ulcer with evidence of recent bleeding. She’s done well on H2 blockade and completed the decorations in high style. She feels secure with a personal response system and her long-distance caregiver/daughter feels better now that she has arranged for on-call emergency care with a local registered nurse case management team.

— Rosemary Laird, MD, MHSA, AGSF, is a geriatrician, medical director of the Health First Aging Institute, and past president of the Florida Geriatrics Society. She is a coauthor of Take Your Oxygen First: Protecting Your Health and Happiness While Caring for a Loved One With Memory Loss.