UBC Objectives: Care of the Elderly, UBC Objectives: Palliative Care, Priority Topic: Disability & Priority Topic: Elderly

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Identify and alter medication therapy that is most likely to cause adverse drug events in an older individual
• Outline the pharmacokinetic changes that commonly occur with aging and demonstrate the ability to modify drug regimens accordingly
• Describe the usual anatomical and physiological changes seen with aging and understand the concept of frailty
• Describe advance planning directives (including the roles of physicians and substitute decision-makers) dealing with personal and financial decision-making emphasizing a “goals of care” approach
• Identify patients who might benefit from a palliative approach and identify this early in the disease trajectory
  • Identify opportunities for advance care planning discussions, whether or not a patient has a life-threatening or life-limiting illness
  • Initiate a palliative care approach early in the illness trajectory
  • Identify the patients stage of illness using appropriate tools
• Communicate with patient, families and care team about palliative and end of life options and care.
  

Disability

Key Feature 2: Screen elderly patients for disability risks (ex: falls, cognitive impairment, immobilization, decreased vision) on an ongoing basis.
Skill: Clinical Reasoning
Phase: History, Hypothesis generation

Elderly

Key Feature 1: In the elderly patient taking multiple medications, avoid polypharmacy by:

• Monitoring side effects
• Periodically reviewing medication (ex: is the medication still indicated, is the dosage appropriate)
• Monitoring for interactions

Skill: Clinical Reasoning
Phase: Treatment, Follow-up

Key Feature 3: In the elderly patient, screen for modifiable risk factors (ex: visual disturbance, impaired hearing) to promote safety and prolong independence.
Skill: Clinical Reasoning
Phase: History, Hypothesis generation

Key Feature 4: In the elderly patient, assess functional status to:

• Anticipate and discuss the eventual need for changes in the living environment
• Ensure that social support is adequate

Skill: Clinical Reasoning, Patient Centered
Phase: Treatment, History

Tomorrow I start my first day caring for elderly patients in a residential care home, which I will continue to do intermittently throughout the year as part of my program requirements and vocational interests. One of the most important skills in geriatric medicine is appropriate prescribing practices; frail elderly patients can be at significantly more risk of harm compared to the general fit patient with negligent prescribing. While it is always important to prescribe thoughtfully (as indicated, where benefits outweigh the harm for the individual patient, with thought given to potential drug interactions, and with monitoring for side effects), the frail elderly patient has less reserve to cope with complications from errors with medication prescribing. As well, decreased kidney and liver functioning become much more common with age, so if the body is unable to clear the medications from the system as effectively, we need to consider the effect that the drug may have if it lingers for longer or builds up to higher levels than it otherwise would. Depending on the drug, and the patient's  kidney and liver function profile, doses may need to be reduced in quantity or frequency.

UpToDate provides a table that summarizes an approach to performing a geriatric medication review:

Medication review in the frail elderly should be part of all routine comprehensive medical care, just like screening is done as part of a periodic health examination. Specific screening interventions that may be particularly indicated in elderly patients include vision screening, hearing screening, and screening for osteoporosis. Impaired vision and hearing increase risk of functional limitation, falls, and if there is comorbid osteoporosis, increase the risk that a patient may sustain a significant fracture such as of the hip, associated with significant increase in morbidity and mortality. 

A defining feature of the frail elderly patient is having limitations on functional abilities. It is also something that occurs along a continuum, with different supports indicated depending on the degree of functional limitation. It is important to incorporate monitoring frailty severity into routine clinical practice of all elderly patients. The Clinical Frailty Scale is one tool that is validated and easy to use clinically.

A comprehensive assessment of a patients overall functional status but also specific functional needs is important to be able to offer beneficial targeted interventions and supports. This also involves considering what supports the patient currently has, their personal values and goals (including Advance Care Planning), and the supports available in their community. An interdisciplinary approach to supporting the frail elderly patient is standard of care, including involving family members or other loved ones as valued and active members of the care team, as the patient wishes, and referring patients for a comprehensive geriatric assessment may be the best place to initiate an assimilation of key members for an individualized support team. In a patient who has chronic mobility or disease that is not reversible, and who is having quality-of-life reducing symptoms on a regular basis, it's never too early to consider palliative care interventions, which are not just for those who are facing life-threatening illness. For those who are approaching end of life or who have symptoms affecting quality of life that can no longer be cured, palliative care interventions are necessary. Having frequent discussions with the patient and all members of the care team helps to keep people on the same page, to optimize care and to anticipate how care can best be optimised as symptoms progress. The Palliative Performance Scale is a tool used by many palliative care physicians to help in the conversation and understanding of the trajectory of palliative care needs.