Editing Geriatrics (section)

== Scope ==
[[File:Nursing home.JPG|thumb|300px|Elderly man at a [[nursing home]] in [[Norway]]]]

=== Differences between adult and geriatric medicine ===
Geriatric providers receive specialized training in caring for elderly patients and promoting healthy aging. The care provided is largely based on shared-decision making and is driven by patient goals and preferences, which can vary from preserving function, improving quality of life, or prolonging years of life. A guiding [[mnemonic]] commonly used by geriatricians in the United States and Canada is the 5 M's of Geriatrics which describes mind, mobility, multicomplexity, [[medication]]s and matters most to elicit patient values.<ref>{{Cite journal |last1=Molnar |first1=Frank |last2=Frank |first2=Christopher C. |date=January 2019 |title=Optimizing geriatric care with the GERIATRIC 5Ms |journal=Canadian Family Physician |volume=65 |issue=1 |pages=39 |pmc=6347324 |pmid=30674512 }}</ref>

It is common for [[Old age|elderly]] adults to be managing multiple long-term conditions (multimorbidity). Age-associated changes in physiology drive a compounded increase in susceptibility to illness, disease-associated morbidity, and death. Moreover, common diseases may present atypically in elderly patients, adding further [[Diagnosis|diagnostic]] and therapeutic complexity to patient care.

Geriatrics is highly interdisciplinary consisting of specialty providers from the fields of medicine, nursing, pharmacy, social work, and physical and occupational therapy. Elderly patients can receive care related to medication management, pain management, psychiatric and memory care, rehabilitation, long-term nursing care, nutrition, and different forms of therapy including physical, occupational, and speech. Non-medical considerations include social services, transitional care, advanced directives, power of attorney, and other legal considerations.

===Increased complexity===
The decline in physiological reserve in organs makes the elderly develop some kinds of diseases and have more complications from mild problems (such as [[dehydration]] from a mild [[gastroenteritis]]). Multiple problems may compound: A mild [[fever]] in elderly persons may cause [[confusion]], which can advance to a fall and to a fracture of the [[Femur neck|neck of the femur]] ("broken hip").The presentation of disease in elderly persons may be vague and non-specific, or it may include [[delirium]] or falls. ([[Pneumonia]], for example, may present with low-grade [[fever]] and [[confusion]], rather than the high fever and cough seen in younger people.) Some elderly people may find it hard to describe their [[symptoms]] in words, especially if the disease is causing confusion, or if they have [[cognitive impairment]]. [[Delirium]] in the elderly may be caused by a minor problem such as [[constipation]] or by something as serious and life-threatening as a [[myocardial infarction|heart attack]]. Many of these problems are treatable, if the root cause can be discovered.

===Cognition===

Cognitive aging is characterized by declines in fluid abilities like processing speed, working memory, and executive function, while crystallized abilities such as knowledge remain stable (Anstey & Low, 2004; Murman, 2015). Age-related changes in brain structure and function correlate with these cognitive declines (Murman, 2015). Older adults show weaker occipital activity and stronger prefrontal and parietal activity during cognitive tasks, possibly reflecting compensation (Cabeza et al., 2004). Subjective cognitive complaints are common among older adults, particularly regarding working memory (Newson & Kemps, 2006). Various factors influence cognitive aging, including genetics, lifestyle, and health (Bäckman et al., 2004). Cognitive impairments can progress to [[Mild cognitive impairment|mild cognitive impairment (MCI)]] or [[dementia]] (Mendoza-Ruvalcaba et al., 2018).

MCI is a transitional state between normal aging and Dementia, affecting 10-20% of adults over 65 (Schwarz, 2015). Geriatricians encounter MCI patients in various care settings, with '''diagnoses''' relying on clinical assessment and mental status examinations (Tangalos & Petersen, 2018). MCI is highly prevalent among older adults with depression and may persist after depression remits (Lee et al., 2006). While MCI is considered a high-risk condition for developing [[Alzheimer's disease]], there is heterogeneity in its presentation and outcomes (Petersen et al., 2001).

Dementia is a prevalent condition in geriatric populations, affecting cognitive function and daily activities (Talawar, 2018; Mirzapure et al., 2022). Alzheimer's disease is the most common cause, accounting for 40-80% of cases (Mirzapure et al., 2022; Chulakadabba et al., 2020). Geriatric patients with dementia often have comorbidities and other geriatric syndromes, requiring holistic and integrated care (Chulakadabba et al., 2020; Nguyen et al., 2023). Geriatricians play a crucial role in dementia care, but many feel current training is inadequate and seek more structured experiences (Mayne et al., 2014). Improving access to geriatricians and enhancing general practitioners' diagnostic skills could improve timely and accurate dementia diagnosis (Mansfield et al., 2022). However, there are significant shortages of dementia specialists, particularly in rural areas (Liu et al., 2024; Christley et al., 2022). Geriatricians support comprehensive post-diagnosis information provision, including sensitive topics like advance care planning (Mansfield et al., 2022). Collaboration between specialists and family physicians is essential, with specialists often handling contentious issues like driving competency (Hum et al., 2014). Geriatric training may influence end-of-life care patterns for dementia patients (Gotanda et al., 2023). A geriatrics perspective emphasizes prevention, considering lifestyle factors that promote healthy cognitive aging (Steffens, 2018).

There are various tests to assess cognition.
These include the [[Mini–mental state examination|MMSE]], the [[Montreal Cognitive Assessment]], and GERRI (geriatric evaluation by relative's rating instrument), which is a diagnostic tool for rating [[cognitive function]], [[social function]] and [[Mood (psychology)|mood]] in geriatric patients.<ref>{{cite journal |doi=10.2466/pr0.1983.53.2.479 |title=Development and Validation of the Geriatric Evaluation by Relative's Rating Instrument (Gerri) |year=1983 |last1=Schwartz |first1=Gerri E. |journal=Psychological Reports |volume=53 |issue=2 |pages=479–88 |pmid=6647694|s2cid=46265352 }}</ref>

=== Geriatric pharmacology ===
Elderly people require specific attention to [[medications]]. Elderly people particularly are subjected to [[polypharmacy]] (taking multiple medications) given their accumulation of multiple chronic diseases. Many of these individuals have also self-prescribed [[herbal medication]]s and [[over-the-counter drug]]s. This polypharmacy, in combination with geriatric status, may increase the risk of [[drug interaction]]s or [[adverse drug reaction]]s.<ref>{{Cite journal |last1=Dagli |first1=Rushabh J |last2=Sharma |first2=Akanksha |date=2014 |title=Polypharmacy: A Global Risk Factor for Elderly People |journal=Journal of International Oral Health|volume=6 |issue=6 |pages=i–ii |pmc=4295469 |pmid=25628499 }}</ref> [[Pharmacokinetics|Pharmacokinetic]] and [[Pharmacodynamics|pharmacodynamic]] changes arise with older age, impairing their ability to metabolize and respond to drugs. Each of the four pharmacokinetic mechanisms (absorption, distribution, metabolism, excretion) is disrupted by age-related physiologic changes. For example, overall decreased hepatic function can interfere with clearance or metabolism of drugs and reductions in kidney function can affect renal elimination.<ref>{{Cite web |title=Pharmacokinetics in Older Adults - Geriatrics |url=https://www.merckmanuals.com/professional/geriatrics/drug-therapy-in-older-adults/pharmacokinetics-in-older-adults |access-date=2022-09-12 |website=Merck Manuals Professional Edition |language=en-US}}</ref> Pharmacodynamic changes lead to altered sensitivity to drugs in geriatric patients, such as increased pain relief with [[morphine]] use.<ref>{{Cite journal |last1=Mangoni |first1=A A |last2=Jackson |first2=S H D |date=January 2004 |title=Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications |journal=British Journal of Clinical Pharmacology |volume=57 |issue=1 |pages=6–14 |doi=10.1046/j.1365-2125.2003.02007.x |pmc=1884408 |pmid=14678335}}</ref> Therefore, geriatric individuals require specialized pharmacological care that is informed by these age-related changes.

=== Geriatric syndromes ===
Geriatric syndromes is a term used to describe a group of clinical conditions that are highly prevalent in elderly people.<ref>{{cite journal |last1=Cicerchia |first1=Marcella |last2=Ceci |first2=Moira |last3=Locatelli |first3=Carola |last4=Gianni |first4=Walter |last5=Repetto |first5=Lazzaro |title=Geriatric syndromes in peri-operative elderly cancer patients |journal=Surgical Oncology |date=September 2010 |volume=19 |issue=3 |pages=131–139 |doi=10.1016/j.suronc.2009.11.005 |pmid=20036531 }}</ref><ref>{{cite journal |last1=Hartmann |first1=Erica L. |last2=Wu |first2=Christine |title=The Evolving Challenge of Evaluating Older Renal Transplant Candidates |journal=Advances in Chronic Kidney Disease |date=July 2010 |volume=17 |issue=4 |pages=358–367 |doi=10.1053/j.ackd.2010.03.012 |pmid=20610363 }}</ref><ref>{{cite journal |last1=Abdelhafiz |first1=Ahmed H. |last2=Sinclair |first2=Alan J. |title=Diabetes in the elderly |journal=Medicine |date=January 2015 |volume=43 |issue=1 |pages=48–50 |doi=10.1016/j.mpmed.2014.10.001 }}</ref> These syndromes are not caused by specific pathology or disease, rather, are a manifestation of multifactorial conditions affecting several organ systems. Common conditions include frailty, functional decline, falls, loss of continence, and malnutrition, amongst others.<ref>{{cite journal |last1=Mallappallil |first1=Mary |last2=Friedman |first2=Eli A |last3=Delano |first3=Barbara G |last4=McFarlane |first4=Samy I |last5=Salifu |first5=Moro O |title=Chronic kidney disease in the elderly: evaluation and management |journal=Clinical Practice |date=September 2014 |volume=11 |issue=5 |pages=525–535 |doi=10.2217/cpr.14.46 |pmc=4291282 |pmid=25589951}}</ref>

==== Frailty ====
Frailty is marked by a decline in physiological reserve, increased vulnerability to physiological and emotional stressors, and loss of function. This may present as progressive and unintentional weight loss, fatigue, muscular weakness, and decreased mobility.<ref>{{Cite journal |last1=Pal |first1=Laura M |last2=Manning |first2=Lisa |date=June 2014 |title=Palliative care for frail older people |journal=Clinical Medicine |volume=14 |issue=3 |pages=292–295 |doi=10.7861/clinmedicine.14-3-292 |pmc=4952544 |pmid=24889576 }}</ref> It is associated with increased injuries, hospitalization, and adverse clinical outcomes.

==== Functional decline ====
Functional disability can arise from a decline in physical function and/or cognitive function. It is associated with an acquired difficulty in performing basic everyday tasks resulting in an increased dependence of other individuals and/or medical devices.<ref name="Edemekong 2022">{{Citation |last1=Edemekong |first1=Peter F. |title=Activities of Daily Living |date=2022 |url=http://www.ncbi.nlm.nih.gov/books/NBK470404/ |work=StatPearls |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29261878 |access-date=2022-09-12 |last2=Bomgaars |first2=Deb L. |last3=Sukumaran |first3=Sukesh |last4=Schoo |first4=Caroline}}</ref><ref>{{Cite journal |last1=Aliberti |first1=Marlon J. R. |last2=Covinsky |first2=Kenneth E. |date=2019-02-01 |title=Home Modifications to Reduce Disability in Older Adults With Functional Disability |journal=JAMA Internal Medicine |volume=179 |issue=2 |pages=211–212 |doi=10.1001/jamainternmed.2018.6414 |pmid=30615064 }}</ref> These tasks are sub-divided into basic activities of daily living (ADL) and instrumental activities of daily living (IADL) and are commonly used as an indicator of a person's functional status.

[[Activities of daily living|Activities of daily living (ADL)]] are fundamental skills needed to care for oneself, including feeding, personal hygiene, toileting, transferring and ambulating. Instrumental activities of daily living (IADL) describe more complex skills needed to allow oneself to live independently in a community, including cooking, housekeeping, managing one's finances and medications. Routine monitoring of ADL and IADL is an important functional assessment used by clinicians to determine the extent of support and care to provide to elderly adults and their caregivers. It serves as a qualitative measurement of function over time and predicts the need for alternative living arrangements or models of care, including senior housing apartments, skilled nursing facilities, palliative, hospice or home-based care.<ref name="Edemekong 2022"/>

==== Falls ====
{{Main|Falls in older adults}}
Falls are the leading cause of emergency department admissions and hospitalizations in adults age 65 and older, many of which result in significant injury and permanent disability.<ref>{{Cite web |last=CDC |date=2020-12-16 |title=Keep on Your Feet |url=https://www.cdc.gov/injury/features/older-adult-falls/index.html |access-date=2022-09-12 |website=Centers for Disease Control and Prevention |language=en-us}}</ref> As certain risk factors can be modifiable for the purpose of reducing falls, this highlights an opportunity for intervention and risk reduction. Modifiable factors include:

* Improving balance and muscle strength.
* Removing environmental hazards.
* Encouraging use of assistive devices.
* Treating chronic conditions.
* Adjusting medication.

==== Urinary incontinence ====
[[Urinary incontinence]] or [[overactive bladder]] symptoms is defined as unintentionally urinating oneself. These symptoms can be caused by medications that increase urine output and frequency (e.g. anti-hypertensives and diuretics), urinary tract infections, pelvic organ prolapse, pelvic floor dysfunction, and diseases that damage the nerves that regulate [[Urinary bladder|bladder]] emptying.<ref>{{Cite web |title=Urinary Incontinence in Older Adults |url=https://www.nia.nih.gov/health/urinary-incontinence-older-adults |access-date=2022-09-12 |website=National Institute on Aging |date=24 January 2022 |language=en}}</ref> Other [[Human musculoskeletal system|musculoskeletal]] conditions affecting mobility should be considered, as these can make accessing bathrooms difficult.

==== Malnutrition ====
[[Malnutrition]] and poor nutritional status is an area of concern, affecting 12% to 50% of hospitalized elderly patients and 23% to 50% of institutionalized elderly patients living in long-term care facilities such as assisted living communities and skilled nursing facilities.<ref name="Evans 2005 38–41">{{Cite journal |last=Evans |first=Carol |date=2005 |title=Malnutrition in the Elderly: A Multifactorial Failure to Thrive |journal=The Permanente Journal |volume=9 |issue=3 |pages=38–41 |doi=10.7812/TPP/05-056 |pmc=3396084 |pmid=22811627 }}</ref> As malnutrition can occur due to a combination of physiologic, pathologic, psychologic and socioeconomic factors, it can be difficult to identify effective interventions.<ref>{{Cite journal |last=Evans |first=Carol |date=Summer 2005 |title=Malnutrition in the Elderly: A Multifactorial Failure to Thrive |journal=The Permanente Journal |volume=9 |issue=3 |pages=38–41 |doi=10.7812/tpp/05-056 |pmid=22811627 |pmc=3396084 }}</ref> Physiologic factors include reduced smell and taste, and a decreased metabolic rate affecting nutritional food intake. Unintentional weight loss can result from pathologic factors, including a wide range of chronic diseases that affect cognitive function, directly impact digestion (e.g. poor dentition, [[gastrointestinal cancer]]s, [[Gastroesophageal reflux disease|gastroesophageal]] reflux disease) or may be managed with dietary restrictions (e.g. congestive heart failure, diabetes mellitus, [[hypertension]]). Psychologic factors include conditions including depression, anorexia, and grief.<ref name="Evans 2005 38–41"/>

=== Practical concerns ===
Functional abilities, independence, and [[quality of life]] issues are central concerns to geriatricians and their patients. Elderly people generally want to live independently as long as possible, which requires them to be able to engage in [[self-care]] and other [[activities of daily living]]. A geriatrician may be able to provide information about [[elder care]] options, and refer people to [[home care]] services, [[skilled nursing facilities]], [[assisted living facilities]], and [[hospice]] as appropriate.

[[Frailty syndrome|Frail elderly]] individuals may choose to decline some kinds of medical care, because the risk-benefit ratio is different. For example, frail elderly women routinely stop [[screening mammogram]]s, because [[breast cancer]] is typically a slowly growing disease that would cause them no pain, impairment, or loss of life before they would die of other causes. Frail people are also at significant risk of complications following surgery and the need for extended care, and an accurate prediction—based on validated measures, rather than how old the patient's face looks—can help older patients make fully informed choices about their options. Assessment of older patients before elective surgeries can accurately predict the patients' recovery trajectories.<ref name=Frailty>{{cite journal | vauthors = Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP | display-authors = 6 | title = Frailty as a predictor of surgical outcomes in older patients | journal = Journal of the American College of Surgeons | volume = 210 | issue = 6 | pages = 901–908 | date = June 2010 | pmid = 20510798 | doi = 10.1016/j.jamcollsurg.2010.01.028 | name-list-style = vanc }}</ref> One frailty scale uses five items: unintentional weight loss, [[muscle weakness]], exhaustion, low physical activity, and slowed walking speed. A healthy person scores 0; a very frail person scores 5. Compared to non-frail elderly people, people with moderate frailty scores (2 or 3) are twice as likely to have post-surgical complications, spend 50% more time in the hospital, and are three times as likely to be discharged to a skilled nursing facility instead of to their own homes.<ref name=Frailty /> Frail elderly patients (score of 4 or 5) who were living at home before the surgery have even worse outcomes, with the risk of being discharged to a nursing home rising to twenty times the rate for non-frail elderly people.