Treating Older Patients:
Not just 'older versions of younger adults'

Karen Hall Photo: Martin Vloet

When she works with residents in their rotation through the VA system, says Karen Hall, "there's something I hear again and again: they say their heart sinks when an older patient with multiple problems comes into their clinic. They're thinking the assessment will take hours, that they don't feel comfortable dealing with incontinence or dealing with dementia, and they're often overwhelmed by all the social problems these patients face."

That's because "they don't feel that they know what to do, they don't have a plan," she says. Raising that comfort level by putting geriatric skills front and center in their training is one of the Medical School's major curriculum revision initiatives.

Hall is one of a cadre of faculty who are playing a key, early role in the implementation of "geriatrics infusion" at the house officer level. "We don't want to turn everyone into geriatricians," she says, "but we do want to raise their awareness of some common geriatric issues that might affect their particular fields.

"The thinking was, years ago, that elderly people are just older versions of younger adults. But older people have changes in their ability to metabolize drugs and their normal day-to-day physiology that make them different. You can't treat them the same way." They are more likely to have multiple disorders, chronic conditions, cognitive dysfunction, a difficult living situation, and adverse reactions to the array of medications that they may or may not be taking as directed. Caring for them thus requires treating the whole person, rather than a disorder or system, and often necessitates the involvement of other physicians, as well as other health professionals and the patient's family and friends.

"Although most physicians take care of older people, they often take care of them in a fragmented fashion," says Brent Williams, who heads the house officer phase of the Reynolds geriatrics project, "and yet older people, especially, don't do well under limited and overly focused care because they often have multiple problems, and the problems often interact with each other. You can't pick off one of them and treat it independently of the others. If you do, something else gets stressed."

But new physicians will need to think even more globally, enlisting the aid of a variety of other caregivers and loved ones who might once have been regarded as interlopers in the doctor-patient relationship. "One of the defining characteristics of geriatrics is the involvement of a multidisciplinary team," says Mark Supiano, who directs the medical student component of the Reynolds geriatrics initiative.

Norman Foster with Evangelos Athanasiou Photo: Bill Wood

And not just medical disciplines. For example, Norman Foster, M.D., professor of neurology and a member of the project's executive steering committee, says one of the specific skills for managing a patient with dementia is "the ability to involve other informants or caregivers in obtaining a medical history and to form an alliance with other individuals, other care providers, in providing care. These techniques are not typical of medical practice. Physicians usually see adult patients by themselves; they don't know how to go about involving other people in the evaluation or management of adult patients, and many physicians would view this as being intrusive."

"Sensitivity to psychiatric disorders in older patients, such as depression, anxiety, cognitive impairment and psychosis, is critically important to a comprehensive understanding of their health care needs," says Alan Mellow, also a member of the executive steering committee for the Reynolds project. "Such disorders often complicate both the presentation and outcomes of other medical illnesses. Many of the biases and myths concerning older people -- for example, that it is 'natural' to be depressed as one ages -- often create barriers, erected both by health care providers and patients themselves, to adequate diagnosis and treatment."

Not all, or even most, elderly people suffer from dementing disorders, of course; that seems to be a common misconception both within as well as outside of the medical profession. "There is a lot of confusion among the general public and also among physicians about what is expected for normal aging," says Foster. "Studies show that physicians both over- and under-diagnose dementia. In other words, they're not very good. They have stereotypes derived from their training and their own biased experience." Adds Hall, "Thirty-five or 40 percent of 90-year-olds have some memory problems or impairment in thinking, but that still leaves a lot of people who don't."

Communicating effectively with that majority also entails special skills. "Older people are more thrown off by jargon because when they were young, much of it didn't exist," says Hall. "Part of the process of explaining to patients why you're recommending a test or treatment is getting them to understand what the point of it is. When you use a lot of jargon, they may feel you're putting them down or that you don't care to explain it. I think older people need more time to think about things, too. They often want to go and talk to someone else, get some advice. Some-times residents get frustrated because a person doesn't say 'yes' right away or goes off on a tangent. To me, that's a sign that they may not be ready to deal with the issue, and if it's not vital to be taken care of this minute, or unbelievably life threatening, I say, 'Why don't you think about it and we'll discuss it again?'"

Hall says she became interested in the practice of geriatrics while she was doing a research fellowship at U-M. "I started to realize that I really enjoyed talking to older patients," she recalls, "and I also enjoyed the challenge of trying to balance the benefits of treatment for multiple problems." There's a personal dimension, too. "I've always believed pretty strongly in people designing their lives to fit what they really want," says Hall. "Some doctors have a really hard time not treating something; they feel guilty or frustrated or that they're not doing a good job if they can't persuade someone to have treatment. My feeling is that my job is to identify a problem and help the person deal with it. Dealing with it may involve not treating it. If that's their choice, and if I can be convinced that it's a reasonable choice, I'll go along with it."

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Treating Older Patients: Not just 'older versions of younger adults'

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