Care of older adults

American Family Physician,  Nov 1, 1994  

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The ultimate concern of an physicians must be 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 practicing family physician will encounter must be an integral part of residency training; the patient's age and background often mandate different approaches to care.

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, and the aging population win continue to grow. Yet the health care system has become geared to acute and episodic rather than chronic and comprehensive care.

The characteristics of family practice as a specialty match particularly well the characteristics of the elderly population and its health care needs. Although it is clear that 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 lifestyles 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.

In summary, this core curriculum 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 our future family physicians.

Attitude

The resident should develop attitudes that encompass: A. An awareness of the importance

of the physician's own

attitudes to aging,

disability and death. B. Compassion and humanism,

balancing realism and

practicality in the consideration

of inevitable decline and loss. C. The promotion of dignity

through self-care and self-determination. D. A recognition of the

importance of family and

home in the overall life and

health of patients. E. Minimal interference, with

appropriate limitation of

investigation and treatment for

the benefit of the patient. F. The approach of a lifelong

learner and contributor, by

research, to the body of

knowledge about aging, health

and the medical management

of aging patients. G. An awareness of the importance

of a multi-disciplinary

approach to the enhancement

of individualized care. H. Continuing accessibility and

accountability for his or her

patients. I. An awareness of the

importance of cost containment. J. An awareness of the benefits

and limitations of advanced

directives, living wills and

durable powers of attorney.

Knowledge

The resident should develop knowledge of: A. The underlying physiologic

"normal aging" changes in the

various body systems,

including diminished

homeostatic abilities, altered

metabolism and effects of

drugs, and other changes that

directly relate to the assessment

and treatment of elderly

patients. B. The normal psychologic, social

and environmental changes of.

aging, including reactions to

common stresses and changes

such as retirement, bereavement,

relocation and ill health,

and the changes in family

relationships that affect health

care of the elderly. C. The unique modes of presentation

of elderly patients for

care, including altered and

nonspecific presentations of

specific diseases. D. The tendency of elderly

patients toward iatrogenic

disease, immobilization and its

consequences, dependency or

long-term institutionalization

while in the process of

receiving medical care. E. The means for promoting

health and health maintenance

through screening, preventive

care and early diagnosis, and

the assessment of risk factors. F. 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. G. The place of the house call, its

indications and benefits in the

assessment and management

of elderly patients. H. The characteristics of the

various types of long-term

care facilities and alternative

housings available to the

elderly. I. The specific regulations for the

care of patients in long-term

facilities. J. The pitfalls of geriatric care

such as polypharmacy,

iatrogenic illness, overdependency,