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Caring for Elderly

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Clinical Directorate


Caring for Elderly

Dr. Jay Kirtani
Internal Medicine

Geriatrics or geriatric medicine is a specialty that focuses on health care of elderly people. It aims to promote health by preventing and treating diseases and disabilities in older adults.

Geriatrics differs from standard adult medicine because it focuses on the unique needs of the elderly person. The aged body is different physiologically from the younger adult body, and during old age, the decline of various organ systems becomes manifest. Previous health issues and lifestyle choices produce a different constellation of diseases and symptoms in different people. The appearance of symptoms depends on the remaining healthy reserves in the organs. Smokers, for example, consume their respiratory system reserve early and rapidly.

Geriatricians distinguish between diseases and the effects of normal aging. For example, renal impairment may be a part of aging, but renal failure and urinary incontinence are not. Geriatricians aim to treat diseases that are present and achieve healthy ageing

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 may lead to a fall and to a fracture of the neck of the femur.

Elderly people require specific attention to medications. Elderly people particularly are subjected to polypharmacy (taking multiple medications). Some elderly people have multiple medical disorders; some have self-prescribed many herbal medications and over-the-counter drugs. This polypharmacy may increase the risk of drug interactions or adverse drug reactions. Drugs metabolites are excreted mostly by the kidneys or the liver, which may be impaired in the elderly, necessitating medication adjustment.

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.

The so-called geriatric giants are the major categories of impairment that appear in elderly people, especially as they begin to fail. These include immobility, instability, incontinence and impaired intellect/memory. Impaired vision and hearing loss are common chronic problems among older people. Hearing problems can lead to social isolation, depression, and dependence as the person can no longer talk to other people, receive information over the telephone, or engage in simple transactions, such as talking to a person at a bank or store. Vision problems lead to falls from tripping over unseen objects, medicine being taken incorrectly because the written instructions could not be read, and finances being mismanaged.

Functional abilities, independence and quality of life issues are of great concern 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 refers people to home care services, skilled nursing facilities, assisted living facilities, and hospice as appropriate.

Frail elderly people may choose to decline some kinds of medical care, because the risk-benefit ratio is different. For example, frail elderly women routinely stop screening mammograms, 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 post-surgical complications 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. 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 intermediate 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. 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.

Dr. Jay Kirtani
Consultant - Internal Medicine
Max Super Speciality Hospital, Saket