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Norway Differences between adult and geriatric medicine Geriatric providers receive specialized training in caring for older patients and promoting healthy ageing. 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,
medications and matters most to elicit patient values. It is common for
older adults to be managing multiple long-term conditions (multi-morbidity). 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 older patients, adding further
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. Older 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
neck of the femur ("broken hip"). The presentation of disease in older 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
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 (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
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 in geriatric patients.
Geriatric pharmacology Older people require specific attention to
medications. Older 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 medications and
over-the-counter drugs. This polypharmacy, in combination with geriatric status, may increase the risk of
drug interactions or
adverse drug reactions.
Pharmacokinetic and
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 the clearance or metabolism of drugs and reductions in kidney function can affect renal elimination. Pharmacodynamic changes lead to altered sensitivity to drugs in geriatric patients, such as increased pain relief with
morphine use. Therefore, geriatric individuals require specialized pharmacological care that is informed by these age-related changes.
Geriatric syndromes Geriatric syndromes are a term used to describe a group of clinical conditions that are highly prevalent in elderly people. These syndromes are not caused by specific pathology or disease, rather, they are a manifestation of multifactorial conditions affecting several organ systems. Common conditions include frailty, functional decline, falls, loss of continence, and malnutrition, amongst others.
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. 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. 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 (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. 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
bladder emptying. Other
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. As malnutrition can occur due to a combination of physiologic, pathologic, psychologic and socioeconomic factors, it can be difficult to identify effective interventions. 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 cancers,
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. 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. 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. == Subspecialties and related services ==