John P. Sloan

Falls and Instability

As discussed in Chapter 2, and elsewhere, elderly people present nonspecifically and with “geriatric giants” when illness of any kind develops. Falling, and unsteadiness in mobility which precedes it, is one of these presentations. A falling patient may be suffering from almost any medical, surgical, psychiatric, or pharmacological condition. The clinical setting is often enough to make the diagnosis, but specific falling causes must still be considered.

Rehabilitation of Elderly Patients

Too many old people get sick and do not recover, just because they lose their mobility and motivation in the process of being “cured”. The dangers of ageism may be applied more harmfully here (to the frail elderly who develop a sudden illness) than to any other group. In fact, elderly, multiply pathological, cognitively impaired people have been shown time and again to recover their strength as reliably as younger people do, once an illness is over. Maybe they just look so hopelessly immobilized that we give up, or maybe there sometimes develops an insidious underground railway connecting our acute-care wards with extended care nursing homes. In any case, a lot of people lose independence unnecessarily in this way. Good geriatric rehabilitation is easy and rewarding to practice and can come naturally to all of us.

Ethical Issues in Geriatrics

Modern medical practice is made possible by widely accepted schemes and protocols for diagnosis and care. Older people, because they are diverse and defy definitions of “normality,” tend not to fit these schemes and protocols. Nowhere is this more true than in nonmedical decision-making. Difficult questions may arise, usually about patients in early infancy or at advanced age, for which medical and other health care professional training does not equip us. Consider, for example, choosing between comfort and prolonging life. Often, we can provide one or the other, but not both. Which will it be?

Joining up care around the individual – lessons from Vancouver

Purpose – The purpose of this paper is to describe lessons learned from a homecare practice for frail elderly people. Design/methodology/approach – It is strictly a description of a point of view in respect of care of frailty designed to avoid institution. Findings – Generally, frail elderly patients choose care focused on comfort and function as opposed to the traditional systematic healthcare goals of rescue and prevention. This choice should be respected. Research limitations/implications – There are no formal research findings. Practical implications – Cost-saving as well as improvement in care is possible through team-based relationship-oriented homecare of the frail elderly where that care emphasizes comfort and function. Originality/value – This paper is authored by Dr John Sloan and is entirely original.

Terminal or Palliative Care

There is no better opportunity to help another human being than the one we meet when that person can no longer be cured of their illness or is near death. I find the terminology we use for this important type of care a bit strange. The cold, statistical word “terminal” means very little, and “to palliate” suggests covering up or disguising the problem, which is not our intention at all. Caring for dying people involves fine diagnostic and treatment skills directed at effective symptom control. The object of our work here is the person him or herself, not an illness. Maybe this is why some physicians find this kind of care rewarding.

Essentials of Geriatrics and Aging

There is a huge volume of information available on geriatrics. For me as a primary care physician, there are six concepts which dominate my thinking about the care of the frail elderly. I present them in mnemonic form in the “Notes” for Chapter 1 (see p. 153). Here I introduce them to point out how each idea sets geriatric care apart from the rest of medical practice.

Comprehensive Geriatric Assessment

Physicians size up patients in various ways. A pediatric assessment includes a pregnancy history, and an obstetrics assessment includes previous pregnancies and fetal examination. A geriatric assessment likewise has particular aspects which are uniquely geriatric. Broadly speaking, geriatric assessment means any comprehensive look at an older patient, whether in a family practice office, an acute care hospital, a nursing home, or a geriatric specialty unit. The principles are the same, though the detail may differ. The focus is on function and independence.

Nursing Home Care

Nursing home is a term used in geriatric literature to characterize a variety of different types of residences for older people. In the United Kingdom, Canada, and the United States, various names are used for various types of long-term care facilities. Generally, senior citizen’s housing, or personal care, is a light-level facility where people live in apartments with or without provision of meals and supervision. Nursing homes, ambulatory care facilities, and intermediate care facilities refer to homes for frail elderly people needing daily assistance with activities of daily living, but who do not require 24-hour nursing care and who are usually ambulatory. Extended care or skilled nursing facilities are units in which elderly people are not independently ambulatory and require heavy personal support for activities of daily living (ADL) up to and including feeding.

Theory of Drug Therapy and Aging

Frail elderly people are as unlike healthy younger adults as babies are. Neonatology has worked out much of the biology and pharmacology of infants, during decades of clinical experience and research. Geriatrics has now begun the fascinating project of defining a clinical science of frailty. Elderly people are also as different from one another as they are from younger adults, and so they tend to defy generalization, biologically and pharmacologically.

Practical Prescribing to the Elderly

Chapter 12 reviews the basis in biology and pharmacology for a different approach to elderly people when prescribing medication. Repeatedly, we concluded that the outcome is less certain in the elderly than it is in younger adults. This chapter presents ten simple rules, to be used as a first-order guide to the difficult juggling act of geriatric pharma-cotherapeutics. Traditionally, treatment regime rules consist of drug names, doses, and schedules; here the rules are necessarily more general. Practice makes perfect, and an intuition for pitfalls and safe practice develops with experience.