Geriatric syndromes (delirium, falls, polypharmacy)

The syndromes, named together

Older adults are people aged 65 years and above. The common geriatric syndromes are named as a group in the diabetes material, where older adults with diabetes are said to be at greater risk than other older adults for poly-pharmacy, cognitive impairment, urinary incontinence, falls and malnutrition. The same patients have higher rates of premature death, functional disability, accelerated muscle loss, and coexisting illnesses such as hypertension, coronary heart disease and stroke, and are more prone to developing depression and hypoglycemia. Approximately one-quarter of people over the age of 65 years have diabetes and one-half of older adults have pre-diabetes.

What a comprehensive assessment contains

In patients aged 65 years and older with diabetes the recommendation is to perform a comprehensive assessment of the general health and wellbeing. That assessment has named parts:

• General medical assessment, and a diabetes-focused evaluation
• Screening for mild cognitive impairment or dementia
• Screening for depression
• Assessment of the functional status and ability to carry on activities of daily living

On the basis of that assessment the patient is classified, and only then are treatment targets and goals assigned. The order matters: the target follows the assessment, it does not precede it.

How that is written down appears in a worked case. An 85-year-old female with chronic atrial fibrillation and mild cognitive impairment who meets the criteria for frailty lives with her daughter and uses a walker, but is independent for basic activities of daily living such as feeding, bathing and toileting; she does need assistance with paying bills and other instrumental ADLs; her quality of life is good overall and she enjoys interacting with friends and family; and she has been falling about once a month but has not sustained a serious injury. Basic ADLs, instrumental ADLs, frailty, the walking aid, the frequency of falls and whether any fall caused injury are each set down on their own, and together they are what a falls and frailty assessment asks.

Renal function is assessed as its own item, because it changes what every drug does. Renal function declines with age as a result of the anatomical and physiological changes that occur with aging, so clearance of renally excreted and metabolized drugs may be markedly impaired in the renally impaired or elderly patient, and a dosage adjustment is often necessary depending on the renal function. The commonly used markers of renal function will not be raised above the normal range until a substantial amount of function is lost, so the more accurate GFR, or its approximation the CrCL, is measured whenever renal disease is suspected or careful dosing of nephrotoxic drugs is required.