By Gianna Melillo
Experts covered all things aging during the Wednesday pre-meeting course “Geriatrics and Palliative Care Medicine for Internal Medicine Physicians.”
Topics ranged from the benefits of an individualized approach to assessing frailty and function to identifying cognitive impairment in primary care.
To kick off the session, Helen Fernandez, MD, MPH, professor and vice chair of education in the Brookdale Department of Geriatrics and Palliative Medicine at Icahn School of Medicine in New York, walked attendees through the 5 Ms of geriatric medicine: mind, mobility, medications, what matters most, and multi-complexity.
“Older adults are unique in terms of their care,” Dr. Fernandez explained. To address this heterogeneity in the outpatient setting, she recommends assessing the Ms in each older patient, then making a plan to incorporate them into annual wellness visits and routine physical exams. This can involve deprescribing, depression screening, and functional assessments like hearing impairment or fall risk.
Assessing function is particularly crucial in this population, said Kathryn E. Callahan, MD, MS, a geriatrician and professor of internal medicine, gerontology, and geriatric medicine at Wake Forest University School of Medicine in North Carolina.
“Older adults want active engagement with life, and that may mean different things to different people, but the more we can do to preserve cognitive and physical function, the more they'll be able to engage in that way,” she said.
Function isn’t defined solely as fitness or maintaining activities of daily living, Dr. Callahan said. Rather, it’s an older adult’s ability to remain independent.
“Fascinatingly, how fast someone walks has been shown to be one of the most reliable prognostic indicators for older adults. … Gait speed is a vital sign and is a wonderful way to capture the function that an older adult has and understand what their risk may be for losing function and independence in the future,” she explained.
On the flip side, frailty can be thought of as an estimate of a person’s physiological and functional reserve and is key to individualized decision making.
While most 40-year-olds are similar to most other 40-year-olds, “when people start hitting around 60 to 65, that is the greatest heterogeneity of health in the human lifespan, between the ages of 60 and 90,” Dr. Callahan explained.
This fact underscores the importance of taking an individualized approach to patients. “You really don't know what someone's level of function and health is until you start digging a little deeper,” she said. This knowledge can help predict how an individual will respond to disease and to management of that disease, as well as their likelihood of maintaining function and independence over time, she added.
Documenting a baseline assessment of patients’ normal function also helps other clinicians understand the impact of a hospitalization or other health crisis and determine if additional support is needed.
Several tools exist for primary care physicians to conduct these assessments, including the Timed Up and Go, the Three Chair Rise, and Short Physical Performance Battery, all of which can be carried out in the office. “The best frailty tool to use is the one that is most usable for your environment,” said Dr. Callahan.
Taking the time to carry out these tests can be lifesaving too. “One in three community-dwelling older adults and over half of those in nursing homes fall each year, and it is the number one cause of traumatic death in older adults,” she continued.
Physicians should always ask older patients about any prior falls and understand the circumstances around those falls: where they happened, if any medications had been recently changed, whether they’d eaten that day.
The next presenter, Barak Gaster, MD, drilled down further on function, focusing his talk on mild cognitive impairment and dementia.
For Dr. Gaster, director of cognition in primary care and professor of medicine in the Division of General Internal Medicine at the University of Washington in Seattle, addressing cognitive impairment in primary care is “really about communication.”
First and foremost, cognitive evaluations warrant their own individual visits, he said, adding that these visits should also be attended by a family member or friend. Not only can that loved one help implement the treatment plan, but they can also provide additional information on the patient’s daily cognitive functioning.
“It's not that you can't do a cognitive evaluation without that person there, but having that person there increases your ability to evaluate their cognition 100 times and is so, so important.”
The dedicated visit should include a three-part evaluation, consisting of a cognition check list, cognitive function assessment (with the Montreal Cognitive Assessment [MoCA] or similar tool), and input from the family member or friend.
These three parameters can help physicians determine if the patient has mild cognitive impairment or dementia and plan out next steps.
Dr. Gaster also took time to lay out the differences between delirium and dementia for the audience.
“It is extremely common for elderly people who have an acute illness—and it could be something as small as a UTI [urinary tract infection], but especially if it's in the hospital with severe pneumonia for three weeks—that sort of delirium, that transient change in their cognition can last for weeks and maybe even months, if they were really, really sick,” he explained.
Mild cognitive impairment or dementia should therefore not be assessed or diagnosed in the setting of severe illness, he stressed. However, delirium can raise the risk of future or worsening dementia.
“A person over age 65 who develops delirium, that's a person who absolutely needs to have a cognitive evaluation, but you're going to wait a few months until they have fully recovered from that illness before doing the evaluation,” he said. ■