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COMMENTARY |
Medical College of Wisconsin, Division of Geriatrics, VAMC–Milwaukee, and Froedtert Hospital Senior Health Program, Milwaukee.
Address correspondence to Edmund H. Duthie, Jr., Division of Geriatrics, VA Medical Center–Milwaukee, 5000 W. National Ave. (CC111G), Milwaukee, WI 53295. E-mal: eduthie{at}mcw.edu
Robine and Michel (1) have summarized a large body of literature in regard to the growth of the geriatric population. They note that declining infant mortality associated with declining mortality rates for the aged themselves have resulted in burgeoning older populations. Geriatric medicine is the direct result of these population changes. The authors go further to examine the interaction of chronic illness and disability on this growing elderly population. This commentary will briefly describe the potential impact of these findings on clinical patient care.
Goals of Care
Traditional patient care approaches have emphasized making a diagnosis, understanding pathophysiology of the disease, and structuring a management plan that is based on evidence. What has become apparent is that this approach can neglect some overriding considerations. In other words, the diagnosis is "x," but so what? The missing element is the impact of the condition on function. Manton (2) has made this point clear in his studies of disease and function. This work suggests that the burden of chronic illness among the aged is persistent in recent decades. Despite this, functional loss has not achieved the degree that might have been anticipated from the experience of the oldest cohorts. Clinicians, therefore, must consider functional assessment as part of their clinical repertoire if they wish to measure the impact of disease, particularly multiple complex diseases, on their patients.
Katz (3) has taken this step further by suggesting that active life expectancy should be considered when evaluating geriatric outcomes. This is emphasized in the Robine and Michel report with the catchy acronym "HALE," healthy active life expectancy (4). Clinicians have often regarded mortality as the end point for a condition or diagnosis. When utilizing active life expectancy, the end point for study becomes functional disability. But even this is not enough, and the notion of disability versus severe disability where a bedridden state and home confinement occur help to stratify the amount of disability that is occurring. This is particularly important since severe disability places the greatest demands on resources and can require institutional alternatives to care that are costly.
Patients intuitively know all this. How often do clinicians hear "I just don't want to be a burden" or "I don't know how long I will live, but please help me to stay active so that I can remain in my home"? Clinical practice for elderly patients must incorporate assessment of function. Function not only helps to measure the severity of a condition, it also is the sum of multiple complex processes that are occurring in the individual. Further, it is the best predictor of outcome available to the clinician, the geriatric APGAR (appearance, pulse, grimace, activity, and respiration) or APACHE (Acute Physiology and Chronic Health Evaluation). Academic geriatricians need adequate exposure to medical students and residents so that this skill can be introduced and refined. Trainees need to see the routine application of functional assessment in primary care and specialty settings so that the practice and application of functional assessment is reinforced. Easy, valid, reliable instruments are needed for practitioners so that functional assessment can be part of a busy primary care practice. The ultimate result should be the clinician and patient getting "on the same page" with the goal of optimal function in late life. The impact of interventions can then be measured in terms of functional outcomes.
The complex interaction of growing geriatric populations, the burden of chronic illness, and the improved life expectancy in later life remains to be elucidated. Robine and Michel argue that populations with the lengthiest life expectancies at age 65 have an expansion of disability, while those with the shortest life expectancies have a compression of morbidity. Further study is needed to understand these interactions and the clinical applications.
Normality
This construct of function and frailty can be further extended to clinical practice. Determining what is normal for a patient is important to clinicians. Simple mathematical considerations are not always adequate. For example, in the case of blood pressure and lipids taking a population mean and looking for outliers has not identified the proper populations to treat. Rather, the risk of an adverse occurrence, with implied dysfunction, has become the target of study. Experts evaluate the risk conferred by a value measured in a clinical encounter and suggest desirable targets. It is felt that not meeting a preestablished threshold value will result in unacceptable risk.
This approach can be applied to function. Reuben (5) has reported the impact of albumin and inflammatory markers on function. From this work, one can infer an optimal level of albumin that is associated with the best level of functioning. Pennix (6) has done the same sort of analysis for hemoglobin. These approaches suggest that desirable targets for clinical parameters can be linked to functional outcomes. Future clinicians caring for aged patients will likely be considering this when evaluating patients and structuring treatment plans.
Conclusion
Although in-depth demographic analyses help to understand how we arrived at this point in regard to the population we serve, a day in the clinic or on the wards tells us that geriatrics is a significant part of the clinical landscape. Patients and clinicians hope for lives that are characterized by independence and good quality of life. The aphorism "Add years to life and life to years" continues to apply to geriatric practice. Those of us practicing medicine need to develop and refine our ability to assess function so that our patients' goals are met. Geriatricians appreciate this and should lead others in translating this approach into meaningful clinical practices.
References
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