JAMA Launches New Series on Care of Older Patients Facing Frailty and Decline

Physicians urged to respect the patient’s desire to remain in home

“Are physicians ready for the challenges of ‘the aging century?’” ask the authors of an editorial introducing a new series from the Journal of the American Medical Association (JAMA), entitles “Care of the Aging Patient: From Evidence to Action.”

The proportion of the worldwide population aged 60 years or older is expected to increase from 10% in 2005 to 22% in 2050, with those 85 years or older the fastest growing segment, the writers note. Half of visits to U.S. physicians are by people 65 years older, and care of patients living into their 10^th decade is likely to become 21^st-century medicine’s “new frontier.”

The fact that not all people age alike contributes to the challenge, the authors point out. For example:

• Common disease can often present atypically in older patients.
• Many geriatric syndromes are not straight-forward and do not fit the conventional paradigm of disease.
• Coping with illness is made more difficult by loss, as older patients lose their physical abilities, friends and family, and financial resources.

To help physicians prepare to meet the needs of aging patients as they face frailty and decline, the new series plans to focus on specific problems of older patients. Accompanying each series article will be a commentary providing a forum for discussion of policy issues related to the care of older adults. The first such commentary is from Christine K. Cassel, MD, president of the American Board of Internal Medicine, Philadelphia.

Cassel advocates for a system of personalized, evidence-based care allowing clinicians and their aging patients to develop a care plan that will:

• Respect the patient’s desire to remain at home.
• Reduce the risk of injury.
• Optimize function.
• Maintain patient independence and dignity for as long as possible.

FOCUS ON FALLS

One of the first articles in the series is titled “The Patient Who Falls: ‘It’s Always a Trade-off,” The authors of the article remind clinicians that fall prevention is multifactorial, and must be coordinated among members of a multidisciplinary team. Primary care clinicians can ensure care coordination of elderly, community-dwelling patients’ components of care, and referring patients to home care or outpatient rehabilitation.

“If homebound, a patient is eligible for treatment by a Medicare-certified home care agency if progress is documented,” write the authors. “Treatment at home allows assessment and management of mobility in the patient’s own environment.” Otherwise, assessment of home safety issues must rely on self-or-family-report.

“Because the factors contributing to falls affect important health outcomes such as symptom burden and function, fall prevention strategies bestow multiple health benefits,” the authors conclude.

Source: “Clinical Care in the Aging Century Announcing ‘Care of the Aging Patient: From Evidence to Action,” Journal of the American Medical Association; December 23/30, 2009; 302(24):2703-2704. Landefeld CS, Winker MA, Chemof B. Division of Geriatrics, University of California, San Francisco, and San Francisco VA Medical Center. “Policy for an Aging Society,” ibid.; pp. 2701-2702. Cassel CK; American Board of Internal Medicine, Philadelphia. “The Patient Who Falls: ‘It’s Always a Trade-off,’” ibid.; January 20, 2010; 303(3):258-266. Tinetti MA, Kumar C; Departments of Medicine and Epidemiology and Public Health, Yale University School of Medicine New Haven, Connecticut.