Table Of ContentProtocols in Primary Care Geriatrics
John P. Sloan
Protocols in
PriInary Care Geriatrics
With a Foreword by B. Lynn Beattie
Springer-Verlag
New York Berlin Heidelberg London
Paris Tokyo Hong Kong Barcelona
John P. Sloan, M.D.
The University of British Columbia
and Vancouver General Hospital
495 West 40th Avenue
Vancouver, BC V5Y 2RS
Canada
Library of Congress Cataloging-in-Publication Data
Sloan, John P.
Protocols in primary care geriatrics 1 John P. Sloan.
p. cm.
ISBN-13: 978-0-387-97395·1
1. Geriatrics. 2. Geriatrics - Case studies. 3. Geriatrics
-Outlines, syllabi, etc. I. Title.
[DNLM: 1. Geriatrics-case studies. 2. Primary Health Care.]
RC952.S56 1990
618.97 -dc20
DLMIDLC
for Library of Congress 90-10155
CIP
Printed on acid-free paper.
© 1991 Springer-Verlag New York Inc.
All rights reserved. This work may not be translated or copied in whole or in part
without the written permission of the publisher (Springer-Verlag New York, Inc., 175
Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with
reviews or scholarly analysis. Use in connection with any form of information storage
and retrieval, electronic adaptation, computer software, or by similar or dissimilar meth
odology now known or hereafter developed is forbidden.
The use of general descriptive names, trade names, trademarks, etc., in this publication,
even if the former are not especially identified, is not to be taken as a sign that such
names, as understood by the Trade Marks and Merchandise Act, may accordingly be
used freely by anyone.
While the advice and information in this book is believed to be true and accurate at the
date of going to press, neither the authors nor the editors nor the publisher can accept
any legal responsibility for any errors or omissions that may be made. The publisher
makes no warranty, express or implied, with respect to the material contained herein.
Typeset by Bytheway Typesetting Services, Inc., Norwich, New York.
9 8 7 6 5 432 1
ISBN·13: 978·0·387-97395-1 e-ISBN·13: 978-1-4684-0388·6
DOl: 10.1007/978-1·4684-0388·6
1b Robin, Sa~ Gordy, and Geoff
Foreword
The 1980's were an important time in the evolution of geriatrics. Dur
ing this decade there was, first in Canada and subsequently in the
United States, formal recognition of geriatrics as having a specific
body of knowledge and with that a validating examination process for
specialists in Geriatric Medicine. At the same time, it became ac
cepted that the family physician is the mainstay for primary care of
elderly patients. Although jurisdictional issues are inherent in the
emergence of this idea, the fundamental need is education. In other
words, it isn't good enough to presume that osmosis will teach geriat
rics. Simply looking after lots of older people does not automatically
imbue individuals with satisfactory knowledge in the field. Further
more, it had to be realized that geriatrics was not an area to retire into
but one to graduate into. In medicine there was a need to develop the
role for consultants in geriatrics and to improve the competence of the
primary care physician. After all, there are generations of medical
school graduates instructed in the body systems (and relevant technol
ogy), learning that the essence of practise was the "focus of the scope."
The demographic imperative was ignored and the need for focus on
function was overlooked.
Now, as the fastest growing segment of the popu1ation is over 80,
many of our patients are frail and need not only astute medical diagno
sis and treatment, but interventions which address physical and men
tal function. They also need us to consider capably their social situa
tions, and their ability to live as independently as possible in the
community.
The development of geriatric education programs is a quiet revolu
tion. It must be practical. It truly must teach old dogs new tricks!
There are diseases for which age is the greatest risk factor, such as
dementia (e.g. Alzheimer Disease), osteoporosis, and cancer of the pros
tate. There are ethical issues which are important and decision trees
which must be addressed. Just because a treatment is available, must
it be undertaken? What is the outcome? Will the risk outweigh the
benefit? Examples that come to mind include drugs such as ACE inhib-
viii Protocols in Primary Care Geriatrics
itors, and procedures such as resuscitation. When the former came on
the market, how much did we really know about their performance in
the frail elderly with physiological declines, complicated by multisys
tem chronic disease and several other prescribed medications? How is
it that the issue of resuscitation has become so contentious in the
nursing home where the outcome is so likely to be futile? Even in acute
care there is only very limited effectiveness of this intervention, and
the frail, functionally-impaired elderly are often wisely not subjected to
it.
John Sloan is a family physician who wants to continue to be a
family physician. He has two special interests which have helped geri
atrics come of age for the 1990's. The first is that he saw, despite the
fact that he had little undergraduate training in geriatrics in medical
school (and little postgraduate training in geriatrics in Family Practice)
that he was faced with a significant number of elderly people in his
practice. He therefore elected to take an additional training apprentice
ship in the Division of Geriatric Medicine, Department of Medicine at
UBC. The second is that he was inclined to teach residents in Family
Practice and as he prepared practical material on the geriatric syn
dromes, he developed handouts for the trainees. The material was
sprinkled with mnemonics, pointedly terse observations, and direc
tions. It has become a mainstay of the Family Practice training pro
gram at UBC and has been used in a number of other venues. It is this
material that has been expanded, refined, and organized into this book.
The cases are presented and discussed in a homely fashion so that the
reader is not bored by reading about neverending theory. Instead, it is
as though he/she is in the clinic or at the office facing common prob
lems. The approach to solving these problems is included in such a way
that one feels in the midst of a corridor consultation with a colleague:
one with a sense of humor, timeliness, and appropriate concern. Not all
the solutions presented are black and white; often there is no absolute
ly correct answer. In Chapter 17, for example, the illustrative cases are
provocative, and raise issues whose best decisions are not fixed but
colored by the vagaries of human nature and cultural, legislative, and
ethical concerns.
I hope this volume will find itself well-thumbed and on the shelves of
primary care physicians concerned with providing the best quality care
for their elderly patients. There is no substitute for knowledge, and this
book will assist with solving the day-to-day problems seen in geriatrics
in primary care.
B. Lynn Beattie, MD, FRCPC
Associate Professor and Head
Division of Geriatric Medicine
Department of Medicine
University of British Columbia
How to Use this Book
People learn in various ways. Protocols in Primary Care Geriatrics is
directed at primary care physicians and others with an interest in de
veloping their knowledge and skills in caring for frail elderly people. Its
format is designed to accommodate various learning styles.
The first section contains discussions of various important topics in
geriatrics, arranged in chapters. Those who learn best by reading, or
who wish to read for interest, may find this section helpful. At the end
of each chapter is a teaching exercise which seeks to test the knowledge
and skills that have been covered in the chapter.
These exercises are usually case studies, followed by questions. Com
ments on the various possible answers are found in the section Re
sponses to Clinica1 Exercises. These comments may be found following
the instructions at the end of each answer. The learning exercises may
help anyone who finds they learn best by doing. Reading them will a1so
provide examples of and elaborations on the ideas presented in the
chapters.
The second part of the book, entitled "Notes;' is in fact an outline of
Part One. It is intended for quick reference, for augmenting the reading
of Part One, .a nd for the benefit of readers who learn best by memoriz
ing, particularly utilizing mnemonics. The "Notes" part is, however,
written to be read, as well, and readers with limited time may find it a
succinct source of information. It is intentionally informa1 and collo
quia1 in style.
Terminology presents a problem when discussing certain aspects of
hea1th care with a geographically diverse audience. I have presented
medications by their generic name and tried to include common Cana
dian trade names in parentheses. Nursing home levels of care are more
challenging. Generally, the most care-intensive facilities are referred to
as skilled nursing facilities in the United States and extended care
units in Canada. Intermediate care facilities refer to nursing homes in
which patients are ambulatory, but require nursing care. Beyond these
generalities, I find the terminology so various as to be confusing. I will
adopt the convention of using "intermediate care facility;' and "extend
ed care or skilled nursing facility" for these two levels of care.
Acknowledgments
Gaining knowledge involves incurring a form of debt, payable to those
who teach and help us. Writing a book precipitates an accounting,
usually looked after in a section such as this one. Knowledge, of course,
can only be built on existing understanding, and truly original
thoughts are few. Certainly, there are none that I am aware of between
the covers of this book.
I want to recognize major assistance from Richard Ham in bringing
this book to publication. Among my teachers and mentors, I thank
especially Martha Donnelly, Bill Dalziel, and Lynn Beattie. The format
of presentation of case histories and questions is taken from Preparing
Instructional Objectives, an excellent book by Robert F. Mager. The
staff at Springer-Verlag have taken the risk and inconvenience of a new
author in their stride.
Ray Ancill, Larry Dian, J acquie Fraser, Carol Herbert, Bev McLean,
Janet Martini, Grady Meneilly, Sandy Robb, and Duncan Robertson
have been kind, helpful, and patient in ways which have made writing
this book possible. Thanks to each of you.
Finally, the Family Practice Residents at the University of British
Columbia, and the elderly patients whose problems we have encoun
tered together have allowed me to pursue a clinical and teaching prac
tice which gives a book-like this one its form and substance.
Contents
Foreword vii
How to Use this Book ix
Acknowledgments xi
Introduction 1
Part One: Geriatrics Topics and Questions 5
A. The Basics 5
1. Essentials of Geriatrics and Aging 7
2. Comprehensive Geriatric Assessment 13
3. Rehabilitation of Elderly Patients 19
4. Atypical Presentation of Disease 25
B. The Giants 33
5. Falls and Instability 35
6. Incontinence 41
7. Confusion 49
8. Depression 55
9. Constipation 61
10. Pressure Sores 65
11. Agitation 69
C. Iatrogenic Geriatrics 77
12. Theory of Drug Therapy and Aging 79
13. Practical Prescribing to the Elderly 83
14. Selected Therapeutic Problems 89
D. Special Issues 97
15. Nursing Home Care 99
16. Terminal or Palliative Care 105
17. Ethical Issues in Geriatrics 111
Responses to Clinical Exercises 117
Bibliography 145
Part 1Wo: Notes on Geriatrics 151
Index 195
Introduction
Late at night, an elderly woman in a nursing home is suddenly taken ill
with vomiting anq confusion. A telephone call is made, and a family
physician responds. The response is informed by a body of knowledge
to which the physician has access mainly via the educational efforts of
experts in the field of geriatrics. Specialist physicians, who people the
cutting edge of research, study, and teaching, provide and work with a
form of information which is comprehensive, but which is sometimes
hard to fit usefully to the mixture of academic and practical contact
that family physicians face.
But the family physician's response to an urgent phone call is also
given form by his or her clinical experience, which is distinct and differ
ent from academic knowledge. The protocol of good primary care prac
tice has the legitimacy of repeated clinical experience, complete with
practical limitations. Late at night, when the nursing home staff need
help for their patient, it is not normally the internal medicine professor
of geriatrics whom they call.
This book is written by a practicing primary care generalist, with the
idea in mind that excellence in this field is more than a lesser version of
various specialty practices. There is a proportion to good primary care
which is unique, and its strength is indebted to, but different from,
academic specialty excellence. We are concerned here with a practical
approach that works.
This book is about primary care geriatrics. Its topic is the care of
elderly people, particularly frail elderly people, by physicians and other
health professionals, who are not geriatric specialists. This group is
growing rapidly and includes many experienced physicians whose pro
fessional and postgraduate training did not include formal teaching in
geriatrics.
The material presented here developed from a series of lectures given
to Family Practice Residents at the University of British Columbia,
during the mid-1980s. My experience in teaching this group of physi
cians leads me to believe that a need for clear, simple, practical, clinical
1
