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CHAPTER 1: IMPORTANT CONSIDERATIONS


Your health needs as an older person require a different perspective from when you were younger. Your range of problems is different; the signs of distress are more subtle and may have greater consequences; and improvements are sometimes less dramatic and slower to appear. You may face a wider array of diseases, and symptoms of illness may not point directly to the underlying disease. For example, changes in mental status, changes in behavior, walking problems, or weight loss are typical symptoms the physician may have difficulty interpreting. You are also now more likely to have a persistent condition. In such circumstances the goal for you and your doctor is to maintain your ability to function as comfortably as possible. Even when a total cure of a given problem is not available, any discomfort or disability can often be modified substantially.

Individual Variability

Although elderly people typically demonstrate some decline in organ function, there is a wide range of variation among individuals. These differences highlight the importance of your doctor developing an individualized approach to your care. In health care, one size does not fit all, and as we age our unique differences must become an integral part of health care decisions.

Having Multiple Illnesses

The likelihood of having one or more diseases increases as we age. Among people who are 65 and older, 85 percent have at least one chronic illness, and 30 percent have three or more chronic diseases. Having more than one disease complicates care in several ways. Sudden change or illness in one system may put stress on another system, making the interpretation of symptoms more complex. A common example is the difficulty in evaluating mental confusion when it occurs with fever caused by pneumonia. In addition, the symptoms of one disease may hide those of another. For example, a person with severe heart disease and arthritis may never express the symptoms of the heart disease because of limited physical activity caused by the arthritis. It can also happen that treatment for one illness will cause a problem with another illness. This occurs, for example, when treatment using an over-the-counter medication causes bladder problems in a person with previously normal bladder function. Because of this, it is important for you and your physician to recognize the extent to which multiple conditions may be present and be alert to possible effects that any treatment may have on other conditions.

Exposure to Many Medications

Because older people appear to be at a much greater risk of adverse drug reactions, you need to be alert to any medications that may aggravate other conditions. This issue is explored in more detail in Chapter 9. It is essential for you to reduce this risk by carefully reviewing your medication regimen with your doctor in order to determine its necessity, effectiveness, and any potential for harm. You need to examine both nonprescription and prescription medications to reduce your chance of experiencing an adverse event.

Reporting Your Illness

Older people often do not take full advantage of the health services available to them. This is due to many factors, ranging from personal attitudes to increased social isolation. Old age is not necessarily linked with disability, so you should not dismiss any changes by asking "What do you expect, at my age?" Although you may feel frustrated by an inaccessible or unresponsive system of health care, you must accept your responsibility in making your relationship with your doctor work. At times you may even experience depression, but instead of limiting yourself by asking "What do I have to gain?" you should know that depression is both common and treatable. You may also experience denial, resulting from fear of economic, social, or functional consequences--this is why you should know as much as possible in advance to alleviate any fears you may have. If you feel isolated, explore opportunities to increase your interactions with people and to discuss your state of health, attitudes, or ideas.

Some illnesses and disease, such as hip fractures or Parkinson's disease, are virtually confined to the later stages of life. Certain diseases, such as cardiovascular disease, malignancy, malnutrition, thyroid gland problems, and tuberculosis are more common in old age. You and your caregivers, therefore, should bear in mind such altered distributions of illness and disease when you notice symptoms.

Your changing response to illness is another important dimension of your health behavior. Personal attitudes, social factors, and changes in the sensory organ may affect how you perceive illness. The acute signs of some diseases diminish often as we age. For example, the chest pain due to a heart attack may be absent or less dramatic. And finally, symptoms in one organ may reflect abnormalities in another. For example, an older person with a urinary tract infection may also experience confusion and disorientation. Because of this nonspecific and possibly misleading presentation of significant problems, your physician must exercise very careful attention to evaluate any change in your health status.

Your Doctor's Response

How critical is it for your physician to determine the precise nature of the underlying disease (the abnormality in anatomy or physiology) when helping you with an illness (the manifestations or symptoms of distress)? Certainly, the quest to identify the disease causing your distress is important when the disease is reversible or remediable or both. Since the 17th century, a first principle of medical practice has been the mandate to define the one disease that underlies the person's distress. Treatment directed at this underlying disease represents the most direct and effective way to reduce the symptoms. Three arguments that favor precise determination of the underlying disease seem particularly compelling: The first is that identifying reversible or remediable disease is obviously rewarding to your welfare; the second is that your doctor's uncertainty is thereby reduced; and the third is that accurate prognosis may be possible.

Despite the overwhelming success of this disease-illness paradigm, its limitations must be remembered: Some symptoms are independent of the diseases; many diseases do not necessarily produce symptoms; and the quality of the distress may not be predictable from knowing that the disease is present. For example, knowing the extent of rheumatoid arthritis in a person does not allow a physician to predict the capacity of that person to work. Your doctor's search for reversible disease, while important, is secondary to the management of most of your conditions.

The discovery of a reversible disease when you are chronically ill remains an important medical responsibility, but a clinical relationship based solely on uncovering reversible disease can be detrimental if a search for remediable disease becomes the focus of your doctor's attention. It may undermine or distort the doctor-patient relationship when all reversible diseases have been excluded. Contrary to the situation in sudden illness, in which the expeditious discovery of remedies is an imperative, your doctor's search for reversible disease when you are chronically ill can be pursued in a more leisurely manner. Most experienced physicians readily define and treat remediable conditions in their elderly patients. Often these reversible problems are those produced by health care interventions, especially drug toxicities and abusive physical restraints.

A focus on disease deemphasizes the dominant issue in the management of chronic illness, which is the maximization of your productivity, creativity, well-being, and happiness. This goal of improving your function and satisfaction to the utmost is often achieved without curing the underlying problem.

The need to reduce clinical uncertainty, to leave no stone unturned, is another rationale for defining disease in the setting of a chronic illness. A common argument is that you may be spared unnecessary diagnostic procedures once any underlying condition is totally defined. The decision on how far to proceed with a diagnostic evaluation is ultimately between you and your physician. The benefit of a diagnostic procedure depends upon the likelihood that it will yield useful information, which in chronic illness is elusive. Diagnostic tests are often an exercise reflecting more the need to reduce your doctor's anxiety than to resolve clinical uncertainty, and testing is often counterproductive. If the relief of your distress is the primary concern of you and your doctor, many diagnostic tests become irrelevant.

As previously mentioned, the third argument for defining disease in chronically ill elderly people is to allow accurate prognosis, or prediction of a person's future health. Because prognosis generally involves estimating the remaining life span, its value is highest in diseases that markedly influence longevity. For such diseases, prognostic estimates help in making decisions regarding therapy. For example, treatment regimens that are especially toxic or risky are usually reserved for circumstances in which longevity is immediately threatened. Small reductions in life expectancy are a less important concern in the management of chronic disease and become nearly irrelevant for many elderly people. Even for some less chronic problems such as malignant disease, many people seem to prefer improved quality of life over extended life span.

Another factor that limits the utility and accuracy of prognostic estimates in older people relates to the constancy of the human life span. If the age at which people have their first infirmity continues to increase, then the overall period of infirmity must decrease, assuming that life span remains constant. In view of this compressed morbidity, delaying the onset or progression of the symptoms produced by chronic illness becomes as important as curing the disease. For example, if the progression of symptoms for Alzheimer's disease were delayed for ten years, the impact of dementing illness would be substantially reduced. Even limited prognostic inferences are unreliable because older people manifest such wide biologic variability.

The Importance of Function

The word function, as used in the health field, refers to your ability to manage your daily routine--a critical issue for all of us. Loss of this ability is invariably due to a serious illness and, in this country, often leads to long-term care. In some instances, the loss of independence results from organ dysfunction or failure, but that is the exception. Why should an older person with reasonably preserved organ, mental, and musculo-skeletal function be subject to the loss of independence?

Manual ability in particular appears to be intimately and principally associated with the ability to live independently. A person's manual ability, as measured by timing the performance of a few simple tasks that reflect the skills necessary to perform basic daily activities, is helpful in making decisions related to what type of assistance you may require. This means that an evaluation of your functional abilities can be more useful than a disease-oriented one in defining certain health needs. Because most older people have chronic disease, most assessments of an older person's well-being are based on measurements of functional ability.

When function rather than disease is the focus, your physician can be most helpful to you. Reliable care and your quality of life may be more important than thorough and efficient diagnosis of disease or prediction of life expectancy. In fact, your functioning can often be improved without even knowing what disease you may have; it is the knowledge of your disability that is necessary. For example, treatment of urinary incontinence focuses on determining how bladder control can be improved if not completely restored, as well as on improving the person's confidence and self-esteem. This treatment does not depend on knowing whether the bladder activity is due to brain injury, a stroke, dementia caused by Alzheimer's disease, or any other irreversible process. Knowledge of the disability rather than the underlying disease is what most enables your doctor to provide help. When your problems are treated in this way, both you and your doctor avoid the disappointment and frustration of not being able to define or cure the primary disease.

As we age, we experience different types of problems. We become more unique and notice more variability in our performance; our care must be individualized to address the chronic illnesses we will confront. And our doctors must be attentive to these changes. In our later years, care becomes more important than cure, and function becomes more important than diagnosis.




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