Recent Advances in Geriatric Medicine

Coronary artery disease (CAD) is one of the leading causes of death in both men and women aged > 65 years. However, older patients have been underrepresented in clinical trials resulting in limited data about the effectiveness of different treatment strategies in this population. Furthermore, the atypical clinical presentations of CAD in elderly patients, often make diagnosis challenging and can lead to suboptimal implementation of treatment and secondary preventive measures by health care professionals. This chapter reviews clinical presentations and diagnosis consideration of CAD in the elderly. This review will also address clinical challenges that often arise when considering medication therapy and percutaneous coronary intervention (PCI) in the elderly, as well as cardiac rehabilitation in this population. To optimize the benefits of therapy in the elderly, providers should consider complex interplay of variables such as comorbidities, functional and socioeconomic status, side effects associated with multiple drug administration, and individual biological variability.

The prevalence of heart failure rises with increasing age. Although patients with heart failure are mainly elderly (age ≥65 years), evidence for efficacious diagnostic and therapeutic approaches are limited in this population. Diagnosis of heart failure in older people is challenging because of comorbidities masking symptoms and signs; different diagnostic cut-offs of natriuretic peptides; and the high prevalence of heart failure with preserved ejection fraction (HFPEF). Geriatric syndromes (such as cognitive impairment, frailty, falls and incontinence) are common in heart failure and can affect patients’ prognosis. In older patients with reduced ejection fraction, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and betablockers have improved clinical outcomes. However no therapeutic strategy has yet been found to improve prognosis of HFPEF which affect many older people.

Our population is ageing, and as older people (≥65 years of age) are affected by hypertension, these individuals are at increased risk of organ damage or cardiovascular disease (CVD). They pose many management dilemmas because most hypertension trials had upper age limits with participant recruitment or did not present age-specific results. Because evidence-based guidelines have limited information on managing older patients with hypertension, recommendations are mostly based on expert opinion. Drug treatment for elderly hypertensive patients are generally recommended but with a greater degree of caution because of changes in drug distribution and elimination, as well as the need to consider quality of life factors. However, patients in most hypertension trials were aged <80 years. Pooling the limited number of octogenarians from several trials, this group of treated patients showed a reduction in both stroke and cardiovascular (CV) morbidity, but a trend toward higher all-cause mortality compared to controls.

Therefore, the overall benefits of lowering the blood pressure in octogenarians remain unclear despite epidemiological evidence that hypertension remains a major CV risk factor in this age group. Resistant hypertension (i.e., blood pressure that remains above target when patient adheres to lifestyle measures and maximum tolerated doses of complementary antihypertensive agents which usually includes a diuretic) is more frequent with advancing age. Older patients with higher baseline systolic blood pressure characteristically have more severe or longer duration of hypertension, resulting in more difficult blood pressure control because it is often associated with autonomic dysfunction and organ damage.

Diabetes mellitus has a significant impact on the health and well-being of older people with this condition. The prevalence of diabetes and its associated complications is increasing in older people, leading to decline in functional status and quality of life. The appropriateness of tight glycaemic, blood pressure and lipid control for an older person with diabetes needs to be assessed individually. Although many pharmacological treatments for diabetes are available, their use in older people can be challenging due to increased risk of adverse reactions and drug-drug interactions with other medications. Rates of geriatric syndromes (e.g. depression, cognitive impairment, functional disability, urinary incontinence and falls) are increased in older people with diabetes. Multidisciplinary and multidimensional approach to management is essential to maintain independence and quality of life in older people with diabetes.

Alzheimer’s disease is a major public health concern globally and has been identified as a research priority. Although this disease has been recognized for more than a century, there is an urgent need to improve our understanding of its pathogenesis in order to advance development of disease-modifying treatments. Clinical diagnosis of Alzheimer’s disease remains the main method of identifying the disease but neuroimaging and biomarkers are emerging as adjunct tests in selective cases. Only a few pharmacological treatments are available for Alzheimer’s disease and modest benefits are only observed in the mild-to-moderate disease. Without effective treatment, non-pharmacological approaches and prevention remain important. Nonpharmacological approaches such as exercise, cognitive stimulation therapy and computerized mind games are potentially beneficial in slowing the progression of Alzheimer’s disease. Behavioural and psychological symptoms in Alzheimer’s disease are still challenging to manage and require a combination of non-pharmacological and pharmacological approaches. Several novel therapies are currently under investigation and clinical trials of these agents will reveal if they are beneficial in the treatment of Alzheimer’s disease.

The incidence and prevalence of ischaemic stroke increase substantially with age. In addition, clinical outcomes after a stroke are influenced significantly by age. Risk factor profiles for ischaemic stroke differ between young and older patients. Furthermore older patients with ischaemic stroke often receive less effective treatment and experience poorer outcomes than the younger population. For those who survive an acute ischaemic stroke, a comprehensive approach involving lifestyle modifications, antiplatelet or anticoagulant therapy, blood-pressure control, cholesterol-lowering and carotid artery stenosis intervention where applicable, is effective in reducing the risk of recurrent stroke. Long-term rehabilitation and supportive care is critical in the management of older people after an acute ischaemic stroke. Future research is still needed to reduce the incidence of ischaemic stroke and improve outcomes in the older population.

Chronic obstructive pulmonary disease (COPD) is one of the most common chronic diseases in older people. COPD in the older population is a challenging disorder to diagnose and manage because of several unique age-related aspects. Agerelated changes in pulmonary function can predispose older people to increased risk of mortality and other complications from COPD. The established Global Initiative for Obstructive Lung Disease criteria can be applied effectively to older people with COPD. This approach requires the use of spirometry which can be performed satisfactorily in most older patients. Treatments that are effective to reduce acute respiratory exacerbations include smoking cessation, vaccinations against influenza and pneumococcus, and the use of short- and long-acting bronchodilators. Other beneficial management strategies for COPD in older adults include pulmonary rehabilitation, domiciliary oxygen and noninvasive positive airway pressure when indicated. Care should also be focused on common comorbidities associated with COPD as these can often complicate the health of older people.

The incidence of cancer in older people (aged ≥65 years) is about 8-fold higher than in the younger population and there is a growing number of cancer survivors living beyond the age of 65 years. When cancer is suspected or diagnosed in an older person, clinicians face many challenges related to diagnosis and management. Treatment decisions in older cancer patients need to take into account the individual’s level of function and reserve. The best approach to assess an older individual’s medical, psychological and functional capabilities is through the application of a Comprehensive Geriatric Assessment (CGA). CGA has been shown to predict treatment outcomes and survival in oncology settings as well as guide the implementation of multidisciplinary interventions. The goals of cancer treatment in older adults should be cure if possible and prolongation of active life expectancy as well as maintaining quality of life. There is still a dearth of clinical trials evaluating cancer treatment in the older people; an issue which needs to be addressed urgently as the population ages.

Osteoarthritis is a common diagnosis in older people aged 65 years and above, which causes significant pain leading to disability and decreased quality of life. Nonpharmacological measures such as exercise and footwear are essential in the management of osteoarthritis-related pain and disability in the older population if medication adverse effects and polypharmacy are to be avoided. Pharmacological approaches to pain management should complement nonpharmacological treatment. Most drug therapies give mild-to-moderate pain relief but their long-term efficacy and safety in older people remain undetermined. In older patients with severe osteoarthritis of the hips or knees responding poorly to analgesics, total joint arthroplasty offers the most effective intervention for those who are fit for surgery.

Osteoporosis is characterised by bone demineralisation, reduction in bone mass and changes in bone micro-architecture or the presence of a fragility fracture. Osteoporosis is still frequently underdiagnosed and undertreated. Advancing age is a risk factor for underdiagnosis and undertreatment of osteoporosis. The goal of treatment is to reduce morbidity and mortality associated with the first fracture and prevent subsequent fractures. Osteoporosis management in older adults (≥65 years of age) must involve both non-pharmacological and pharmacological interventions. Beneficial non-pharmacological interventions include falls risk assessment and management, participation in exercise programs and the use of hip protectors. Pharmacological treatments including calcium, vitamin D, bisphosphonates, denosumab, strontium and teriparatide are generally safe for use in older people and significantly reduce fracture risk especially vertebral fractures. However the evidence is not as strong for reducing the risk in non-vertebral and hip fractures.

With population ageing and increasing life expectancy, the prevalence of chronic kidney disease (CKD) is rising. In addition to its associated cardiovascular risk, CKD in older people have increased prevalence of geriatric syndromes such as cognitive and functional decline, leading to frailty and disability. Clinical trials evaluating treatment for CKD have usually excluded patients older than 70 years, making it difficult to translate current therapeutic recommendation to the older population. Available evidence suggests that patients over 75 years of age with CKD in the presence of multiple comorbidities have greatly reduced life expectancy and quality of life, even if they choose to have renal replacement therapy. Therefore offering a conservative approach to management supported by palliative care is a more reasonable option for some patients. Kidney transplantation can lead to better life expectancy and quality of life in older people if selected carefully. There is a need for the inclusion of older people in future CKD trials so that evidence-based therapies can be offered to this group.

The end-of-life support older people receive is an important aspect of high quality health and social care, especially for those with chronic diseases. To provide high-quality end-of-life care, it is important to clarify with patients their values and goals in treatment through advanced care planning. Such an approach improves the concordance between expressed preferences for care and delivery of care as well as the satisfaction with care. Available research indicates that majority of older people would like the opportunity to discuss their end-of-life care but there are still barriers to such conversations. End-of-life care of older people with chronic diseases should focus on identifying and treating symptoms. Therefore, in end-of-life care, medications which are not intended for symptom control should be avoided.