Geriatrics and the art of medicine

Now that we're approaching the end of the Life Cycles block, we are appropriately covering the end of life. Geriatrics is one of those fields that primarily focuses on symptom management and quality of life.

For example, the other day I saw an 84 year old man whose distal left femur splintered when he tried to stand up. This was after 3 years of not walking on it because of a hip fracture. His options were to correct it with surgery or to put it in a cast. The orthopedic surgeon recommended a full-leg cast for obvious reasons: surgery is not without risk, especially in a frail elderly man, and the patient would not even realize any benefits since he was non-ambulatory before breaking his femur. Watching him and his wife arrive at that decision was sad. It was the lesser of two evils. I thought about my own grandparents and some of the difficult decisions that they have had to make.

One major take-home message of our geriatrics lectures is the danger of drug side effects and drug-drug interactions in older patients who are on many different drugs for many different diseases.

For example, let's say you have high blood pressure. Your doctor puts you on an ACE inhibitor - a perfectly reasonable treatment. But one side effect of ACE inhibitors is nausea. So your doctor prescribes Zofran or Benadryl to help with the nausea. Well, constipation is a common side effect for both of those drugs, so now you're also taking a stool softener such as Milk of Magnesia, which itself can cause folic acid deficiency and anemia. And it goes on and on...

That's already three drugs: one to treat the hypertension and two to address the resulting side effects. You may think that constipation is innocuous enough, something you can live with. But what if that is combined with dry mouth (another common side effect of Benadryl)? Then you're starting to talk about decreased appetite and poor nutrition, which can lead to a downward spiral in an elderly patient who is already frail.

It's easy to see how this can get out of control when you consider that more than one drug is oftentimes required to adequately manage high blood pressure, and that patients typically suffer from multiple medical conditions or diseases. Managing a patient with congestive heart failure, COPD, and urinary incontinence on top of hypertension could be very tricky indeed. And in such a patient, it's not uncommon for one of those drugs or all of them combined to induce a state of delirium or reversible dementia. This not only profoundly impairs their quality of life but could also directly lead to their being placed in a nursing home or assisted living facility.

Our lecturer noted that balancing pharmacological treatment for medical conditions and a patient's quality of life is where the art of medicine comes into play.

(After describing this horror-story polypharmacy scenario, I feel that I should emphasize that prescription drug treatments are usually beneficial and safe when monitored by a physician. I wouldn't want to scare someone out of taking their blood pressure medications. It bears remembering, however, that drugs should not be blindly prescribed or taken. If a particular drug isn't working, try modifying the dose or finding a different drug with a different side effect profile.)