Über die Autorin bzw. den Autor

Alan Sinclair is Dean and Professor of Medicine at the Bedfordshire & Hertfordshire Postgraduate Medical School at the University of Bedfordshire, UK. He was a founding member and Academic Director of the European Union Geriatric Medicine Society EUGMS) and previously Charles Hayward Professor of Geriatric Medicine at the University of Birmingham, UK. His principle research interests are in the areas of diabetes, older people, nutrition and frailty. He is the recipient of both national and international research awards. Professor Sinclair recently established the Institute of Diabetes for Older People (IDOP), which is the first institute of its kind to be solely dedicated to the enhancement of quality diabetes care in older people.
 
John Morley is Dammert Professor of Gerontology, Director of the Division of Geriatric Medicine and the Division of Endocrinology at Saint Louis University School of Medicine. Dr. Morley has directed the clinical training programs in both endocrinology and geriatrics and supervised research activities ranging from basic biomedical investigation to epidemiology and health services research. He is the editor of the Journal of Gerontology: Medical Sciences, and recipient of the Ipsen Foundation of Longevity Award in 2001, the American Geriatrics Society's Lascher/Manning Award for Lifetime Achievement in Geriatrics in 2002, and the Gerontological Society of America's Freeman Award in 2004. He has developed a number of educational games and has a special interest in continuous quality improvement (CQI).
 
Bruno Vellas is Professor of Internal Medicine and Geriatrics, Chair of the Gerontopcle in Toulouse, France, including the Alzheimer's Disease Research and Clinical Centre. Professor Vellas is President of the IAGG (International Association of Gerontology and Geriatrics) and Editor-in-Chief of the Journal of Nutrition, Health and Aging.

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This new edition of the comprehensive and renowned textbook Principles and Practice of Geriatric Medicine offers a fully revised and updated review of geriatric medicine.  It covers the full spectrum of the subject, features 41 new chapters, and provides up-to-date, evidence-based, and practical information about the varied medical problems of ageing citizens.

The three editors, from UK, USA and France, have ensured that updated chapters provide a global perspective of geriatric medicine, as well as reflect the changes in treatment options and medical conditions which have emerged since publication of the 4^th edition in 2006.  The book includes expanded sections on acute stroke, dementia, cardiovascular disease, and respiratory diseases, and features a new section on end-of-life care. 

In the tradition of previous editions, this all-encompassing text continues to be a must-have text for all clinicians who deal with older people, particularly geriatric medical specialists, gerontologists, researchers, and general practitioners.

This title is also available as a mobile App from MedHand Mobile Libraries. Buy it now from Google Play or the MedHand Store.

Praise for the 4^th edition:
"...an excellent reference for learners at all clinical and preclinical levels and a useful contribution to the geriatric medical literature."
—Journal of the American Medical Association, November 2006

5th edition selected for 2012 Edition of Doody's Core Titles™

Aus dem Klappentext

This new edition of the comprehensive and renowned textbook Principles and Practice of Geriatric Medicine offers a fully revised and updated review of geriatric medicine. It covers the full spectrum of the subject, features 41 new chapters, and provides up-to-date, evidence-based, and practical information about the varied medical problems of ageing citizens.
 
The three editors, from UK, USA and France, have ensured that updated chapters provide a global perspective of geriatric medicine, as well as reflect the changes in treatment options and medical conditions which have emerged since publication of the 4th edition in 2006. The book includes expanded sections on acute stroke, dementia, cardiovascular disease, and respiratory diseases, and features a new section on end-of-life care.
 
In the tradition of previous editions, this all-encompassing text continues to be a must-have text for all clinicians who deal with older people, particularly geriatric medical specialists, gerontologists, researchers, and general practitioners.
 
Praise for the 4th edition:
"...an excellent reference for learners at all clinical and preclinical levels and a useful contribution to the geriatric medical literature."
--Journal of the American Medical Association, November 2006
 
5th edition selected for 2012 Edition of Doody's Core Titles(TM)

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Principles and Practice of Geriatric Medicine

John Wiley & Sons

Chapter One

Introduction

Preventive geriatrics is not an oxymoron. It is, however, a challenging area of medicine for many reasons. (1) How can guidelines for prevention take into account the variability seen among older persons? (2) How can preventive geriatrics balance the dichotomy between the treatment of populations and the treatment of the individual? (3) How can clinicians handle the unclear areas or `grey zones' of preventive geriatrics? (4) Does early detection or case finding equate with better outcomes?

To deal with these questions, this chapter presents a model of preventive geriatrics called the Health Maintenance Clinical Glidepath, which is primarily for office-based practices. It addresses screening for geriatric specific areas (e.g. cognition, gait and balance) and also screening for common medical illnesses and diseases (e.g. certain cancers, heart disease).

Background

Prevention in medicine has traditionally been divided into primary, secondary and tertiary prevention. Primary prevention is the prevention of disease before it actually starts.

The traditional definition of secondary prevention is the detection of disease at an early stage. This can be detection of asymptomatic disease by screening tests or identification of unreported problems by case finding. The following caution needs to be added to the definition. Detection should only be done if detection is likely to improve outcomes such as mortality, morbidity, function or quality of life. The priority and importance of outcomes need to be made based on patient preference.

Tertiary screening, using a comprehensive geriatric assessment approach, allows for identification and intervention of established health conditions such as cognitive impairment, gait and balance disorders, malnutrition and urinary incontinence. The goal of the intervention would be to prevent or minimize a patient's functional decline in order to maintain their independent lifestyle, since functional decline and loss of independence are not inevitable consequences of ageing.

The Health Maintenance Clinical Glidepath

The Health Maintenance Clinical Glidepath answers the first two questions above and addresses the limitations of two types of clinical decision-making tools: practice guidelines and evidence-based medicine (EBM). Although practice guidelines and EBM have been important in raising the standards of healthcare in the past decade, their use in preventive geriatrics is limited. Many guidelines do not include older age groups and, if they do, they are no more specific than `over 65 years of age'. EBM emphasizes outcomes of populations, whereas clinical practice emphasizes the outcome of the individual. One of the limitations of EBM is the discrepancy between patients in the EBM studies and in clinical practice. For example, many randomized controlled trials of medication interventions for common diseases such as congestive heart failure and osteoporosis exclude patients who are frail, demented or at the end of life.

The older we get, the more unique we become. Chronological age does not equate with physiological or functional age. Guidelines for preventive geriatrics need to take this into account. One approach is to use life expectancy and functional status to help delineate categories of older persons that are more useful than those based on chronological age. Overall health status is a good predictor of life expectancy compared with age alone and functional capacity among older persons has been found to be a predictor of mortality. Four categories can be used to help guide decisions about preventive measures. Although overlap exists and functional status may fluctuate, Gillick proposed the following: Robust (life expectancy of >5 years and functionally independent); Frail (life expectancy of <5e years and significant functional impairment); Moderately Demented (life expectancy 210 years and may or may not be functionally impaired); and End of Life (usually a life expectancy of <2 years).

Preventive geriatrics requires making decisions. Healthcare decisions are complex, involving society, healthcare workers and patients. Guidelines for preventive geriatrics need to take into account the following practice principles: (1) patients' expectations and needs, including quality of life, satisfaction and reassurance; (2) physicians' need for diagnostic certainty; (3) physicians' comfort with risk taking and concerns about malpractice; (4) the need for cost-effective medical care; (5) variations in practice patterns, particularly with regard to subspecialty care; and (6) the practical realities of running a practice.

Healthcare decisions are not black and white. Thus, four levels of recommendation were developed to allow for decisions to be made on a `graded' rather than an `all or nothing' basis and to allow for better patient involvement in decision-making. The four levels are also based, when available, on the strength or weakness of EBM that exists or does not exist. The four levels are `Do', `Discuss', `Consider' and `****'. `Do' reflects the strongest recommendation. `Discuss' reflects a recommendation that the physician discusses the riskbenefit of the decision with the patient. `Consider' reflects a recommendation that the physician gives consideration, but does not necessarily need to discuss the decision with the patient. `****' reflects that a particular evaluation or management measure is not recommended, based on these principles.

Table 12.1 is a shortened version of the original Health Maintenance Clinical Glidepath which details the recommendations for each area of prevention and for each category of Robust, Frail, Moderately Demented and End of Life. It will be noted in the following sections whether recommendations are based on organizational guidelines, EBM or expert consensus. All areas of the Glidepath underwent a Delphi process.

Office visits

Although there is no direct evidence available on how often Robust elderly versus Frail or Moderately Demented elderly need office visits, because other screening procedures need to be done, the minimum frequency should be once per year. `Do as needed' is recommended for elderly at the End of Life because of potential limitations or inability on the part of the patient to get to the office.

Blood pressure (BP) including orthostatic measurements

Performing BP measurements in all groups is recommended at each visit. Although this pertains to screening for hypertension in all four categories, it also pertains to hypotension (and associated symptoms) in the Frail, Moderately Demented and End of Life categories. Recommendations for hypertension screening are based on organizational guidelines. Although most organizations agree on the importance of screening for hypertension, they do not agree on how often. For example, the recommendations of the American College of Physicians (ACP) for BP screening for adults range from every 1–2 years to every 2–5 years for normotensive patients. The Seventh Report of the Joint National Committee for Hypertension (JNC 7) and The United States Preventative Services Task Force (USPSTF) recommend BP screening for normotensive patients every 1–2 years and yearly for prehypertensive patients. Note that these organizations do not take into account extreme ages of the elderly (for example, the difference between an...