Internal vs Geriatric Medicine: What You Need to Know

The Beers Criteria, developed and updated by the American Geriatrics Society, provides guidelines for healthcare professionals to identify potentially inappropriate medications in older adults, organized into five lists: medications to avoid in most older people, medications to avoid in older people with specific conditions, medication combinations causing harmful interactions, medications to use cautiously, and medications requiring different dosing in renal dysfunction; these guidelines help address the challenges of polypharmacy and age-related pharmacokinetic/pharmacodynamic changes that increase risks of falls, cognitive impairment, and mortality in elderly patients.

Polypharmacy in elderly patients, defined as taking 5 or more medications, poses significant risks including adverse drug reactions, drug interactions, and medication errors; the Beers Criteria (updated 2012) identifies potentially inappropriate medications for older adults, including benzodiazepines, sliding scale insulin, and certain diabetes medications, and should be used alongside medication reconciliation and individualized therapy reviews to reduce unnecessary drug use and improve patient safety.

Quality prescribing in older adults addresses unique challenges including polypharmacy, physiological changes affecting drug metabolism, multimorbidity, limited geriatrics expertise, time constraints, and an evidence gap from exclusion of older adults from clinical trials. Medication-related problems fall into three categories: underuse (missing evidence-based treatments), overuse (unnecessary medications), and inappropriate use (risks outweigh benefits). The Beers Criteria, developed by the American Geriatrics Society and updated every three years, provide evidence-based guidance for identifying potentially inappropriate medications. The 2019 update refined recommendations by removing weak criteria (H2 blockers for dementia, aripiprazole for Parkinson's) and adding new concerns (SNRIs in fall-prone patients, sulfonylureas for hypoglycemia risk). These criteria should be viewed as warning signals prompting clinical evaluation rather than absolute contraindications, with key principles emphasizing patient-specific factors and clinical judgment.

This section introduces the fundamental challenges of prescribing medications to older adults. Key topics include the prevalence of polypharmacy (with 39% of prescriptions being for patients aged 65+), the increased vulnerability of elderly patients to harmful medication effects due to physiological changes, and the consequences of inappropriate prescribing including drug interactions, medical errors, and adverse drug events. The lecture establishes why special attention is needed when prescribing to older adults, setting the foundation for understanding tools like the Beers Criteria that help identify potentially inappropriate medications.

The American Geriatrics Society Beers Criteria is an evidence-based list of medications that are potentially inappropriate for older adults (age 65+), developed to help healthcare providers identify and avoid medications that carry higher risks of adverse effects, drug interactions, or reduced efficacy in this population; the criteria categorizes medications into those to avoid, those to use with caution, and those requiring dosage adjustments based on kidney function, and covers common high-risk classes including anticholinergics, sedatives, NSAIDs, and certain cardiovascular medications.

End-of-life care requires: (1) Palliative care at end of life focusing on comfort and symptom management, (2) Recognition that obstinacy therapeutic (distanasia) prolongs suffering, (3) Respect for patient wishes in geriatric care, and (4) In emergencies, beneficence may take precedence over autonomy when life is at immediate risk.

Palliative care is specialized medical care for patients with serious illness focused on relieving symptoms, pain, and stress to improve quality of life for both patients and families, distinct from hospice care which is a defined benefit program for those with less than six months to live. Key ethical principles include autonomy (patient self-determination), truth-telling, beneficence (promoting patient well-being), and non-maleficence (avoiding harm). Effective palliative care requires understanding cultural differences in decision-making, proper pain assessment using geriatric-specific tools like PAINAD, and recognizing that early palliative care can actually increase life expectancy in conditions like cancer. Healthcare providers must navigate complex ethical dilemmas, including moral distress when patient wishes conflict with medical recommendations, and ensure advance directives are properly documented and followed.

Geriatric palliative care addresses patients with multiple chronic pathologies, cognitive impairments, and dependency. Key challenges include establishing prognosis, obtaining informed consent, and managing complex drug interactions. Patients often have life expectancies under 10 years with uncertain clinical courses. Pain management requires careful assessment, with morphine preferred for elderly patients due to better tolerability. Pre-medication one hour before painful procedures optimizes pain control. The agonal phase is unpredictable but recognizable through signs like longer respiratory pauses and marbling. Hydration and feeding have no benefit in the terminal phase. Palliative care decisions should consider cultural, ethnic, spiritual, and social dimensions. Legal rights including advance directives and the person of trust must be respected. The principle of proportionality and futility applies—care must be proportional to expected outcomes.

Palliative care is defined as supporting the needs and objectives of elderly people as they age, requiring balance between prolonging life, preserving functional state, mitigating risks, and treatment through comfort and symptom relief. Palliative care for geriatric patients presents unique challenges: decreased energy and diminished intrinsic capacity make patients respond inadequately to stressors; multiple conditions make treatment challenging as all aspects of the patient's life must be evaluated; cognitive deterioration limits patient participation in decision-making, shifting responsibility to family members; multiple disease interactions reduce the potential benefit of interventions; and the greatest potential for harm comes from medical interventions, as excessive treatment of inevitable conditions can cause more damage than the disease itself. Palliative care is defined as basic dignity care, comfort measures, and symptom relief for patients in terminal situations, allowing natural death. It is ideally interdisciplinary and offers care to the patient's family and environment. Key principles include reaffirming life, considering the dying process as natural, not accelerating or postponing death, and focusing on helping patients and families resolve normal problems. Palliative care should be a philosophy of thinking and working, not just a specialized office, and can be implemented anywhere. Benefits include improved quality of life, increased satisfaction with care, reduced family stress, decreased hospitalizations, less depression, and statistically significant extension of life (up to 12 months). Treatment objectives should evolve over time: at the beginning of terminal illness, treatment should focus on preserving or prolonging life; as the disease progresses, treatment should gradually shift toward alleviating pain, improving quality of life, and integrating palliative care; eventually, treatment for life prolongation should be discontinued in favor of comfort care; after death, treatment should continue for the family through the grief process. Adequate end-of-life care requires: promoting person-centered and family-centered attention; effectively estimating prognosis; establishing care objectives at each stage; evaluating and treating symptoms; adapting therapeutic approaches to the patient's situation; and offering end-of-life care. End-of-life care is defined as care offered to people calculated to live 12 months or less who receive both palliative and curative care.

Advanced palliative care requires integrating diagnostic evaluation (if clinically useful), collegial discussion about proportionality of interventions, and caregiver support. The goal shifts from curative treatment to symptom management and quality of life. Investigations and treatments must be proportionate to expected benefits and patient goals. In terminal malignant bowel obstruction, management focuses on symptom relief through decompression and pain control rather than curative surgery. Continuing aggressive diagnostic procedures when they cannot benefit the patient represents inappropriate care. Decisions should be based on objective clinical criteria rather than subjective caregiver fatigue. The principle of avoiding futile treatment applies particularly in terminal illness, requiring candidates to demonstrate restraint and appropriate clinical judgment.

A seven-question self-assessment tool helps determine frailty stage: hospitalization, self-perceived health, medication count, weight loss, depression, incontinence, and sensory problems. Scoring: 0-2 normal, 3-4 pre-frailty, 5+ frailty. Prevention requires regular lifestyle habits, exercise, avoiding alcohol, and stress management. For existing frailty, consulting specialists for conditions like sarcopenia, cognitive decline, and sleep disorders is crucial. Delaying treatment can transform manageable conditions into serious diseases requiring expensive treatment. Health management requires consistent effort, not quick fixes.

Sarcopenia is the age-related loss of muscle mass and function, serving as the first domino effect among age-related diseases. The human body contains approximately 600 skeletal muscles accounting for 40% of body weight. Muscle loss begins in the late 30s and accelerates after age 50, potentially halving by age 75. Risk factors include hormonal imbalances, inadequate protein intake, insufficient exercise, and chronic diseases like diabetes. Muscles function as endocrine organs secreting myokines that benefit brain, blood vessels, heart, bones, and immune system. Frailty represents an abnormal aging process where normal stressors cause rapid, irreversible functional decline. A validated assessment evaluates five indicators: difficulty climbing stairs, finding activities strenuous, avoiding heavy lifting, weight loss, and walking difficulty. One or more positive responses indicate pre-frailty, while three or more suggest frailty. Prevention requires adequate protein intake (0.9-1.2g/kg daily) and consistent exercise (20 minutes daily, twice weekly, with aerobic exercise preceding strength training). Research shows approximately 15% of pre-frail individuals can return to healthy status through high-intensity exercise interventions.

Frailty is an age-related syndrome of physiological decline characterized by weight loss (≥5% in one year), exhaustion from normal activities, muscle weakness (assessed by grip strength), slow walking speed (>6 seconds for 15 feet), and decreased physical activity. Having three or more criteria indicates frailty; one or two indicates pre-frailty. Sarcopenia refers to age-related muscle mass loss and reduced muscle cell effectiveness, beginning around age 40 but accelerating later in life. While exercise (especially strength training) is by far the most important factor for prevention and treatment, research shows that combining supplemental protein with resistance training can help counter sarcopenia and build strength more effectively than either intervention alone.

Frailty syndrome represents abnormal, accelerated aging distinct from normal aging, characterized by reduced appetite, weight loss, decreased muscle strength, slower walking, and increased fall risk. It significantly increases disability and mortality rates. A validated assessment tool includes five criteria: difficulty climbing stairs, increased daily activity difficulty, lack of vigorous exercise, significant weight loss, and walking difficulty. Meeting one criterion indicates pre-frailty, while three or more confirms frailty. Frailty is a critical transitional stage between health and disability, but unlike natural aging, it can potentially be reversed through intervention. Effective treatment requires combining adequate protein intake (0.9-1.2g per kg body weight daily) with balanced nutrition and consistent exercise. Optimal exercise includes aerobic activity (30-60 minutes daily, 5+ days weekly) and resistance training (2+ days weekly, 20 minutes per session). Since no specific pharmacological treatments exist, prevention during pre-frailty stages is more effective than reversing established frailty.

To prevent frailty: maintain social connections through hobby circles and community activities; prevent falls by keeping homes clutter-free; consume adequate protein (1.2-1.5g/kg body weight); maintain appropriate calorie intake; avoid both undereating and overeating; ensure vitamin D intake through diet and sun exposure; exercise regularly (15+ minutes daily). Starting with just one strategy can significantly impact frailty risk.