Guest editorial

Medicine in the elderly: Unique challenges and management

S Z Kalula, MB ChB, FRCP, PhD

Division of Geriatric Medicine, Institute of Ageing in Africa, University of Cape Town, Cape Town, South Africa

Corresponding author : S Z Kalula (sebastiana.kalula@uct.ac.za)

Population ageing is a global phenomenon. It is most advanced in so-called developed, or more affluent countries, but its pace is most rapid in the low- and middle-income countries. Key contributing factors to a population-ageing trend are increases in longevity, decreases in fertility, improvements in public health and HIV/AIDS-related mortality in younger age groups.

In 2013, South Africa has a population aged >60 years of some 4 million, which constitutes 7.8% of the total population – this is projected to almost double and reach 14.8% by 2050.1 A life expectancy at age 60 is 14 years for men and 18 years for women – figures not dissimilar to those in some developed countries.1

There is scant evidence of South Africa’s preparedness to meet the challenges of providing adequate and appropriate healthcare to the older population in the future. Of the eight medical schools in the country, only four offer some training at undergraduate and postgraduate levels in geriatric medicine. For the large part, healthcare professionals are inadequately trained in the care of older patients; they are poorly resourced moreover, and lack the knowledge and skills needed to manage unique medical conditions in these persons. The healthcare of older patients not only entails the management of acute diseases, but also of a complex of multiple chronic diseases, reduced physiological reserves and polypharmacy, as well as psychosocial needs. The goal of management in geriatric medicine is to maintain function and to improve quality of life.

How is old age defined?

The United Nations uses 60 years as the lower age cut-off for the definition of older persons, although some developed countries with a large proportion of older persons use an age cut-off of 65 years. Old age is commonly categorised, however, in three age groups: the young-old (60 - 74 years), the old-old (75 - 84 years) and the very-old (85 years and over). In addition, the number of centenarians is increasing in all countries, but particularly in countries such as Japan. Chronological age is not synonymous with biological age; the latter indicates body function. Changes in organ function with age progression occur at different rates in different body systems, within and between individuals. This differential leads to increased heterogeneity in the older population and demands individualised disease management.

Disease presentation in the elderly

Diseases in elderly persons commonly present as geriatric syndromes, which include falls, frailty (functional decline), dizziness, syncope, urinary incontinence, and delirium and dementia.2 Articles in this issue of CME discuss some of the common geriatric syndromes or health conditions typically seen and treated in medical practice.

Emeriau discusses hypertension and its management in elderly patients. Hypertension is a common risk factor for the geriatric syndromes, and presentations, such as isolated systolic hypertension, lowered diastolic blood pressure and wide pulse pressure, each have prognostic significance.

Dave discusses an evidence-based approach to the manage­ment of osteoporosis. The disease, which has a variety of causes, including age, is a common cause of morbidity, particularly following low-trauma fractures.

Cumming discusses risk factors for falls and an approach to their prevention. Instability and falls are a major cause of morbidity, disability and mortality in older people. Not commonly known is that a fall, even if not associated with injury, may lead to fear of falling and restricted mobility – themselves predisposing factors for further falls.

Movement disorders not only predispose older persons to falls but can present a diagnostic and management challenge for health practitioners. Carr discusses causes of movement disorders and an approach to their management.

Frailty syndrome in patients in older age groups (i.e. >75 years) presents frequently to health practitioners. De Villiers discusses steps to recognise this syndrome, and a need for comprehensive assessment and multidisciplinary management.

Delirium, which also presents commonly in patients of advanced age (> 75 years), and particularly in those who are frail, is a medical emergency. Delirium has poor prognosis if the underlying cause(s) are not identified and managed promptly. Butler et al. discuss an approach to the management of patients presenting with delirium. Potocnik provides insight on ethical and medico-legal issues encountered by health practitioners in managing patients, particularly where cognitive impairment is present. These practitioners are required to assist patients and their families with these issues, as well as to counsel patients on their rights.

Finally, a common legal issue is when a decision should be taken that a patient is no longer fit to drive, particularly if cognitive impairment is present. Ross discusses a guideline to assist practitioners in this regard.

South Africa has multiple challenges and limited resources to meet the growing demand for healthcare of an expanding older population, and to meet challenges such as those dealt with in this issue. Forward planning to maintain a healthy and active ageing population is one way of reducing the demand on limited resources.

1. UNDESA Population Division. World Population Prospects: The 2010 Revision, and UNDESA, World Population Ageing and Development 2012. http://www.un.org/en/development/desa/population/publications/pdf/ageing/2012PopAgeingandDev_WallChart.pdf (accessed 1 October 2013).

1. UNDESA Population Division. World Population Prospects: The 2010 Revision, and UNDESA, World Population Ageing and Development 2012. http://www.un.org/en/development/desa/population/publications/pdf/ageing/2012PopAgeingandDev_WallChart.pdf (accessed 1 October 2013).

2. Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric Syndromes; Clinical, Research and Policy implications of a core Geriatric concept. J Am Geriatr Soc 2007;55:780-791.

2. Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric Syndromes; Clinical, Research and Policy implications of a core Geriatric concept. J Am Geriatr Soc 2007;55:780-791.