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Introduction to Geriatrics

by Richard W. Besdine, MD

Geriatrics refers to medical care for the elderly, an age group that is not easy to define precisely. “Older people” is sometimes preferred but is equally imprecise; > 65 is the age often used. Gerontology is the study of aging, including biologic, sociologic, and psychologic changes.

Around 1900 in the US, people > 65 accounted for 4% of the population; now, they account for > 13% (40 million, with a net gain of10,000/day). In 2026, when post–World War II baby boomers begin to reach age 80, estimates suggest that > 20% (almost 80 million) will be > 65. Mean age of those > 65 is now a little more than 75, and the proportion of those > 85 is predicted to increase most rapidly.

Life expectancy is an additional 17 yr at age 65 and 10 yr at age 75 for men and an additional 20 yr at age 65 and 13 yr at age 75 for women. Overall, women live about 5 yr longer than men, probably because of genetic, biologic, and environmental factors. These differences in survival have changed little, despite changes in women’s lifestyle (eg, increased smoking, increased stress).

Aging

Aging (ie, pure aging) refers to the inevitable, irreversible decline in organ function that occurs over time even in the absence of injury, illness, or poor lifestyle choices (eg, unhealthy diet, lack of exercise, substance abuse). Initially, the changes in organ function (see Selected Physiologic Age-Related Changes) do not affect baseline function; the first manifestations are a reduced capacity of each organ to maintain homeostasis under stress (eg, illness, injury). The cardiovascular, renal, and central nervous systems are usually the most vulnerable (the weakest links).

Diseases interact with pure aging effects to cause geriatric-specific complications, particularly in the weak-link systems—even when those organs are not the primary ones affected by a disease. Typical examples are delirium complicating pneumonia or UTIs and the falls, dizziness, syncope, and weight loss that often accompany many minor illnesses in the elderly. Aging organs are also more susceptible to injury; eg, intracranial hemorrhage is more common and is triggered by less significant injury in the elderly.

The effects of aging must be taken into account during diagnosis and treatment of the elderly. Clinicians should not

  • Mistake pure aging for disease (eg, slow information retrieval is not dementia)

  • Mistake disease for aging (eg, ascribe debilitating arthritis, tremor, or dementia to old age)

  • Ignore the increased risk of adverse drug effects on weak-link systems stressed by illness

  • Forget that the elderly often have multiple underlying disorders (eg, hypertension, diabetes, atherosclerosis) that accelerate the potential for harm

In addition, clinicians should be alert for diseases that are much more common among the elderly (eg, diastolic heart failure, Alzheimer disease, incontinence, normal pressure hydrocephalus).This approach enables clinicians to better understand and manage the complexity of the diseases that often coexist in older patients.

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