Wednesday, January 22, 2014

Why in the world does my patient need a Geriatrician?

Prior to my rotation on Geriatrics I always asked myself, “why would I send my patient to a Geriatrician when almost all of my patient’s in my Internal Medicine Clinic meet the age criteria as a geriatrics patient?” This answer was quickly answered within one week on this rotation. I soon realized how easily patients can hide their dementia with jokes, laughter, wittiness or even compliments. I have performed mini-mental status exams in the past, but most of the time it was on patient’s that clearly had dementia. When I performed these tests on patients that appeared to have “normal cognition” I was amazed how subtle dementia can be. It was then that I realized that some of these patients are not getting the time and attention they deserve.

One thing that really stuck with me after this rotation is the realization that a full Geriatrics H&P will tell you more about that that patient than three, or even four, Internal Medicine clinic visits will. I had one patient in my regularly scheduled Internal Medicine Clinic that I had seen about three times in the past. His vitals and labs have always looked good compared to any of my other patients. On the surface there were no signs of dementia or even mild cognitive impairment.

However, I decided to ask about ADL’s and IADL’s and I performed a mini-mental status exam on this patient. At that point I realized that this patient had subtle, mild dementia and was requiring a lot more help at home than I had previously expected. This made me reevaluate this patient’s medication list. I asked myself, “do I really need his blood pressure at 120/80 while on HCTZ? What if he becomes orthostatic and he falls and breaks a hip? Does he really need his A1c at 5.7 while on Glipizide and Metformin and risk him having a hypoglycemic event? What is wrong with a goal of 7 or even a little bit higher for his age?”

At that point I decided to really take a look at his medication list and remove those meds that can actually do him more harm in the short run than good in the long run. I was well aware at this point what the life expectancy of a patient is who is 85 years old and I was also aware of the mortality rate of patient with a broken hip after 2 years. I did not want to contribute to this patient’s possible future suffering due to trying to overly correct lab values and vitals. Sometimes less is more.

I have always been trained to have a certain blood pressure and certain A1c and as long as it falls within those ranges then I’m doing my patient a great service. But this is not the case in the elderly population, especially those with dementia which will undoubtedly progress, as the statistics show. So thanks to this rotation I really feel that this new insight and way of thinking will help me as a Hospitalist when I’m caring for my patient and when I’m getting ready to discharge them home or to a facility.
- Michael Gutierrez, MD

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