Ep 139: First Time Visit for a 73-Year-Old Man

This episode reviews primary care principles for caring for older adults.

See more on this topic on AccessMedicine.

Transcript

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[Ms. Heidhausen] This is Katerina Heidhausen, executive editor of Harrison's Principles of Internal Medicine. Harrison's Podclass is brought to you by McGraw Hill's AccessMedicine, the online medical resource that delivers the latest content from the best minds in medicine. And now, on to the episode. 

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[Dr. Handy] Hi, everyone. Welcome back to Harrison's Podclass. We're your co-hosts. I'm Dr. Cathy Handy. 

[Dr. Wiener] And I'm Dr. Charlie Wiener, and we're joining you from the Johns Hopkins School of Medicine. 

[Dr. Handy] Welcome to episode 139: a 73-year-old man establishing care. 

[Dr. Wiener] Cathy, today's patient is a 73-year-old, recently retired insurance salesman who moved to town to be closer to his children and his grandchildren after his spouse passed away. He reports a history of hypertension and hyperlipidemia but admits he's really not sought primary care for the last three years. His last colonoscopy for screening for colon cancer was when he was 55, and it was normal. His only past surgery is a torn ACL in his 50s while he was skiing. His medications are lisinopril and atorvastatin. He's a lifelong non-smoker, consumes alcohol rarely, and is not sexually active. He still exercises daily with a variety of activities, including walking, pickleball, and chasing his grandchildren. He lives independently and still drives his car. 

[Dr. Handy] Sounds like a pretty normal and relatively healthy guy. Before we get into the case, let's talk about the aging population as it's growing. 

[Dr. Wiener] Yeah, the US and other countries will continue to experience a rapid increase in the number of older adults who seek healthcare, just like this gentleman. In fact, the most rapidly growing segment of the population in the US and many other developed countries is those older than 80 years old. 

[Dr. Handy] And in people over 70 years old, over 2/3 have at least two chronic illnesses, as in our patient. 

[Dr. Wiener] Yeah, he has hypertension and hyperlipidemia. Let's talk briefly about the physiology of aging. 

[Dr. Handy] Yeah, that's an important point. Aging is not a disease. Normal aging changes generally do not cause symptoms but do increase susceptibility to many diseases and conditions due to diminished physiologic reserve, which has been termed homeostenosis. Also, iatrogenic illnesses are common, especially related to overmedication or adverse drug reactions, immobility, and related deconditioning. 

[Dr. Wiener] Okay, well, let's get to the question. The patient seeing you is at the insistence of his children to establish ongoing primary care. Your physical examination reveals that he seems well-developed and fully oriented with no apparent signs of cognitive impairment. His pulse is 75 and regular, blood pressure is 145/80, respiration is 12, and resting oxygen saturation is 97% in room air. Other than an S4, he has no other abnormalities on his exam. His leg and his arm strength are good. 

[Dr. Handy] It sounds like he's in pretty good shape. 

[Dr. Wiener] Yeah. Our question is going to address your evaluation and goals of care. So which of the following statements regarding this patient is true? Option A. is you should continue his losartan with a goal systolic blood pressure less than 150. Option B. is you should discontinue the atorvastatin. Option C. is he does not need a screening colonoscopy. Option D. is his goal hemoglobin is greater than 10 grams per deciliter. And option E. is his goal hemoglobin A1C is less than 7.5%. 

[Dr. Handy] Okay, lots to talk about here. Let's put some of this into context. So when caring for older geriatric patients, the clinician obviously needs to understand their patient. Not all 73-year-olds are the same, and it's vital for the clinician to understand the individual's lifestyle and goals of care. Much morbidity is done because of doing too much, but at the same time, there are some clear indications for therapy and screening for older patients. 

[Dr. Wiener] This man seems pretty healthy and has very few comorbidities. He also seems to want to stay active and participate in his active family life. 

[Dr. Handy] Exactly, and that should impact some of the decisions we're about to discuss. So first off, let me say that the answer to the question and the only correct statement is E. His goal hemoglobin A1C is less than 7.5%. 

[Dr. Wiener] Tell me more. 

[Dr. Handy] Well, I think we all know how prevalent diabetes is in the older adult population, with some estimates over 25%, and that number is not going down. Current recommendations are for an A1C target of less than 7.5% among older adults with intact cognitive function and functional capacity with few comorbidities. But remember that studies have demonstrated that intensive glycemic control does not reduce major macrovascular events in older adults for at least ten years or results in improved microvascular outcomes for at least eight years. At the same time, intensive glycemic control increases the risk of severe hypoglycemia by one and a half to three-folds. And hypoglycemic episodes are associated with progressive cognitive decline in older adults, especially those with existing cognitive impairment. So we want to avoid that. On the other hand, uncontrolled diabetes is associated with an increased risk of all-cause dementia. 

[Dr. Wiener] So the decision of whether to treat, then how aggressively to treat, must be taken in the context of your individual patient, their goals, and their likely lifespan. That's often tough. 

[Dr. Handy] Exactly right. 

[Dr. Wiener] Okay, well, we still have to discuss hemoglobin, hypertension, lipids, and the screening colonoscopy. 

[Dr. Handy] Well, first, as I said, aging is not a disease. A low hemoglobin or hematocrit is not a normal age-related change in older adults. If this man's hemoglobin is less than 14, he needs an evaluation for anemia. 

[Dr. Wiener] Okay, well, that was easy. How about hypertension? He's on lisinopril. What should be his goal systolic blood pressure then? 

[Dr. Handy] Again, the answer to that is going to vary with your patient. You have to balance the cardiovascular protective benefits of lowering systolic blood pressure versus the risk of treatment-related adverse events. Remember, falls are a major cause of morbidity and mortality in the elderly and are often associated with over-treatment of hypertension. There have been a number of studies, but generally, for older patients with minimal comorbidities, no postural hypotension, and low risk of falls and volume depletion, the benefit-risk ratio favors a target systolic blood pressure of less than 130 mmHg. However, for those with diabetes, heart failure, or postural hypotension, careful treatment of blood pressure with higher systolic blood pressure targets less than 150 is probably a safer approach. 

[Dr. Wiener] Okay, again, so this man, he's overall healthy. He's got low risk. We should target a systolic blood pressure of less than 130 with the lisinopril. 

[Dr. Handy] Yes, and if we get a few more readings like today's, then he may need additional therapy. 

[Dr. Wiener] Okay, what about the lipids? I guess we shouldn't stop his atorvastatin either. 

[Dr. Handy] Again, I'm focusing this answer on our patient, and the answer is no. 

[Dr. Wiener] Tell me why. For him, this is primary, not secondary prevention. 

[Dr. Handy] There's good evidence regarding the benefits of statins on primary cardiovascular risk prevention in patients less than or equal to 75 years old without reasons for a shortened lifespan. However, the use of statins in those older than 75 or 80 for prevention of cardiovascular events and mortality is the subject of ongoing debate in the geriatric literature. In those patients, it's harder to demonstrate a benefit, although the risk of therapy is low. 

[Dr. Wiener] Okay, so I guess our man is 73, does not have indications of a shortened lifespan. We'll continue the atorvastatin. Let's finish with the screening for colon cancer. Does he need a screening colonoscopy at this age? 

[Dr. Handy] Again, most consensus says that otherwise healthy adults less than 75 with an expected lifespan of over 10 years should receive screening for colon cancer. So for our patient, a colonoscopy would be reasonable. Again, this is an individualized decision, balancing expected lifespan, individual goals, the timeline of colon cancer if discovered, and the likely morbidity of treatment. 

[Dr. Wiener] Okay, so today's teaching points are that the care of an aging or elderly patient really needs to be individualized based on the patient's function and goals. Remember, aging is not a disease, but it does narrow the therapeutic window of many treatments and increases the risk of iatrogenic morbidity. 

[Dr. Handy] If you liked this episode, you can find this question and others like it on Harrison's Self-Review, and you can read more about this topic in the Harrison's chapter on caring for the geriatric patient. Visit the show notes for links to helpful resources, including related chapters and review questions from Harrison's, available exclusively on AccessMedicine. If you enjoyed this episode, please leave us a review, so we can reach more listeners just like you. Thanks so much for listening. 

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