The Importance of Geriatric Syndromes.

John e. Morley, Md, Bch, is in the divisions of Geriatric Medicine and endocrinology, saint Louis University school of Medicine, st. Louis, Missouri. Contact: morley@slu.edu With advancing age persons tend to accumulate multiple medical conditions. This multimorbidity tends to accelerate the chances of the person developing disability and of dying, as shown by the Frailty Index of Rockwood. Multimorbidity tends to lead to polypharmacy, which has been shown to cause poor outcomes in older persons. Unfortunately, the recognition of multimorbidity while connoting poor outcomes in older persons, does not help to provide a guidance plan to enhance management. In contradistinction to multimorbidity, a focus on geriatric syndromes and away from a disease focus has been shown by the Geriatric Evaluation and Management studies to improve outcomes in the older person. The modern geriatric syndromes consist of frailty, sarcopenia, anorexia and weight loss, depression, delirium, falls, cognitive dysfunction, and caregiver stress. While successful management approaches exist for each of these conditions, physicans often fail to recognize these syndromes or to employ the available therapeutic strategies. The physical frailty phenotype originally described by Fried et al has been shown to respond to treatment responses involving physical exercise nutrition, behavioral therapy and treatment of specific medical conditions. It can be rapidly identified in a busy medical practice using the FRAIL questionnaire, which has been validated in 5 continents. Sarcopenia is defined as functional impairment due to a loss of muscle mass. Like frailty, it can be identified by a short questionnaire – SARC-F – which has been validated. The treatment of sarcopenia involves long-term resistance exercise, a leucine enriched essential amino acid supplement and 1000 IU of vitamin D daily. The anorexia of aging and weight loss can be identified by the Simplified Nutritional Assessment Questionnaire (SNAQ) and monitoring of the patient’s weight. A number of reversible causes of weight loss have been identified. In addition, a caloric supplement may slow the rate of weight loss and improve outcomes. Depression can be recognized by the Patient Health Questionnaire-2. Treatment of depression involves not only medications but supportive therapy which should include exercise. Falls are a common problem in older persons. Importantly, they lead to hip fracture. Approximately a third of older persons who fall have the fall precipitated by a syncopal episode. Common causes of syncope are postural hypotension, postprandial hypotension (treatable with acarbose premeals) and arrhythmias. If the cause is not apparent, an implantable loop recorder should be considered. Arrythmias are very common in persons with diabetes mellitus. For persons who do not have syncope, the Toulouse – Saint Louis University Falls Assessment can be used to identify treatable causes of falls. All persons with recurrent falls should be screened for sarcopenia and treated when it is present. A home environmental assessment is often useful in frail older persons. Specific exercise programs for older persons with recurrent falls, e.g., the OTAGO program, are available. All persons with falls should be taught balance exercises. When an older person has new onset of falls, they should be checked for delirium. Delirium is defined as fluctuating confusion or lack of attention due to an acute problem. Common causes of delirium are anticholinergic drugs, hypoxia (stroke, myocardial infarction, pulmonary embolism and anemia), infections, epilepsy, dehydration, metabolic conditions (hypothyroid, vitamin B 12 deficiency) and retention of urine or feces. Often 2 or more of these causes are found to be the reason for a single delirious episode. Cognitive dysfunction [mild cognitive impairment (MCI) and dementia] is increasingly common as a person ages. These can be screened for using either the St. Louis University Mental Status (SLUMS) or the