What is the recommended management approach for patients presenting with geriatric syndromes?

Management of Geriatric Syndromes

Implement the Geriatric 5Ms framework as your systematic approach to managing geriatric syndromes, addressing Mind, Mobility, Medications, Multicomplexity, and What Matters Most simultaneously through a multidisciplinary team. 1

Understanding Geriatric Syndromes

Geriatric syndromes—including falls, delirium, incontinence, frailty, and functional decline—are multifactorial conditions sharing four common risk factors: older age, baseline cognitive impairment, baseline functional impairment, and impaired mobility. 2 These syndromes are often multifactorial in a single patient, resulting from complex combinations of causes rather than single etiologies. 3

The Geriatric 5Ms Framework: Your Management Algorithm

1. Mind (Cognitive and Psychological Assessment)

Screen annually for cognitive impairment in all adults ≥65 years using validated tools. 1

• Assess for depression, which commonly co-occurs with cognitive decline and affects treatment adherence 1, 4
• Distinguish between delirium (acute, reversible) and dementia (permanent decline) 4
• Evaluate for underlying contributors: vitamin deficiencies, medication side effects, depression 1
• Provide cognitive stimulation therapy for mild-to-moderate impairment 1
• Support caregivers with education and respite services to prevent burnout 1

Critical pitfall: Cognitive impairment affects informed consent, medication adherence, and self-care abilities—never overlook this assessment. 4

2. Mobility (Falls and Movement Management)

Conduct multifactorial fall risk assessment including medication review, vision testing, and gait evaluation. 1

For patients presenting after falls, answer this key question: "If this patient was a healthy 20-year-old, would they have fallen?" If no, conduct comprehensive assessment including: 3

• History elements: Age >65, location/cause of fall, gait/balance difficulty, prior falls, time spent on ground, loss of consciousness, near-syncope/orthostasis, melena, comorbidities (dementia, Parkinson's, stroke, diabetes), visual/neurological impairments, alcohol use, medications, ADL status, appropriate footwear 3
• Physical examination: Orthostatic blood pressure, neurologic assessment for neuropathies and proximal motor strength, complete head-to-toe evaluation for occult injuries 3
• Functional testing: "Get up and go test"—patients unable to rise from bed, turn, and steadily ambulate require reassessment before discharge 3

Implement multicomponent exercise programs focusing on strength, balance, and gait training. 1

• Provide balance training supervised by physical therapists 1
• Address orthostatic hypotension through medication adjustment and lifestyle modifications 1
• Monitor for immobility complications: pressure ulcers, venous thromboembolism 1
• Initiate VTE prophylaxis with LMWH or UFH in high-risk patients 1

Consider syncope as a cause in approximately 30% of nonaccidental falls in older adults—amnesia and cognitive impairment diminish history accuracy. 3

3. Medications (Systematic Review and Deprescribing)

Review all medications regularly to identify potentially inappropriate medications and deprescribe high-risk agents. 1

• Focus on medications increasing fall risk, cognitive impairment, or incontinence 1
• Address polypharmacy, drug-drug interactions, and age-related reduction in hepatic/renal clearance 3
• Reduce medications that lower blood pressure 3
• Special attention to: vasodilators, diuretics, antipsychotics, sedative/hypnotics 3

Critical context: Older adults account for >700,000 emergency visits annually for adverse drug events, with insulin and warfarin as leading causes. 4

4. What Matters Most (Patient-Centered Goals)

Identify each patient's meaningful health outcome goals and care preferences, aligning treatment plans with patient values. 1

• Discuss advance care planning early, before cognitive decline progresses 1
• Involve family/caregivers in care planning discussions 1
• Recognize that autonomy and quality of life are primary goals, not disease cure 4
• Ensure shared decision-making where patients are well-informed and therapeutic choices are tailored to individual needs 3

5. Multicomplexity (Coordinated Care for Multiple Conditions)

Address the intersection of multiple chronic conditions with social determinants of health through coordinated specialty care. 1

• Assess underlying cardiovascular and noncardiovascular diseases 3
• Evaluate circumstantial factors: dehydration, infection, fever 3
• Consider frailty characteristics: weight loss, weakness, exhaustion, reduced physical activity, physical slowing, cognitive decline 3
• Assess social support needs, living conditions, caregiver presence, financial status 1, 4
• Implement early palliative care when appropriate for symptom management 1

Frailty is an independent mortality risk factor affecting approximately 25% of persons ≥85 years and predicts outcomes better than chronological age alone. 4

Multidisciplinary Team Structure

Establish geriatric-trained staffing protocols including physician and nurse leadership with ancillary services. 3

Core team members:

• Physicians: Encouraged to complete 4 hours of geriatric-specific CME annually 3
• Nurses: At least 2 years geriatric experience, 8 hours BRN-approved geriatric CEU every 2 years 3
• Essential ancillary services: Social workers, case managers, pharmacists, physical therapy, occupational therapy 3, 5
• Geriatric consultation services: Can reduce ED revisits (IRR 0.59) and hospital admissions (IRR 0.64) at 12 months when identifying unrecognized needs 3

Discharge Planning and Transition of Care

Maintain community relationships and resources to facilitate safe discharge, as acute hospitalization increases delirium, nosocomial infections, iatrogenic complications, and functional decline. 3

Required discharge elements:

• Medical follow-up with primary physician or medical home 3
• Case manager to assist with compliance 3
• Safety assessments: mobility, access to care, medical transportation 3
• Medical equipment and prescription assistance 3
• Home health including outpatient nursing resources 3
• ADL resources 3
• Home safety assessments (expedited outpatient follow-up) 3
• Consider admission if patient safety cannot be ensured 3

Environmental safety requirements in ED/hospital:

• Rubber/nonskid floor surfaces, even floors, handrails, aisle lighting, bedside commodes, grab bars, properly positioned bedrails, appropriate patient gowns 3

Comprehensive Geriatric Assessment Process

Follow systematic screening, assessment, care plan development, implementation, and ongoing monitoring with dynamic adjustment. 1, 5

The assessment should be multidimensional across medical, psychological, functional, and social domains, ideally performed in-person (clinical setting or patient's home) with physician, family/caregivers, and social worker as key contributors. 5

Critical pitfall: Never attribute symptoms to "old age" without investigation—elderly patients often present atypically without typical symptoms. 4