What is Internal Medicine?
Internal medicine is a clinical specialty devoted to the comprehensive care of adults from adolescence through end of life, focusing on prevention, diagnosis, and non-surgical treatment of diseases affecting internal organs and systems. 1, 2
Scope and Definition
Internal medicine physicians are specialists who:
- Manage the broad spectrum of illnesses affecting adults, serving as experts in diagnosis, treatment of chronic illness, health promotion, and disease prevention 3
- Handle complex acute and chronic conditions across all body systems (excluding gynecological-obstetric problems) 2
- Provide care in both hospital and ambulatory settings 1
- Receive extensive training in diseases affecting all human body systems 4
The specialty is characterized by its focus on:
- Comprehensive clinical syndromes and multisystemic diseases 5
- General diagnostic and therapeutic procedures 5
- Intensive patient-physician relationships 5
Unique Challenges in Adult and Geriatric Populations
Multimorbidity Management
More than 50% of older adults have three or more chronic conditions, requiring a shift from disease-specific to patient-centered care. 6
Internal medicine addresses multimorbidity through:
- Assessment of interacting conditions and treatments, including comprehensive medical history, clinical and psychosocial evaluation, medication reviews, and coordination across healthcare encounters 6
- Recognition that applying single-disease guidelines to patients with multimorbidity can be impractical or harmful 6
- Understanding that family physicians manage multimorbidity in up to 80% of consultations, while essentially all geriatric patients have multiple conditions 6
Cardiovascular Disease Burden
CVD affects 65-70% of persons aged 60-79 and 79-86% of those aged 80 and older, making cardiovascular drugs the most commonly used therapeutic class in older adults. 6
Specific prevalence rates include:
Polypharmacy Considerations
Patients with multiple conditions commonly take multiple prescriptions, increasing risks of drug interactions, prescribing cascades, and adverse drug effects. 6
The approach requires:
- Eliciting patient preferences and expectations through shared decision-making regarding treatment options and level of involvement 6
- Optimization of treatment benefits over possible harms 6
- Clear communication about medication/care plans 6
- Coordination across care transitions (emergency departments, inpatient/outpatient units, skilled nursing facilities) where older adults are most vulnerable 6
Age-Related Pharmacological Changes
Advanced age (≥65 years) is a risk factor for medication-associated complications due to altered pharmacokinetics and pharmacodynamics. 7
Key considerations include:
- Body fat mass increases while total body water decreases, leading to more rapid increases in plasma drug concentrations 6
- Plasma albumin levels decrease, potentially increasing the free active fraction of highly protein-bound drugs 6
- Hepatic clearance depends on liver enzyme expression/activity, hepatic blood flow, and plasma protein binding—all affected by aging 6
- Renal impairment increases myopathy and rhabdomyolysis risk with certain medications 7
Clinical Management Framework
Risk Assessment and Individualization
Clinical management must consider limited available evidence, interactions among conditions or treatments, patient preferences and goals, prognosis, multifactorial geriatric syndromes, and feasibility of implementation. 6
The assessment includes:
- Medical history review, physiological status evaluation, medication reviews, and documentation of healthcare encounters to ensure informational continuity 6
- Recognition that older adults with multimorbidity are heterogeneous in illness severity, functional status, prognosis, and personal priorities even with identical disease patterns 6
Goals of Care
Main goals prioritize preserving quality of life, maintaining functional capacity (cognitive and physical), controlling symptoms, and reducing treatment burden and hospitalizations—life extension may be of less interest to older patients. 6
This requires:
- Collaborative goal setting between patients, family, caregivers, and physicians to personalize care and adapt it to patient values and resources 6
- Switch from disease-specific approach to patient-centered care 6
- Decisions individualized based on overall health context, functional status, life expectancy, and personal preferences 6
Multidisciplinary Team Approach
Coordinated teamwork between cardiologists, medical specialists, nurses, pharmacists, social workers, family, and caregivers is essential for establishing cardiovascular pharmacotherapy goals according to patient preferences. 6
The team approach:
- Assists in decision-making and enables personalized treatment strategies 6
- Evaluates complexity, feasibility, and adherence to treatment 6
- Selects drugs and doses to optimize benefits while minimizing harm 6
- Improves quality of life and outcomes 6
- Coordinates care across transitions when older people are most vulnerable 6
Monitoring and Follow-Up
Strategies must address care planning, self-management, medication-related aspects, patient communication including safety instructions and adherence, coordination regarding referral and discharge management, and medication appropriateness and safety concerns. 6
Statin Management Example
Treatment Decisions by Age
Up to age 75, cardiovascular preventive medication effectiveness is undisputed; for vital adults aged 75-85, benefits of statins generally outweigh risks, especially in secondary prevention. 6
However:
- High-quality evidence is not yet available for primary or secondary statin prevention in people aged 85+ or those with complex health problems, as they are excluded from trials 6
- In a meta-analysis of statin efficacy, only 8% of patients were older than 75 at enrollment 6
Deprescribing Considerations
When confronted with declining health status and complex health problems, preventive medications with long-term effects may become questionable—treatment priorities shift, life expectancy shortens, and adverse effect risks increase due to pharmacokinetic/pharmacodynamic changes, polypharmacy, and multimorbidity. 6
Guidelines provide three groups of instructions for statin discontinuation:
- Related to statin intolerance 6
- Consideration in patients with poor health status 6
- None specifically aimed at older adults 6
Critical Pitfalls to Avoid
Physicians report inadequate confidence about deprescribing cardiovascular preventive medication, with considerable treatment variation in discontinuation advice. 6
Common barriers include:
- Lack of clarity around ongoing indication and when medications can be stopped 6
- Medications often continued until death despite questionable benefit 6
- Application of disease-oriented guidelines to multimorbidity patients without considering cumulative effects 6
- Failure to recognize unrecognized treatment burden 6
- Inadequate decision support to optimize benefits and minimize harms in complex patients 6
Research Gaps
Limited availability of reliable risk prediction models, feasible interventions of proven effectiveness, decision aids, and limited consensus on appropriate outcomes of care highlight major research deficits. 6
Priority areas include: