Clinics in geriatric medicine
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Research shows that early access to palliative care can significantly improve the quality of care for patients with chronic and advanced illnesses and reduce the overall costs of care. However, factors such as poor provider reimbursement mechanisms, inadequate formal education and training, workforce shortages, and low provider acceptance and patient engagement have created barriers to the widespread uptake of palliative care. Expanding access to these services requires their integration into new models of payment and delivery, such as Accountable Care Organizations, an overhaul of formal palliative care education and training, and improved messaging about these services to patients and providers.
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Clin. Geriatr. Med. · Feb 2015
ReviewObesity and diabetes in an aging population: time to rethink definitions and management?
Regardless of pathophysiology and diagnostic criteria, the population of older adults with diabetes is highly heterogeneous. As adults with type 2 diabetes age and develop multiple comorbid health conditions, they may experience many challenges to good diabetes care and self-management. ⋯ Treating such a diverse elderly population may result in inadequate glycemic control either because of overtreatment, leading to hypoglycemia, or because of other complications and preexisting comorbidities. It is imperative that treatment decisions are based on patient preferences, unique and likely evolving health status, and longevity.
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Because neurodegenerative dementias are progressive and ultimately fatal, a palliative approach focusing on comfort, quality of life, and family support can have benefits for patients, families, and the health system. Elements of a palliative approach include discussion of prognosis and goals of care, completion of advance directives, and a thoughtful approach to common complications of advanced dementia. Physicians caring for patients with dementia should formulate a plan for end-of-life care in partnership with patients, families, and caregivers, and be prepared to manage common symptoms at the end of life in dementia, including pain and delirium.
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Delirium is a common postoperative surgical complication associated with poor outcomes. The complexity of delirium demands that each patient be assessed individually and a tailored prevention and treatment regimen be put in place. Nonpharmacologic and pharmacologic strategies are available to achieve this goal.
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Clin. Geriatr. Med. · May 2014
ReviewManagement of postoperative complications: cardiovascular disease and volume management.
Postoperative cardiovascular complications are common, predictable, and typically treatable in geriatric patients who have sustained fractures. Although intervention-specific data are sparse, observational evidence from high-performing geriatric fracture centers coupled with an understanding of geriatric principles can serve as a basis for treatment guidelines. Many patients can be safely and effectively managed with close attention to intravascular volume status, heart rate control, and minimization of other physiologic stresses, including pain and delirium. Many chronic cardiovascular therapies may be harmful in the immediate postoperative period, and can usually be safely omitted or attenuated until hemodynamic stability and mobility have been restored.