Management of Geriatric Giants in the Elderly

Introduction to Geriatric Giants Management

• The American Geriatrics Society recommends implementing the comprehensive "Geriatric 5Ms" framework to address multiple domains simultaneously and reduce morbidity, mortality, and improve quality of life in elderly patients 1, 2, 3

The Geriatric 5Ms Framework for Management

Mind (Cognitive and Psychological Health)

• The American Diabetes Association recommends screening annually for cognitive impairment in all adults 65 years and older using validated tools 4, 5, 6
• The American Psychological Association suggests assessing for depression as it commonly co-occurs with cognitive decline 4

Mobility (Falls and Movement)

• The American College of Physicians recommends implementing multicomponent exercise programs focusing on strength, balance, and gait training 1
• The American Academy of Emergency Medicine suggests addressing environmental hazards in the home to prevent falls 7

Medications (Review and Reconciliation)

• The American Geriatrics Society recommends reviewing all medications regularly to identify potentially inappropriate medications 1
• The American College of Clinical Pharmacy suggests deprescribing high-risk medications that increase fall risk, cognitive impairment, or incontinence 1
• The American Diabetes Association recommends avoiding polypharmacy which affects self-management abilities and quality of life 4, 5

What Matters Most (Patient Priorities)

• The American Medical Association recommends identifying each patient's meaningful health outcome goals and care preferences 1
• The American College of Physicians suggests aligning treatment plans with patient values to improve adherence and satisfaction 1
• The American Academy of Emergency Medicine recommends discussing advance care planning early, especially before cognitive decline progresses 1
• The American Geriatrics Society suggests involving family/caregivers in care planning discussions 7

Multicomplexity (Multiple Conditions)

• The American College of Physicians recommends addressing the intersection of multiple chronic conditions and social determinants of health 1
• The World Journal of Emergency Surgery suggests coordinating care across specialties to avoid fragmented approaches 8
• The American Academy of Emergency Medicine recommends considering social support needs and community resources 7
• The World Journal of Emergency Surgery suggests implementing early palliative care when appropriate for symptom management 8

Specific Approaches for Each Geriatric Giant

Immobility Management

• The American College of Sports Medicine recommends ensuring regular physical activity even for those with limited mobility 1
• The World Journal of Emergency Surgery suggests monitoring for complications of immobility including pressure ulcers and venous thromboembolism 8

Instability Management

• The American Geriatrics Society recommends conducting multifactorial fall risk assessment including medication review, vision testing, and gait evaluation 1
• The World Journal of Emergency Surgery suggests initiating venous thromboembolism prophylaxis with LMWH or UFH in high-risk patients 8
• The American Academy of Emergency Medicine recommends providing balance training exercises supervised by physical therapists 7
• The American College of Physicians suggests addressing orthostatic hypotension through medication adjustment and lifestyle modifications 1

Intellectual Impairment Management

• The American Psychological Association recommends providing cognitive stimulation therapy for mild to moderate cognitive impairment 1
• The American Diabetes Association suggests treating underlying contributors to cognitive decline (depression, vitamin deficiencies, medication side effects) 4
• The American Academy of Emergency Medicine recommends supporting caregivers with education and respite services to prevent burnout 7

Implementation Challenges

• The American Geriatrics Society notes that limited geriatric specialists, with only 8.6 geriatricians per 100,000 people in the US, primary care providers must develop geriatric competencies 1
• The American Academy of Emergency Medicine suggests that care coordination is essential to comprehensive management 7

Community Geriatrics Guidelines

Core Components

• The American Geriatrics Society recommends community geriatrics as the practice of delivering comprehensive, multidimensional geriatric assessment and coordinated care management to older adults living in their homes and community settings, with the goal of maximizing functional independence and quality of life, involving comprehensive geriatric assessment, multidimensional evaluation, care coordination, and interprofessional team approach 9
• Community geriatrics involves a multidimensional evaluation across medical, psychological, functional, and social domains of health, as recommended by the American Geriatrics Society 9
• Care coordination in community geriatrics matches complex community-based services to the complex needs of older adults, as outlined by the American Geriatrics Society 9
• The American Geriatrics Society suggests an interprofessional team approach, typically led by geriatricians, nurses, or nurse practitioners, working with social workers, pharmacists, and other healthcare professionals 9

The Geriatric 5Ms Framework

• The American Geriatrics Society recommends implementing the "Geriatric 5Ms" framework, including assessment of cognitive and psychological health, such as screening for dementia, delirium, and depression, as part of the "Mind" component 10

Essential Care Management Process

• The American Geriatrics Society outlines a systematic process for community geriatrics, including screening and case finding to identify older adults who would benefit, comprehensive assessment, care plan development, implementation, and ongoing monitoring, with dynamic adjustment as needs change 9
• Community geriatrics follows a care management process that includes care plan development, addressing identified needs, as recommended by the American Geriatrics Society 9
• The American Geriatrics Society suggests implementation of community geriatrics, coordinating services across multiple providers and settings 9
• Ongoing monitoring with dynamic adjustment as needs change is a key component of community geriatrics, as outlined by the American Geriatrics Society 9

Healthcare Teams

• The American Geriatrics Society notes that interprofessional teams, including social workers, pharmacists, and other healthcare professionals, play a crucial role in delivering community geriatric care 9