Geriatrics
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The primary care practitioner is frequently the first professional to whom the elderly patient will complain of blurred or distorted vision. The authors focus here on the leading cause of vision loss in the elderly--age-related macular degeneration (ARMD)--and the role of primary care in its detection and in referral for treatment. ⋯ The importance of referral of these patients at the primary care level is noted. The authors also comment on patient education, low vision aids, and eye care for the disadvantaged.
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The optimal management of pain in the elderly cancer patient is founded on astute assessment of pain and other symptoms, development of a pain diagnosis derived from the clinical evaluation, treatment of underlying causes where possible, and the expert application of analgesic techniques. Analgesic techniques themselves are multimodal. Pharmacologic approaches are the mainstay, but an individual patient may benefit from the use of anesthetic, neuroaugmentative, surgical, physiatric, or psychological methods, as well. Guidelines for the assessment and integrated management of these patients are suggested, with specific emphasis on the use of pharmacologic therapy.
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Since intensive care is expensive and has limited efficacy, its use should be reserved primarily for patients with acute, reversible illnesses. Although age is related to ICU mortality, more important predictors of ICU outcome are severity of the acute illness, the admitting diagnosis, and previous health status. Thus, age should not be the sole factor considered prior to ICU transfer or the initiation or denial of resuscitative efforts. Geriatric physicians should prospectively develop individualized plans for each of their patients based upon the patients' wishes after a discussion of diagnosis, prognosis, and the likely efficacy and side effects of the available treatments.
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The EEG can be an enormous aid in distinguishing between organic and "functional" problems and between acute drug intoxication and other forms of delirium. The characteristic EEG finding in delirium is bilateral diffuse slowing that parallels the severity of the syndrome. The vulnerability of the elderly cannot be overstressed. Their health and nutritional status, borderline cerebral changes, and sensory deprivation due to impaired vision or hearing are all predisposing factors for delirium.
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Antibiotic therapy should be directed toward any recognized or suspected pathogens. Multiple broad-spectrum antibiotics are most often successful. Ancillary measures ensure adequate oxygenation, maintenance of adequate urinary output, and support of the cardiovascular system. A team approach using an intensive care facility should result in an optimum outcome in the management of elderly septic patients.