Is the acute physiology and chronic health evaluation (APACHE) scale agist? Therapeutic implications in older patients

New perspectives on advanced practice nursing case management for aging patients

Providing case management for older individuals is challenging in that this group rarely fits any DRG or managed-care mold. Because many people are living healthier and longer lives, intergenerational family dynamics such as that observed in Sophie and Leo's case may become more the norm than the exception. Well-intentioned family members, lacking the guidance of an experienced gerontologic APN case manager, may inadvertently place their aged loved ones at risk by attempting to arrive at health care, social, and housing solutions on their own. Even though 82-year-old Sophie stated subjectively that she "felt better than ever", an objective clinical assessment revealed that she still was in a convalescent period following major abdominal surgery at the same time that she was faced with providing in-home care for Leo, her 102-year old father. Sophie may have experienced response shift, or a reconceptualization of her own health state, in the aftermath of serious illness. The advanced practice knowledge and skills, systems acumen, talents, and creativity of two APN case managers in two different states contributed to successful health and social outcomes for two "master survivors," whose longevity and clinical presentations exceeded expectations. The value of APNs as case managers is clear: APNs possess the proficiency, tenacity, knowledge base, and nursing confidence needed to make a positive contribution toward individualizing care for members of the greatest generation.

Preoperative assessment of the elderly patient

Organ system functional reserve variability increases progressively with age. In elderly patients, cardiopulmonary, central nervous system, and metabolic functional reserve seem to be the most important predictors of the ability to undergo surgery. Directed testing for the assessment of organ system functional reserve and identification of organs at risk, rather than the diagnosis of disease itself, is the primary goal of preoperative evaluation prior to surgery and is essential to the formulation of an effective anesthetic plan. The risks of adverse drug interaction, already high in the elderly, make a thorough review of the indications and dosage of perioperative medication an important part of the preoperative assessment process.

Neutralizing ageism in critical care via outcomes research

Ageism, as a mind-set, amplifies a belief that intensive care for the elderly is ineffectual. However, there are little data to support the notion that advanced chronological age alone predicts unfavorable outcomes in response to intensive care. A lack of outcome data, combined with ageism, may place older patients at risk for rationing of intensive care. Currently, neither public policy nor cultural norms directly support a limitation in services to the elderly. However, as pressure to reduce health care costs increases, critically ill elderly patients may be targeted for rationing. In this context, outcomes research involving elderly populations is crucial. The purpose of this report is to explicate the risk of ageism in the delivery of intensive care and to describe methods for implementing outcomes assessment for critically ill elderly patients as an essential element in a continuum of care.

When drug treatment in the elderly is not cost effective. An ethical dilemma in an environment of healthcare rationing

In light of moves towards the view that rationing of healthcare resources is inevitable, the question arises as to whether age is a relevant consideration. To hold age as relevant in this context attracts the charge of agism; however, age may be related to some other characteristic(s) that are pertinent. In the context of drug treatment of the elderly, there is evidence to suggest that there are important differences between older and younger patients in terms of adverse responses to drugs because of factors such as physiological changes and multiple health problems, which occur with aging. On the other hand, some studies show beneficial effects of drug therapy. There is a need for more empirical data on cost effectiveness. Ethics arguably have to take into account factors other than cost effectiveness, such as equity. A central question is whether what is required is a set of criteria in addition to cost effectiveness, or an interpretation of cost effectiveness sensitive to broader considerations, such as quality of life (QOL). In relation to the latter, the issue of age-specific measurements of QOL remains problematic.