The end of the year is often a time of reflection. For most of us, 2012 will have brought events that were planned, perhaps for years, as well as others that were full of serendipity or unexpected misfortune. We are invariably older than we were in January. We approach December with our own rituals: summer holidays, Hanukkah, Christmas or New Year’s Eve. We may reflect on our joys and disappointments, or our actions and lessons learnt.
One of the tensions in medicine is between a preventive and reactive approach to disease. On the one hand, we know that attaining that elusive goal, the healthy lifestyle – free of stress and vices, rich in fruit, vegetables and exercise – can prevent many diseases, and we actively encourage our patients to achieve this goal.
But we are also constantly aware that disease can go unnoticed or be unpredictable, therefore, we take steps to measure and control the risk of disease. As our patients age, we more frequently measure their blood pressure, screen for cancers and order blood markers. We prescribe medications to reduce risk, not alleviate illness. But does this approach medicalise everyday life and its possibilities?
The timely detection of disease does relieve many people of unnecessary suffering. When illnesses arise, being familiar with recent evidence and effective management strategies does lead to better outcomes. The focus of Western medicine on pathophysiology and the fight for new treatments has led to significant gains in quality of life and life expectancy over the past century.
Another challenge – simultaneously frustrating and satisfying – is the management of patients with multiple or interrelated problems. There may not be a sudden cure, but a prolonged struggle to find a new equilibrium. In this process, we recognise the value of high quality, standardised medical care, and also value the individuality of each patient and their general practitioner. In the search for wisdom, we develop new paradigms of thought as we wrestle with the breakdown of previously held divisions between the biological and the social, or between guidelines, values and facts.
I was reminded of these struggles recently as one of my patients, aged in his 80s, cheerful, capable and very thin, came to see me with his daughter, concerned about his new complaint of fatigue. After pathology results revealed a new normocytic anaemia, I wondered how they might view the implications of this finding and I reflected on my own desire for diagnostic precision. I hoped I would be able to guide them through the decisions that lay ahead for them.
The focus articles in this issue of Australian Family Physician all relate to the management of various problems more commonly found in the elderly: cognitive decline, falls and renal impairment. We also visit the importance of the rational use of medications in older patients. These focus articles all take into account the interlinked nature of illness.
In this context, Pond1 suggests that knowledge of a diagnosis of dementia, a disease with no curative options, may positively contribute to planning for patients and their families. Her article describes useful screening, investigation and management tools that may aid the GP when dealing with patients suffering from cognitive decline.
Falls are the cause of much mortality and morbidity in the elderly, but in many cases, this is a modifiable outcome. Waldron and colleagues2 focus on practical ways of assessing and preventing this multifactorial problem. They suggest that rather than speaking of a ‘falls risk’, we may be better understood by our patients if we use the language of a person’s day-to-day concerns, such as the desire to maintain independence and strength.
Also in this issue, Phoon3 seeks to persuade us that the common finding of a reduced eGFR in an elderly patient can be understood and often managed in the primary care setting alone. His article reminds us that chronic kidney disease is best managed in the light of a person’s overall therapeutic goals. And Hilmer and colleagues4 argue for an evidence-based, ethical approach to prescribing and withdrawing medication in the elderly population. The role of polypharmacy in contributing to patient morbidity is increasingly becoming clear. Medications may of course, exacerbate falls, chronic renal impairment and cognitive decline.
General practice excels in the sphere of providing and sustaining patient-doctor relationships through the various stages and rhythms of life. This results in a practice of medicine that is rich in variety and meaning, often because it can be contextualised so closely to the needs and values of each patient and their doctor.
Whatever your December rituals, I hope you enjoy the opportunity to reflect on your practice of medicine in 2012.
- Pond D. Dementia: an update on management. Aust Fam Physician 2012;41:936–9.
- Waldron N, Hill AM, Barker A. Falls prevention in older adults: assessment and management. Aust Fam Physician 2012;41:930–5.
- Phoon RKS. Chronic kidney disease in the elderly.: assessment and management. Aust Fam Physician 2012;41:940–4.
- Hilmer SN, Gnjidic D, Le Couteur DG. Thinking through the medication list. Aust Fam Physician 2012;41:924–8.