Clinical Geriatrics

Primum non nocere…first, do no harm. These words frequently echo in my mind as I hear about various patients. Physicians are often faced with a dilemma; a patient presents with one problem, and in 15 minutes, a decision must be made regarding what the likely cause is and how best to treat it. While this may work when caring for the younger, healthier person in whom “economy of diagnosis” is usually the case and one problem can explain the presenting signs and symptoms, it is a major flaw in the care of the older person whose medical history and medical conditions are frequently more complex, with interacting problems the rule and not the exception. What we do to treat one condition may influence many others, and the end result may be quite serious.

The physician is often faced with the need to fragment the patient’s medical condition into individual problems, and to focus on treating the new condition without much regard for the effect that the treatment may have on other health systems or general well-being. It is not a lack of knowledge necessarily, but there is only so much time in the day, and the 10-15 other patients in the waiting room all must compete for the physician’s time and expertise.

Two particular cases come to mind that help illustrate this principle of Primum non nocere. The first was an elderly man being treated with multiple medications for parkinsonism who developed orthostatic hypotension. The physician began adding additional medications to counteract the drop in blood pressure that was present although still manageable upon detailed questioning with some lifestyle modification. Each additional medication that was added had its own set of side effects including fluid retention and hypertension, and eventually the path led straight to the hospital. After detailed analysis, medications were viewed as the precipitating factor and adjustments were made, leading to improvement and a return home.

The other patient who comes to mind was a healthy woman in her 50’s who had just celebrated a birthday. This was a special birthday, as it marked the fact that she now had exceeded the age of any member of her family in the past three generations; all family members had died early in life, although no specific pattern of disease was discernable. Immediately after this landmark birthday, she complained of vague feelings of “not feeling well.” Her physician admitted her to the hospital where, with the assistance of an overly enthusiastic medical house staff, she underwent a myriad of radiological and laboratory testing despite no abnormalities being found on history or physical examination. Given the fact that there is always the risk of a “false positive” on any test, the more tests that are done, the greater chance of finding something that does not fall within the normal range of values. In this case, one of the many antibodies for some vague rheumatological variant disorder returned slightly above the “norm.” Alas, a diagnosis was within sight, and she was told that while there was no definite diagnosis at this time, it was likely that she had an “autoimmune illness,” a new label for her to carry for the rest of her life. While this may be true, I could not help but think that she would have been better off with reassurance after the initial history and physical examination, and scheduled for routine health screening as would any other woman in her 50’s. This patient clearly left the hospital many days later with a diagnosis, right or wrong, and now had a medical condition to call her own!

There is an entity in medicine called Munchausen syndrome by proxy, which are cases of parents who do whatever necessary to create situations that make their children look ill, and thus the brunt of medical testing.