COMMITTEE
AGE IS JUST A NUMBER
“T
AUTHOR Kathryn Vance
here’s no ‘just’ in geriatrics. Everything is a big deal
in geriatrics.”
Dr. Christian Furman, Medical Director of the
University of Louisville Trager Institute, presented
“Optimal Aging & Medical Directives” to the GLMS
Senior Physicians Committee on Jan. 4, 2020.
Dr. Furman holds the endowed Margaret Dor-
ward Smock Chair in Geriatric Medicine and is Professor of Geri-
atric and Palliative Medicine at UofL. She explained the nuances
of geriatric care from the perspective of both the physician and the
patient, helping members to understand the process of decision
making from each side. In geriatric care, each patient must be
evaluated thoroughly, with emphasis on functioning, and there is
rarely a universal answer on how to treat each person’s symptoms.
While all patients are different, there are three elements that she
said are essential to both reaching old age, as well as thriving in old
age. “Nutrition, exercise and avoiding cigarette smoke, those are
the big three,” she said. Eating a diet rich in fruits and vegetables
and limiting intake of red meat are also important in maintaining
good health.
Exercise is key to maintain muscle tone, stamina and balance,
thus reducing falls risk. “It’s never too late to start walking or lift-
ing weights…or even doing tai chi,” she said, mentioning several
patients who started high-intensity training at 90-years-old. After
a question, she clarified that high-intensity training for the average
person doesn’t mean running marathons or lifting barbells. Using
light weights with multiple reps helps to keep patients active.
Dr. Furman also stressed that exercise also helps to avoid frailty,
something she sees all too often with geriatric patients. “Frailty is a
multisystem reduction in reserve capacity of organs at or past the
threshold of clinical failure,” she said. “Not just one organ, this is
multiple organ reduction all happening at once.” To prevent frailty,
she explained, patients must ensure that key organ systems maintain
adequate physiological capacity above their usual level. They must
stress themselves and their organs with regular exercise.
While physical improvements to one’s health are crucial, we must
also be our own health care advocates when it comes to medical
treatment preferences. There are two types of advanced planning
tools: traditional and actionable.
The traditional advanced planning tool is one that many people
are familiar with: an advanced directive or living will. In short, an
advanced directive confirms wishes for what treatment should be
given or withheld in the future. It has little to no impact on imme-
diate care. This does not take effect immediately, but only in the
future if a patient no longer has decisional capacity.
The actionable advanced planning tool is the Medical Orders for
Scope of Treatment (MOST) form. This form outlines the direct and
relatively immediate impact on a patient’s course of care, or, what
happens tomorrow. This document should travel with the patient at
all times: from specialist appointments, to ambulance transport, to
the emergency room, to a nursing home, etc. This document must
be signed by a physician—it’s an official order from a doctor. This
document is generally designed for people who have less than a year
to live and should be redone annually or when there is a change
in condition. This document should be considered in addition to
an advanced directive or living will, as it is much more robust and
covers the full spectrum of a patient’s wishes. While an advanced
directive covers just DNR and tube feeding preferences, the MOST
form spells out what medical interventions have been rejected or
chosen by the patient.
In closing, Dr. Furman stressed that in geriatric care, whether
that be for our own physicians and families or the patients we are
treating, age is just a number. “It’s really not about age, it’s about
function,” Dr. Furman said. “I’ve got 50-year-olds in a nursing
home and I’ve got 90-year-olds who are water skiing. It’s all about
the function.”
Kathryn Vance is the communication specialist for the Greater Louisville Medical
Society.
FEBRUARY 2020
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