Geriatric Otolaryngology
David E. Eibling
Sarah H. Kagan
Health care in our aging society is widely acknowledged as the force substantially altering current and future health needs, demand for services, and provision of primary and specialty care. Otolaryngologists, as specialists best prepared to treat senescent functional sensory loss and many age-related diseases and syndromes including dysphagia and malignancies of the head and neck, hold a unique role in provision of specialty care for older adults. Addressing health care needs of an aging society through provision of general otolaryngology and specialized otology, rhinology, and laryngology care, as well as head and neck surgery, requires knowledge of several specialized topics in aging and geriatrics. This chapter reviews central concepts relevant to an aging society. It then proceeds to detail aspects of clinical care for older adults relevant to the practice of otolaryngology as it relates to the future of health care. This discussion includes consideration of geriatric competence for the generalist and specialist otolaryngologist. The chapter concludes with consideration of the subspecialty of geriatric otolaryngology in health care for our aging society.
CONCEPTS IN AGING
Terms and Definitions
Language used to define and discuss issues of aging and health care for older Americans is often diverse and difficult to understand. Even terms of reference to older Americans themselves are somewhat controversial. Current conventions acknowledge the slightly pejorative connotation of the grammatically incorrect appellation elderly as a noun. The only accepted use of elderly is as an adjective; however, older is preferred in America and across most international scholarly literature in aging. While American scholars and clinicians often say “older adults,” those in the European Union may prefer “older people.” Interestingly, older adults themselves rank “elderly” among the most negative terms of reference (1). Words and phrases like “senior” or “50+” may be preferable to older adults, especially combined with individually and generationally expressed forms of address that avoid diminutives and informality. Gerontology is the name of the discipline that studies aging, health, and function from biologic, psychological, and social perspectives. Senescence refers to the process of aging and generally refers to cellular processes. Chronologic age is often subdivided into three categories. The young-old are ages 65 to 75. The old are generally considered aged 75 to 85. The old-old—or alternatively, oldest old—are those individuals aged over 85 and are currently the fastest-growing demographic (2). Centenarians—those over 100 years—and supercentenarians—those aged 110 years or older—while few in number are extensively studied to better understand extreme longevity (3). Geriatric is both the term used to define the biomedical study of age-related disease, dysfunction, and disability as well as being the name of the medical specialty of caring for older adults (4). Use of the word geriatric also delimits the subspecialty within other medical disciplines dedicated to care of older adults and to that within other professional groups. Examples of this use of term include geriatric otolaryngology, geriatric nursing, and geriatric social work.
Demographics and Disability
Emphasis on aging demographics and implications for health care are now commonplace in health care literature. Proportional change in the number of older Americans draws most attention. The current projection is that one in five Americans are expected to be aged 65 and older by 2030 (2, 5). In some regions, the percentage of older Americans may rise to one in four or more. Significant
growth in the old-old, those individuals aged 85 and over, compounds this demographic shift (2). Current trends in population aging are the result of improved disease prevention and control and of extended longevity (2). Improved health status and declining disability in late life are also apparent (6).
growth in the old-old, those individuals aged 85 and over, compounds this demographic shift (2). Current trends in population aging are the result of improved disease prevention and control and of extended longevity (2). Improved health status and declining disability in late life are also apparent (6).
Two concepts, existing in balance, explain health and social care burdens in an aging society. Compression of morbidity, classically defined by Fries (7), is the possibility of compressing illness and functional loss as close as possible to the time of death. The elder dependency ratio measures the number of older people against working adults. The elder dependency ratio, like the total dependency ratio that includes dependent children, evaluates care needs at a population level. These population measures are critical to understanding health care needs and projecting necessary services in any society.
Compression of morbidity, once only a concept yet to be realized within our population, is a current reality. Cutler and Landrum (6) offer current analyses reflecting significantly improved health and declining disability of our aging population overall. Notably for otolaryngology, Cutler and Landrum (6) suggest that sensory impairment is declining as elder health status is improving. Nonetheless, they also show stable use of nursing homes, implying potential persistence of unaddressed disability in the old-old. Cai and Lubitz (8) show older Americans are indeed increasingly experiencing compression of morbidity and disability in the time before death. However, in more discrete analyses, differential patterns of functional disability that signal commensurate health and social care needs remain a reality within the aged population.
Concerns about elder dependency ratios persist despite gains made in limiting disability and extending life (9). Some of these concerns lie in the accuracy of projections. Tuljapurkar et al. (9) suggest elder dependency ratios are in fact underestimated in most developed nations including the United States. Thus, in comparing research reported from different disciplines, some debate over projections of morbidity and consequent disability exists and warrants continued analysis to draw clinically relevant conclusions. While overall health status of older Americans is improving, dependency and specific forms of disability continue to drive improved health care education and workforce recruitment to address these needs in our aging population (5)
AGING, DISEASE, AND DISABILITY
Much science investigates interrelationships among aging, disease, and disability (10, 11, 12, 13, 14). However, these entities and their interactive and correlative effects in health and function remain incompletely understood, particularly in translating basic science into clinical contexts. Frailty is the state of declining functional reserve in which response to stressors is diminished, resulting in proportionally more severe sequelae and limited recovery after an insult (14). Fundamentally, study of processes like senescence and inflammation shed increasing light on frailty as a phenomenon of function understood now in physiologic dimensions, differentially expressed in late life (15, 16). Epigenetics is the study of both heritable and nonheritable genetic expression and cellular transcription potential that is generally stable but may be modified by interactions with physiologic, pathologic, and environmental factors over a lifetime (17, 18). Rising interest in epigenetics complements growing evidence in frailty (19). Evidence in epigenetics increasingly elucidates critical aspects of age-related diseases like dementia and cancer (18, 20). Epigenetics may eventually clarify the triad of disability, frailty, and comorbidity outlined by leading frailty researcher Fried et al. (11).
Disability, frailty, and comorbidity are almost certainly causally related, manifesting in overlapping and difficultto- distinguish patterns in late life (11). As molecularly mediated understandings of frailty and epigenetics frame translational science of aging and disease, investigation of frailty, age-related disease, and functional disability increasingly delimit related aspects of clinical geriatrics. Fried et al. (11) highlighted interchangeable use of these three terms, proceeding to outline overlapping prevalence and intercurrent sequelae. Comorbidity—diagnosis of two or more acute or chronic diseases—is highly prevalent in the old-old. The old-old bear proportionally more disability, presence of physical or mental impairment, than younger counterparts do. Both comorbidity and disability are commonly present in the case of clinical frailty. Accruing evidence continues to disentangle the clinical manifestations and consequences of these entities in prognosis, care needs, and health care costs (15, 21, 22, 23, 24, 25, 26).
Age-related disease and geriatric syndromes commonly coexist and may increase as frailty escalates (14). Frailty likely mediates age-related disease though exact mechanisms, beyond epigenetic influences and possible inflammatory processes, remain relatively obscure (18). Geriatric syndromes, unlike diseases with identifiable pathology at hand, are more complex. A geriatric syndrome, such as delirium, falls, or incontinence, manifests in a singularly identifiable presentation (27). However, manifold etiologic factors and interacting pathogenesis are at hand in any single syndrome (27). Unlike disease, there is not an authoritative and comprehensive list of geriatric syndromes. Some like sarcopenia and frailty draw debate and remain controversial. Other syndromes like delirium, falls, incontinence, malnutrition, or geriatric failure-to-thrive are more widely accepted.
Age-related disease and geriatric syndromes may interact, creating risk for complications and increasing care needs (14, 28, 29). A classic example exists in the older person with dementia who is then at greater risk for delirium. Once delirium emerges, this older person
may have a more complicated presentation and less predictable recovery (30). Both presentation—which is often atypical—and recovery may risk excess disability and poor outcomes (11, 27, 31). Atypical presentation describes unexpected signs of illness—such as delirium instead of fever as the presenting sign of pneumonia occurring in an older adult—that often conflict with typical signs and symptoms in diagnosis for a younger adult (31). Many authors contend that frailty is the element of declining functional reserve that undergirds agerelated disease and geriatric syndromes (11, 14, 15, 27). Others argue that frailty itself is a clinically identifiable geriatric syndrome (10, 23). As biologic evidence accrues, the import of relationships between and among frailty, age-related disease, and geriatric syndromes for clinical medicine is clear. These interconnections require parallel investigation of prevention, treatment, and outcomes in the context of medical, surgical, and rehabilitative treatment (22, 24, 32, 33, 34).
may have a more complicated presentation and less predictable recovery (30). Both presentation—which is often atypical—and recovery may risk excess disability and poor outcomes (11, 27, 31). Atypical presentation describes unexpected signs of illness—such as delirium instead of fever as the presenting sign of pneumonia occurring in an older adult—that often conflict with typical signs and symptoms in diagnosis for a younger adult (31). Many authors contend that frailty is the element of declining functional reserve that undergirds agerelated disease and geriatric syndromes (11, 14, 15, 27). Others argue that frailty itself is a clinically identifiable geriatric syndrome (10, 23). As biologic evidence accrues, the import of relationships between and among frailty, age-related disease, and geriatric syndromes for clinical medicine is clear. These interconnections require parallel investigation of prevention, treatment, and outcomes in the context of medical, surgical, and rehabilitative treatment (22, 24, 32, 33, 34).
CLINICAL CARE OF OLDER ADULTS
Geriatric competence optimizes care of older adults across specialties and settings (5, 29, 31, 35
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