**Meet the editor**

Edward T. Zawada Jr., MD, was born in Chicago, Illinois, in 1947. He graduated with a Bachelor of Science degree *summa cum laude* from Loyola University Chicago in 1969 and an MD degree *summa cum laude* from the Loyola Stritch School of Medicine in 1973. He was inducted into *Alpha Omega Alpha* in 1972. He trained in internal medicine and nephrology in David Geffen

School of Medicine at UCLA where he later served as an assistant professor of medicine. He had a long career in academic medicine at the University of Utah, Medical College of Virginia, and Sanford School of Medicine of the University of South Dakota where he is a professor and chairman emeritus of the Department of Internal Medicine. He is board certified by the American Board of Internal Medicine in internal medicine, nephrology, geriatrics, and critical care medicine. He also has board certifications in nutrition by the American College of Nutrition, pharmacology by the American Society of Clinical Pharmacology, and hypertension by the American Society of Hypertension. He has been awarded with a fellowship status by the American College of Physicians, the American College of Chest Physicians, the American Heart Association, the American Society of Nephrology, the American Geriatrics Society, the American College of Clinical Pharmacology, the Society for Vascular Medicine, and the Society of Critical Care Medicine. He was awarded a distinguished service award by the South Dakota Medical Society in 2002 for a career devoted to medical education and master of the American College of Physicians in 2005.

### Contents

**Preface XI**


Tolentino, Ana V. Castellanos Mendez, Alaa-Eldin A. Mira, Ric A. Baxter and Stanislaw P. Stawicki


## Preface

This collection is an update on caring for geriatric patients, often defined as those over 65 years of age, which has seen an increased demand for expertise since the first baby boomers reached this milestone approximately 5 years ago. Patients over 80 years old (oldest old) are the most rapidly growing segment of our society, which is likely to continue for another 18 years as the boomers continue to advance through their 70s into their 80s.

The first chapter recalls some of the newer and very severe diseases and health problems facing them today. The second chapter reviews the concept of frailty. A famous quote of Thomas Hobbes reminds us that we will all reach a point in our lives in which we experience the fact that "Life is nasty, brutish, and short" as we become weaker, lose mobility, have impaired vision and hearing, develop chronic pain, and lose mental acuity. Elder care differs from other segments of the population due to altered pathophysiology due to aging. Homeostasis becomes homeostenosis. Diagnosis and treatment of the elderly take longer, require multidisciplinary expertise, and must integrate the known longitudinal features of diseases with the altered pathophysiology. The tool of geriatric assessment to accomplish this is described in an additional chapter. Prescription of medications for health problems in the elderly requires consideration of altered dosing schedules and care to avoid drug-drug interactions with those medications prescribed by other healthcare providers. This topic is covered in the chapter on polypharmacy. In caring for the elderly, our first choice should be medication reduction or "MED RED." If we do start new medications, we should "start low and go slow." We must adjust the dose for reduced renal and hepatic function. Elders are often not cured of their diseases, just managed to the point of restoring functional status. They have chronic illnesses and even chronic critical illnesses but live on. The rise of the long-term acute care hospital has occurred to combine management of serious illness with a rehabilitation process to return the patient as much as possible to independent activities of daily living. A chapter in this work deals with this novel care pathway. Finally, in today's world, patients can be kept alive for prolonged periods of time by heroic life support measures. A final chapter deals with an update on the ethics of caring for the elderly in the intensive care unit (ICU) with the most dangerous illnesses or combinations of failed organ systems called multisystem organ fail‐ ure.

In conclusion, this work is an update on newer and serious clinical problems facing our expanding elderly population. Newer tools, newer locations, and newer ethics are reviewed concerning the care of the frail elderly who face the most dangerous medical problems, which most often cannot be cured. Thought must be given in their diagnosis as to how much they can tolerate the diagnostic tests, whether adding a new medication or reducing an old one is a solution to some problems, and how we avoid prolonged heroic efforts, which might be futile yet prolong suffering.

**Edward T. Zawada Jr. M.D., M.A.C.P,**

Professor and Chairman Emeritus Department of Internal Medicine, Sanford School of Medicine, University of South Dakota, United States of America
