Guest editorial: Caring for older adults, Part 2: The four Ds in geriatrics

In Part 1 of this two-part theme issue we discussed the value of comprehensive geriatric assessment and how this can be deployed to manage a number of common clinical presentations in older adults. In Part 2 we address four challenging syndromes known as the four Ds in geriatrics: dementia (classified in DSM-5 as major neurocognitive disorder), delirium, depression, and drug-related problems.

Each of the four Ds can exist as a stand-alone condition or can occur in combination.[1,2] The syndromes can present in the acute care or the community setting.[1,3-5] They can be associated with adverse outcomes in the short term or the long term.[6-8] They are poorly understood by the public and even among medical practitioners.[9,10]

One way to gain a better understanding of the four Ds involves a closer examination of the interactions that can occur at three levels: disease-disease, disease-drug, and drug-drug. These interactions are often nonlinear. In other words, the commonly used heuristic of Occam’s razor, which holds that a single unifying diagnosis can explain the complexity of a patient’s clinical presentation, may not apply when dealing with the four Ds.

Examples of disease-disease interactions are common: older people with major neurocognitive disorder are at increased risk of developing delirium during an acute medical illness,[2] and older people who develop delirium during hospitalization have a higher lifetime risk of major neurocognitive disorder.[2] 

Examples of disease-drug interactions are also common: older people with major neurocognitive disorder are at risk of developing drug-related adverse events,[11] medication use is a recognized precipitating factor in the development of delirium,[6] and a number of drugs are associated with an increased risk of depression.[12]

The number of potential and actual drug-drug interactions in older people is vast. In 2015, the American Geriatrics Society published the updated Beers criteria for potentially inappropriate medication use in older adults.[13] While the lists of drugs to be avoided may raise awareness of potential drug-related problems, the lists cannot be used to determine exactly what should be prescribed because of the substantial heterogeneity of older people, both in terms of their background health conditions and surrounding circumstances.

Older people who present with the four Ds require timely identification and appropriate management, as described in the articles that follow. Katalin Balogh and Roger Wong begin by offering 12 concise and evidence-informed tips for assessing and managing cognitive impairment and dementia in older adults. Next, Marisa Wan and Jocelyn Chase review the diagnosis, prognosis, prevention, and treatment of delirium in older adults. Paul Blackburn, Michael Wilkins-Ho, and Bonnie Wiese then consider the diagnostic challenges of late-life depression, and review the psychopharmacological and psychotherapeutic options at the primary care level. Finally, Leo Lai and Mark Fok address drug-related problems and describe how to safely and effectively reduce the number of medications used by older patients.

Management of the four Ds involves core competencies that can be taught and learned, and should be embedded in the training of physicians, both during and beyond medical school and residency.[14] We need to support physicians and all other health professionals so that they feel empowered and ready when working with older people.
—Roger Y. Wong, MD, FRCPC, FACP, FCAHS
Executive Associate Dean, Education 
Faculty of Medicine, University of British Columbia
Clinical Professor, Division of Geriatric Medicine
Department of Medicine, University of British Columbia

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This article has been peer reviewed.

References

1.    Brown TM, Boyle MF. Delirium. BMJ 2002;325:644-647.
2.    Fick DM, Agostini JV, Inouye SK. Delirium superimposed on dementia: A systematic review. J Am Geriatr Soc 2002;50:1723-1732.
3.    Villanyi D, Fok M, Wong RY. Medication reconciliation: Identifying medication discrepancies in acutely ill hospitalized older adults. Am J Geriatr Pharmacother 2011;9:339-344.
4.    Sztramko R, Chau V, Wong R. Adverse drug events and associated factors in heart failure therapy among the very elderly. Can Geriatr J 2011;14:79-92.
5.    Luber MP, Meyers BS, Williams-Russo PG, et al. Depression and service utilization in elderly primary care patients. Am J Geriatr Psychiatry 2001;9:169-176.
6.    Inouye SK. Delirium in older persons. N Engl J Med 2006;354:1157-1165.
7.    Levkoff SE, Evans DA, Liptzin B, et al. Delirium. The occurrence and persistence of symptoms among elderly hospitalized patients. Arch Intern Med 1992;152:334-340.
8.    Wong RY, Miller WC. Adverse outcomes following hospitalization in acutely ill older patients. BMC Geriatr 2008;8:10.
9.    Villanyi D, Wong RY. Self-reported understanding of diabetes and its treatment among elderly ambulatory subjects in British Columbia. Am J Geriatr Pharmacother 2007;5:18-30.
10.    Villars H, Oustric S, Andrieu S, et al. The primary care physician and Alzheimer’s disease: An international position paper. J Nutr Health Aging 2010;14:110-120.
11.    Laroche ML, Perault-Pochat MC, Ingrand I, et al. Adverse drug reactions in patients with Alzheimer’s disease and related dementia in France: A national multicen-tre cross-sectional study. Pharmaco-epidemiol Drug Saf 2013;22:952-960. 
12.    Chrischilles EA, Foley DJ, Wallace RB, et al. Use of medications by persons 65 and over: Data from the established populations for epidemiologic studies of the elderly. J Gerontol 1992;47:M137-M144. 
13.    Fick DM, Semla TP, Beizer J, et al. American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2015;63:2227-2246. 
14.    Madden KM, Wong RY. The health of geriatrics in Canada—more than meets the eye. Can Geriatr J 2013:16:1-2.