This chapter addresses the major cardiovascular conditions faced by clinicians caring for older adults: ischemic heart disease, heart failure, valvular disease, arrhythmias and conduction system disorders, and pericardial diseases. After a brief review of the global burden of heart disease and the effects of aging on the cardiovascular system, each subsequent section of the chapter provides a consistent approach to the description of these disease processes. Beginning with a summary of the epidemiology and clinical presentations relevant to older adults, pharmacologic and procedural recommendations are then presented based on clinical trial data and practice guidelines specific to this patient population. Each section also highlights the importance of individualized care for patients with advanced age or substantial medical comorbidities, including commentary about prognosis and palliative care, when appropriate. With clinically relevant treatment recommendations, comprehensive trial review and data tables, and several illustrative figures, this chapter provides evidence-based guidance to assist with the daily clinical care of our aging population with cardiovascular diseases.

By understanding health-care financing and organization, health-care professionals can provide more effective care and achieve financial success. This chapter covers basic insurance principles and key business operations concepts. There is a focus on Medicare (including Medicare Advantage) and Medicaid. Hospital and professional payment methods are explained. Steps that may help reduce health-care costs, such as better chronic care management, are presented. Whether the United States truly has a health-care system, the social spending crowd-out of health-care spending, and a brief international perspective are presented.

Physical activity is fundamental for achieving healthy aging. Exercise offers older adults substantial benefits, such as reducing risks of all-cause mortality and chronic disease, preserving functional capacity, improving management of chronic conditions, and reducing health-care costs. Given the prevalence of physical inactivity and sedentary behavior among adults 65 and over, exercise needs to be more thoroughly integrated into care plans and counseling in primary care settings. A practical, three-step approach to exercise counseling is recommended. Older adults should strive to do at least 150 minutes of moderate-intensity aerobic exercise weekly, muscle-strengthening and flexibility activities twice weekly, and for those at risk of falls or with mobility problems, balance activities at least three times per week. Older adults with functional restrictions or chronic conditions should be as physically active as their abilities and conditions allow. Any amount of moderate-to-vigorous physical activity gains some health benefits. Appropriate physical activity counseling, prescription, and referral must be tailored for each patient and must take into account such factors as fitness levels, goals and motivations, access to exercise-related facilities and programs, chronic diseases, prescribed medications, common injuries, and hip and knee arthroplasties.

Diabetes mellitus (DM) is a dominant chronic disease in the older adult population in the United States as well as in many other countries of the world. The prevalence of DM in the future is only expected to grow with the increase in the population of adults aged 65 and over, the prevalence of obesity, and physical inactivity. Clinicians are faced with many unique challenges when caring for this older diabetic population. The clinician’s major challenges are (1) to avoid symptoms and complications of hyper- and hypoglycemia, (2) to minimize or delay micro- and macrovascular complications, if possible, and (3) to maximize daily functioning. Underlying these challenges is the realization that the geriatric population is a heterogeneous one. Goals of care and treatment decisions may vary, depending more on the patient’s functional abilities and on other comorbidities or coexisting geriatric syndromes, and less on the age of the patient. This chapter will focus on specific aspects of diabetes care in the older adult.

This chapter gives an overview of the pathophysiology, prevalence, risk factors, and symptoms of peripheral artery disease (PAD). The subsequent screening, diagnosis, and management of PAD are further elucidated. The chapter specifically emphasizes the prevalence of PAD in the elderly and the impact of disease. PAD results from the obstruction of peripheral arteries, leading to a reduction in blood flow to the extremities. PAD may be asymptomatic or lead to a variety of symptoms including claudication, chronic skin discoloration, hair loss, non-healing ulcers, and infections. PAD prevalence increases with increasing age, thus elderly patients should be routinely evaluated for symptoms of extremity pain and non-healing wounds. An ankle-brachial index (ABI) of less than 0.9 is diagnostic for PAD. Treatments for PAD may include the management of medical comorbidities, exercise, smoking cessation, medications such as antiplatelets and vasodilators, and surgical interventions. Early intervention can prevent limb ischemia and ultimately limb loss.

As the aging population continues to grow, the issue of caregiving has increasingly moved into the public spotlight. Caregiving is defined as “assistance provided to individuals who are in need of support because of a disability, mental illness, chronic condition, terminal illness or who are frail.” More recently, the COVID-19 pandemic has added an additional spotlight on the issue of how we are caring for older patients in the midst of societal shutdowns, increasing social isolation, and economic impacts that affect patient and caregiver alike. This chapter focuses on the informal caregivers who care for chronically ill older adults. It also broadens the toolset of the primary care provider to include a more systematic approach when assessing the degree of caregiver burden. Recognizing caregiver needs and burden can then inform the primary care provider to counsel caregivers about common stresses, suggest practical interventions, and provide additional resources.

Older adults are disproportionately affected by many chronic lung diseases. Numerous normal physiologic changes occur in the lungs with age, from reduced parenchymal elastic recoil to thoracic cage distortion. These changes impact pulmonary pathophysiology and disease diagnosis. Clinicians should be cognizant of geriatric issues that can impact diagnosis, treatment, and the occurrence of adverse events secondary to treatment. For example, multimorbidity, the co-occurrence of multiple comorbidities, is more common with increasing age. Additionally, people with chronic lung diseases have a higher burden of geriatric syndromes, such as frailty, functional impairment, falls, and social isolation. Older adults are at increased risk of severe morbidity from acute lung conditions such as pneumonia and pulmonary embolism. Treatment of older patients in the intensive care unit requires special attention to geriatric issues (called “age-friendly care”) that will improve the quality of their care. This chapter reviews the natural history of pulmonary system aging, discusses the most commonly encountered chronic lung diseases with aging, and briefly examines special issues with caring for older adults in a critical care setting.

Retirement is personal and complex. A number of theoretical approaches illuminate diverse retirement experiences. Providers may notice that their patients' retirements are less likely an abrupt or complete departure from employment and more likely a fluid process, typified by bridge job transitions, phased retirement, or labor market reentry. In an effort to fully appreciate the scope and association of retirement with physical, cognitive, and emotional health and social well-being, providers may consider engaging in conversations with patients about their: vocations and avocations; familial and sociocultural norms and expectations around work and retirement; and other contextual factors such as caregiving, social support networks, and access to technology and resources.

Sleep disorders are very prevalent in late life, though they are often unrecognized, underdiagnosed, and poorly treated. Epidemiological evidence suggests that over 50% of elderly people suffer from one of several different sleep disorders, with the most common sleep disorders being insomnia and sleep apnea. Both insomnia and sleep apnea carry many serious negative physical, mental, and social consequences. Epidemiology, diagnosis, and treatment management for both insomnia and sleep apnea in older adults are reviewed. Diagnosis of insomnia in older adults is based on self-report, while sleep apnea diagnosis requires a sleep study. Treatment of insomnia in late life is guided by behavioral and cognitive principles, with the gold-standard treatment approach being cognitive-behavioral therapy or CBT. Positive airway pressure (PAP) therapy is the recommended treatment approach for sleep apnea. Contextual factors that complicate the diagnosis and management of insomnia and sleep apnea in late life are reviewed with the aim of providing practical information for the medical professional working with older patients.

Comprehensive geriatric assessment is a holistic approach to care involving multifaceted patient-centered evaluation and management. Often involving interprofessional teams, it can be adapted to different care settings according to available resources and prioritized goals.

When age-related physical impairments affect a person’s performance of functional tasks, rehabilitation may restore function and improve an elder’s independence and participation in society. Included is a review of how to perform a functional assessment, a description of the members of a rehabilitation team, and an introduction to the various settings where an elder can receive rehabilitation. The chapter describes geriatric assistive devices that improve self-care and mobility and reviews specific rehabilitation interventions for common debilitating conditions such as stroke, Parkinson’s disease, hip fracture, and lower-extremity amputation.

Palliative care, an approach to care that improves the quality of life of patients and families, has rapidly become the standard of care for patients with serious illness in recent decades. A large body of quality evidence supports interprofessional palliative care delivery as a means to improve symptom control, mood, and communication and result in less aggressive treatment at the end of life. One large component of this palliative care is skilled, structured communications; meeting with patient, family, and other medical specialists involved with complex patient care. Additionally, focus on pain and symptom control requires a nuanced approach, especially in the older adult at higher risk of drug-related adverse events. Increasingly important to understand is the complexity in use and prescription of opioids. They have both intended and unintended consequences of use; both effective pain control in serious illness and diversion or misuse. Pain, nausea, vomiting, dyspnea, and delirium increase in prevalence as patients burden of illness increases. Pharmacotherapy and non-medication-based interventions are both often effective as patients approach the end of life. Hospice remains the gold standard of care for dying patients, but because many people still die in hospital settings, it is critical that clinicians are knowledgeable in providing end-of-life care.

The aging experience of individuals with intellectual disability (ID), severe and persistent mental illness (SPMI), and autism spectrum disorder (ASD) is often different from the neurotypical adult. The issue has become more important to address as the number and medical complexity of older adults with ID, SPMI, and ASD continues to increase. In this chapter we review the epidemiology, key medical comorbidities, therapeutic and community resources, and treatment strategies for individuals with ID, autism, and SPMI. The importance of patient-centered care and the interprofessional team will be emphasized.

Transformation of our health-care systems is required to better meet the complex needs of our aging population as we confront the rise of health-care costs around the world. Older adults with multiple chronic health conditions can receive care that is fragmented, incomplete, inefficient, and ineffective. Care delivery and coordination of the complicated needs of older adults resides primarily in outpatient practice, both sub-specialty and primary care. However, the overall coordination is dependent on primary care practices, which through transformation into highly effective interprofessional teams can be designed and equipped to guide comprehensive care for all patients. The term “practice transformation” refers to a process of change in the organization and delivery of care to advance quality improvement and patient-centered care. Practice transformation is a continuous process that involves leadership, goal-setting, workflow changes, quality improvement, and reporting of outcomes. It requires adapting organizational tools and processes to support advances in models of team-based care.

As Medicare has focused more on hospital readmissions and care transitions over time, programs and movements aimed at providing geriatric-focused care have developed nationally. These programs aim to minimize and prevent hazards of hospitalization, decrease readmissions, provide safer transitions to the post-acute setting, and decrease length of stay while acknowledging and addressing specific care considerations of hospitalized older adults, such as dementia, sensory impairment, and mobility impairment. Inpatient geriatric assessments help providers tailor care plans to the specific needs of individual hospitalized older adults and determine their post-acute care needs, and also help with appropriate counseling of family and caregivers. Prevention measures are vital during hospitalization of older adults, who are at higher risk of delirium, pressure injury, falls, aspiration, malnutrition, sleep disturbances, and venous thromboembolism. Detailed transition plans and specialized discharge summaries are important to highlight the needs of older adults as they transition to post-acute care settings, and should allow for providers to resume the care plan seamlessly, including continuation of advanced care planning conversations.

Dysfunction of the endocrine glands can occur at any point in the life cycle. Although many endocrine diseases will present with classic signs and symptoms, atypical presentation of hormonal dysregulation can make diagnosis in the elderly particularly challenging. Normal physiologic changes associated with aging, as well as medical comorbidities and medications, may all cloud the identification of endocrine dysfunction in this complicated population. As such, the diagnosis of endocrinopathies in the elderly population requires a careful medical history, detailed physical exam, rational biochemical workup, and, if necessary, directed imaging. The management of endocrine disorders can be equally complex. Many endocrine disorders are treated with medications that may complicate an already-lengthy list, causing unwanted side effects or even drug–drug interactions. If therapy includes possible surgical referral, careful assessment of the risk–benefit ratio and candidacy of the elderly patient is imperative. Endocrine guidelines have been designed to assist the clinician with accurate diagnosis and therapeutic decision-making; however, guidelines cannot supplant the need for patient-centered care in this vulnerable population in whom disorders of the endocrine glands fail to adhere to “textbook” scenarios.

Our knowledge of dementia stigma is still fairly limited, especially in comparison to stigma relating to mental illnesses. This chapter surveys existing scholarship and explores the historical roots of the concept of stigma and of the way different conceptions (biomedical, biopsychosocial, sociocultural and relational) of dementia generate and/or address stigma. It further identifies language, media and sociocultural structures as mechanisms that perpetuate public dementia stigma, before it turns to a number of domains in which dementia stigma can be addressed. In the domain of literature, destigmatizing efforts have attempted to generate empathy, an appreciation of complexity and insight into the condition of people living with dementia. Apart from contact-based and educational interventions, the chapter asserts that it is especially the development of 'counter-frames' that has the potential to unsettle negative perceptions of dementia. The chapter concludes by recognizing a number of methodological, conceptual and strategic challenges that complicate our evaluation of such strategies, or indeed our understanding of the complex phenomenon of dementia stigma itself.