What Is A Geriatric Syndrome Anyway?

To the Editor: The term “geriatric syndrome” is a commonly used but ill-defined concept among internists and geriatricians alike. Many conditions have been called “geriatric syndromes” including delirium,1 dementia,1 depression,2 dizziness,3 emesis,4 falls,1 gait disorders,1 hearing loss,1 insomnia,1 urinary incontinence,1 language disorders,1 functional dependence,5 lower extremity problems,6 oral and dental problems,6 malnutrition,1 osteoporosis,1 pain,1 pressure ulcers,1 silent angina pectoris,7 sexual dysfunction,6 syncope,6 and vision loss.1 This leaves the impression that any commonly encountered condition in older persons is a geriatric syndrome. Can this be possible? What specifically is a geriatric syndrome anyway? The word syndrome was apparently first used in an English translation of Galen about 1541.8 Derived from the Greek roots “syn” (meaning “together”) and “dromos” (meaning “a running”), this term generally refers to “a concurrence or running together of constant patterns of abnormal signs or symptoms.”8 The term syndrome “has as its philosophic basis not specific disease factors, but a chain of physiologic processes, the interruption of which at any point produces the same ultimate impairment of body function.”9 Cushing's Syndrome is an example of a traditional medical syndrome wherein disruption of a single physiological process (excessive cortisol secretion) results in multiple common phenomenologies (Moon facies, truncal obesity, proximal muscle weakness, etc.; see Figure 1). This implies that, by identifying and correcting a single disruption in the normal chain of physiological events (by removing an adrenocorticotrophic hormone–secreting tumor, for example), one can treat the entire syndrome. Comparison between traditional medical syndromes and geriatric syndromes. One early definition of “geriatric syndromes” is conditions “experienced by older—particularly frail—persons, that occur intermittently rather than either continuously or as single episodes, may be triggered by acute insults, and often are linked to subsequent functional decline.”10 More recently, geriatric syndromes have been viewed as conditions in which “symptoms … are assumed to result not solely from discrete diseases but also from accumulated impairments in multiple systems”3 and develop when the accumulated effect of these impairments in multiple domains compromise compensatory ability.5 Both definitions are a significant departure from the traditional use of syndrome because the outcome is a single phenomenology rather than a spectrum of symptoms and signs and results from numerous rather than a single disruption. In geriatric syndromes, it is multiple abnormalities that “run together” to cause a single phenomenology. For example, in delirium, the cumulative effects of multiple contributors (impaired cognition, severe illness, old age, etc.) result in the delirium phenomenology. Unfortunately, the discrepancy between traditional and geriatric medical usages of syndrome has lead some to conclude that a geriatric syndrome is “a usual concomitant of aging; that there may be no specific disease to identify, but instead undefinable erosions of mood or function.”11 This leads to the unfortunate sense of a frustrating condition with no clear approach and no likelihood of improvement. One resolution of this problem would be to create new terminology. It is clear that conditions associated with characteristics in multiple domains (cardiovascular, neurological, sensory, psychological, and medication related) do not fit the traditional definition of a syndrome.12 Because multiple factors precipitate many health problems of older persons, the Greek root koinoneo (meaning to do in common with, share, take part in a thing with another) seems appropriate. Thus, the term “geriatric synkoinon” could replace geriatric syndrome. Although more accurate, introducing new language is fraught with difficulty, because physicians are unlikely to change their terminology easily. Another approach would be to create a greater appreciation of the specific meaning of syndrome when applied in a geriatric medicine context. This requires precision of thought and persistence by teachers and practitioners of geriatric medicine. Specifically, I would propose that conditions are geriatric syndromes if they are multifactorial, occur primarily in older persons, and result from an interaction between identifiable patient-specific impairments and identifiable situation-specific stressors, and interventions directed toward ameliorating the contributing factors result in a reduction in the incidence or severity of the condition in question. Delirium, falls, and incontinence could be accepted as geriatric syndromes by this definition. Other condition might qualify as the result of more research. The notion that such geriatric conditions arise from “undefinable erosions of mood or function” is increasingly untenable, but it is the job of practitioners and researchers in the care of older persons to demonstrate to the rest of the medical community why this is so.