Geriatric Syndromes

To the Editor: Happy families are all alike; every unhappy family is unhappy in its own way. I would like to express my appreciation of the erudition and scholarship of Inouye et al'. special article on geriatric syndromes in the May issue of the Journal of the American Geriatrics Society.1 I would like to respectfully suggest that they have not gone far enough. Not only are falls and delirium geriatric syndromes, failure to thrive and excess resource utilization are as well. When we first descend into medical school, one of the initial lessons is Ockham's razor; “Numquam ponenda est pluralitas sine necessitate” or “Do not multiply causes unnecessarily.”2 This idea has led to great success in understanding medical problems as diverse as pneumonia and cardiovascular disease. It has succeeded by emphasizing a single mechanism that can be identified and modified. Because the emphasis of the analysis is on finding a single cause, this epistemology has led to the flourishing of a powerful molecular approach, despite the great variability of the human response. It is even being used currently to try to explain the variability of response so intrinsic to the clinical reality as a concatenation of individual single-gene variables (responder analysis). Another factor contributing to the success of the system is its increasing balkanization. Cardiologists treat the heart and podiatrists the feet. However, the individual may be more than the sum of the parts. Our system is an acute care and intervention-driven system. At the same time we encounter Dr. Ockham, we are taught to ask “What brings you here today?” As we mature, we learn that our reimbursement depends on the intervention of the day rather than the outcome of tomorrow. The more we do in the short term, the nicer the car that we drive. Unfortunately, as Dr. Peter Drucker has pointed out, short-term and long-term goals are almost always in conflict (personal communication). As Dr. Kuhn points out in his overquoted and underunderstood Structure of Scientific Revolutions, paradigms form, because they serve as an explanation of the phenomenon noted and define the nature of further relevant research.3 They are also intrinsically ephemeral. As the paradigm continues, an increasing amount of relevant problems that cannot be understood within the reigning paradigm will accumulate. To paraphrase Dr. Durkheim, we can define the limits of the power of the current paradigm by looking at the problems that are resistant to solution within the current system.4 The incredible successes of our acute care system have created a swelling cadre of the frail and chronically ill. In fact, the majority of the frail and chronically ill are treated successfully within our system. Regrettably, those who are unsuccessfully treated consume an ever-increasing amount of resources—to their frustration and the frustration of those who care for them. Oftentimes, in a search to answer their problems, they travel from doctor to doctor, specialist to specialist, and emergency department to emergency department, with hospitalizations along the way, in a search for a balm in Gilead or nepenthe for their problems. Usually, the advice and the treatment are exemplary (albeit uncoordinated). But their problem is not solved. The root of their excess resource utilization is often not the severity of the illness itself but rather the breakdown of the biopsychosocial construct in which the illness occurs. The contributors are cognitive, social, behavioral, and financial and the failure of the system itself to provide care in a way that is appropriate to the patient at hand. The power of the concept of the geriatric syndrome is in abandoning Ockham's razor when appropriate. By abandoning the search for a single culprit, we can try to address the multiple factors. By leaving aside an intervention-driven model, we can try to design a multifactorial approach with multiple equal participants. To address a problem created by the success of a system, we have to go outside of the system's approach. In a way, while abandoning his razor, we have returned to the very essence of Ockham. Ockham was a radical nominalist and held that any generalization away from the particular was a convenient fiction. To treat the complicated patient, we may have to return to the individuality of the patient before us. Each one will present a unique combination of medical, financial, social, and psychological realities to be addressed within the systematic framework of care that the team has available. The successful treatment of any will require all to be addressed. The opinions and assertions contained herein are the private views of the author and are not to be construed as reflecting the views of the Ohio Permanente Medical Group or the Kaiser Foundation Health Plan. Conflict of Interest: William Schwab is a full-time employee of the Ohio Permanente Medical Group. He has no conflicts of interest. Author Contributions: William Schwab is the sole author of this letter and has full responsibility for the content. Although this letter expresses his original deas, he has discussed these ideas with numerous people over several years and gained from those discussions. Sponsor's Role: None. There are no sponsors.