Chronic Illness, Multimorbidity, and Rehabilitation
Goal-concordant chronic care
Guideline-based targets derived from younger populations may not apply when a patient has limited life expectancy, frailty, or competing risks. Apply the concept of time to benefit: a preventive therapy should offer benefit within the patient's remaining lifespan. A 90-year-old with dementia is unlikely to benefit from tight glycemic control or a bisphosphonate, while an 70-year-old with good function may. Consider whether a medication treats a number or a symptom.
Common targets
Glycemic goals are relaxed for frail elders with hypoglycemia risk - avoid sulfonylureas and sliding-scale insulin, and accept A1c values around 8% or higher in those with limited life expectancy. Blood pressure control still reduces stroke and heart failure, but orthostatic hypotension and falls limit intensity in frail patients. Heart failure management favors diuretics for symptom relief, and goals of care guide device decisions such as ICDs. COPD care emphasizes inhaler technique and avoiding over-sedation.
Rehabilitation
Rehabilitation is a core geriatric intervention: after hip fracture, stroke, cardiac events, and deconditioning. Early mobilization reduces complications. Physical therapy targets strength, balance, and gait; occupational therapy addresses ADLs and home safety; speech therapy addresses swallowing and communication. Sarcopenia and frailty are modifiable with resistance exercise and adequate protein. Prehabilitation before elective surgery improves outcomes. Recognize post-acute care settings - inpatient rehab versus skilled nursing facility versus home health - based on tolerance for therapy, not diagnosis alone.
Traps
Overtreating a dying patient because a metric is abnormal; under-treating pain or depression in the name of "comfort" when a symptom is treatable; assuming a patient cannot improve because of age.
Rule of thumb
Ask "What is this patient's goal, and will this intervention help them reach it within their expected lifetime?"