Abstract
The Oxford Case Histories series seeks to provide case-based teaching for clinicians in specialist training. The Geriatric Medicine edition includes 48 well-written clinical cases of older adults presenting with medical issues that range from “bread-and-butter” geriatric medicine topics like incontinence to more uncommon conditions like multiple system atrophy. Initial case presentations often include extensive history, laboratory, and radiologic findings. Cases conclude with series of questions for the reader to consider. The discussion of cases that follows is nuanced and often accompanied by images, graphs, and tables. Some cases unfold over several pages, and all attempt to condense considerable information into each paragraph.
Of note, the series is largely directed at clinicians studying or practicing geriatric medicine in the United Kingdom’s National Health Service (NHS). Case scenarios often reference health care settings and systems of care that are specific to the NHS and the patients that a practicing geriatrician may see there. This results in a focus on management of acute symptoms rather than chronic disease management. These scenarios may be less applicable to clinicians practicing in a different health system or caring for patients in a different setting such as outpatient primary care or long-term care. Similarly, units of measurement that are commonplace in the United Kingdom such as creatinine measured in micromol/L may be confusing to clinicians accustomed to seeing this information presented in mg/dl.
Some cases are particularly strong. For example, Case 1 discusses delirium. A nuanced initial case presentation is followed by text and tables that review the basics of delirium including DSM IV criteria, typical patterns of cognitive changes, differential diagnosis, and screening tools. The discussion then moves on to review detailed evidence about delirium risk factors, multi-component interventions, and prognosis. Other strong cases include Case 14 about pressure ulcers (which includes helpful color photos), Case 33 about motor neuron disease (which describes three different ways this uncommon disease may present), and Case 42 about atrial fibrillation (which includes a detailed discussion of anticoagulation and stroke risk).
Importantly, many cases include important discussions of the ethical, psychological, and social aspects of clinical care that are at the core of good geriatric medicine. Entire cases are dedicated to these topics: Case 3 presents a practical and comprehensive approach to elder abuse, and Case 13 is a nuanced and in-depth discussion of capacity assessment and cardiopulmonary resuscitation decisions. Even when these elements are not the sole focus of the case presentation, they are woven into the case discussions in a way that provide practical guidance for clinicians. For example, Case 41 not only discusses pain management but also reviews prognosis and patient goals as the end of life approaches. Case 5 considers malnutrition and explicitly reviews the social, financial, and functional issues that may contribute to this condition.
However, other case presentations are not as effective and sometimes seem to focus more on general medicine rather than specifically geriatric topics. For example, Case 17 presents a woman with diffuse systemic sclerosis, which the authors acknowledge is extremely rare and has a peak incidence in those aged 30 to 50 years. Some cases, such as Case 9 about drug-induced systemic lupus erythematous, present clinical scenarios that can certainly occur in older adults but are by no means core geriatric topics. Other cases such as Case 38 about pyoderma gangrenosum quickly narrow to focus on relatively uncommon clinical conditions without adequately discussing related conditions (in this case, arterial and venous ulcers) that are much more common.
In general, there is significant variability among cases. Some have a broad focus, and others quickly narrow in on a single condition. Some utilize helpful graphs and tables and others do not. Some take advantage of the unfolding cases to delve deeply into complex topics and others provide a more straightforward description of clinical conditions. Some review standard medical practice more generally, and others describe the evidence for and against particular treatment modalities. Of note, the sources for clinical information presented are not cited in the text of the case. Although these sources are likely included in the “Further Reading” section at the end of each case, it would be helpful to know specifically what evidence the authors are citing.
The case-based format is an ideal way to present and discuss complex geriatric cases. In geriatrics, multi-morbidity and nuanced clinical decision making are the norm. Oxford Case Histories in Geriatric Medicine takes advantage of this format to provide detailed discussions about a wide variety topics, some of which are likely more relevant to geriatricians than others. This book is likely best suited for trainees who are either practicing in or familiar with the NHS system. For those studying in other environments, other case-based geriatrics texts may be more practical and directly relevant to their practice.