Geriatrics 101: How are older patients different from all other patients and why does it matter

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Geriatrics 101How are older patients different
from all other patients and why does it matter?

• Elizabeth Clark, MD, FACP
• Associate Director/Clinical, VISN 3 GRECC
• Bronx VA Medical Center
• Associate Professor of Geriatrics
• Mount Sinai School of Medicine

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Learning Objectives

• Understand some of the unique issues and
  challenges that face older people and the
  healthcare professionals who care for them
• Understand the demographic imperative for all
  health care professionals to learn basic
  principles of geriatrics
• Understand how the presence of one or more
  geriatric syndrome can have a profound effect on
  an older persons ability to meet a new medical
  challenge and maintain function and independence,
  even where there is no prior history of
  disability or functional decline
• Understand how different members of the
  interdisciplinary team work collaboratively to
  address geriatric syndromes and issues and so
  improve the health and independent function of
  older patients

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The Challenges of Aging How older patients are
different from all other patients

• As people age, some physiologic changes are
  inevitable
• Other changes, while not universal, are far more
  common than among younger people
• Older people also face unique psycho-social
  challenges
• These changes and challenges can lead to a
  variety of geriatric syndromes and issues
• These in turn can lead to poor health outcomes,
  functional decline, frailty, disability and
  dependence

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Physiologic Changes Associated with Aging

• Examples of universal changes
• Decreased night vision
• Decreased muscle mass
• Loss of hair pigment
• Decreased lung vital capacity
• Decreased height
• Decreased gait speed

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Physiologic Changes Associated with Aging

• Examples of changes (including diseases) that are
  increasingly common, though not inevitable, as
  people age
• Hearing loss
• Macular degeneration
• Hypertension
• Heart disease
• Cancer
• Parkinsons disease
• Dementia

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Social Problems More Common with Aging

• Loss of income
• Loss of close family
• Loss of community
• Social isolation

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Geriatric Syndromes

• Sensory Impairment (Visual and Hearing)
• Gait Impairment
• Falls
• Incontinence
• Dementia
• Depression
• Delirium
• Polypharmacy
• Sleep Problems
• Pressure Ulcers

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Functional Reserve

• Most of the bodys organ systems have some degree
  of redundancy for instance, there are more
  kidney cells than absolutely needed so that
  kidney function can continue even if cells are
  lost to disease or other insult
• As people age, functional reserve diminishes so
  that an acute insult can have much more severe
  consequences, whether it is in kidney function or
  cognitive function or even social function

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Functional Reserve
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The Challenges of an Aging Population Why it
matters

• In the 2000 US Census, 12.5 of the US population
  was gt64
• By 2030, it is predicted that 20 of the US
  population will be gt64
• As the elderly population increases the care
  needs and expenditures for that care will
  increase
• The geriatric workforce is not predicted to
  increase to meet this demand

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The Challenges of an Aging Population
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2000 U.S. Census DataNumber of persons ( of
population)
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VISN 3 Primary Care Patients Age Distribution
of Unique SSNs seen in FY2007
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VISN 3 Primary Care Patients Age Distribution of
Unique SSNs seen in FY2007
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VISN 3 FY2007 Med./Surg. Discharges
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VISN 3 FY2007 Med./Surg. Discharges
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Geriatric Interdisciplinary Team

• Medicine
• Nursing
• Social Work
• Psychiatry
• Psychology
• Case Management

• Physical Therapy
• Occupational Therapy
• Speech Pathology
• Pharmacology
• Chaplaincy
• Recreation Therapy

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Case Discussion

• We will look at the case of a highly functional
  and independent senior citizen who has recently
  been diagnosed with diabetes
• We will discuss 3 geriatric syndromes (visual
  impairment, falls and dementia) and see how these
  could have a deleterious effect on her ability to
  manage this new diagnosis, maintain her ADLs and
  IADLs and ultimately to remain in the community.
• We will also discuss how different members of
  the interdisciplinary team can contribute to her
  care

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The Case of Jenny Smith

• Jenny Smith is an 83 year old woman with
  hypertension and osteoporosis for which she is on
  appropriate medication and follows a diet and
  exercise program. Her doctor recently diagnosed
  her with diabetes.
• She was initially treated with oral agents but
  now has started taking insulin
• Jenny retired from her job as a high school
  English teacher 15 years ago but keeps herself
  busy with volunteer work as a tutor, church
  activities and exercise classes at the Y.
• Jenny was widowed 5 years ago. She has 2 grown
  daughters one lives near her on the Upper West
  Side, the other lives in California but calls
  frequently.

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Sensory Impairment - Vision
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Sensory Impairment - Vision

• How could the development of macular degeneration
  or cataracts interfere with Jennys ability to
  monitor and treat her diabetes?
• What other aspects of Jennys life could be
  affected by visual loss?
• What are some of the barriers to diagnosis and
  treatment of visual loss in the elderly?
• In addition to the ophthalmologist who examines
  Jennys eyes, how can the different members of
  the interdisciplinary team help Jenny to learn to
  cope with her visual impairment so that it does
  not lead to additional functional decline?

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Sensory Impairment - Vision

• Visual impairment affects 20-30 of people over
  the age of 75.
• Visual impairments that occur with greater
  frequency as people age include
• Refractive error
• Cataracts
• Glaucoma
• Macular degeneration
• Diabetic retinopathy
• Blindness

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Cataracts
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Glaucoma
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Macular Degeneration
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Diabetic Retinopthy
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Low Vision Aids
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Low Vision Aids
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Gait Abnormalities and Falls
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Gait Abnormalities and Falls

• How could a fall interfere with Jennys ability
  to monitor and treat her diabetes?
• What other aspects of Jennys life could be
  affected by gait disturbance or a fall?
• What are some of the barriers to diagnosis and
  treatment of gait abnormalities and falls risk
  in the elderly?
• What roles can the different members of the
  interdisciplinary team play help Jenny to address
  her recent fall so that it does not lead to
  additional functional decline?

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Gait Abnormalities and Falls

• Gait disorders are common in the elderly
• At least 20 of community dwelling seniors
  report gait problems requiring assistance
• In one study, gt50 of those 85 and older reported
  difficulty walking
• The presence of a gait disorder often heralds
  functional decline
• The etiology of gait disorders is usually
  multifactorial

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Gait Abnormalities and Falls

• Falls
• 30-40 of community dwelling seniors fall each
  year
• Falls often result in decreased independence
• Decreased functional status
• Increased rate of NH placement
• Increased use of medical services
• Increased fear of falling
• Falls result in injury and death
• Most result in soft tissue injury, 10-15 in
  fracture
• Complications from falls are the leading cause of
  death from injury among those gt65
• Death rate from falls increases with age
• Lifetime cost of falls related injuries for those
  gt65 has been estimated at 12.6 billion
• Etiology of falls multifactorial
• Includes medical, environmental, sensory and
  postural issues

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Gait Abnormalities and Falls
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Gait Abnormalities and Falls
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Gait Abnormalities and Falls
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Gait Abnormalities and Falls
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Gait Abnormalities and Falls
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Dementia
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Dementia

• How could the development of dementia interfere
  with Jennys ability to monitor and treat her
  diabetes?
• What other aspects of Jennys life could be
  affected by dementia?
• What are some of the barriers to diagnosis and
  treatment of dementia in the elderly?
• How can the different members of the
  interdisciplinary team help Jenny and her family
  in addressing her dementia and maintaining
  independence and function for as long as
  possible?
• What are some of the key issues that need to be
  addressed as she faces this progressively
  debilitating and life limiting illness?
• If Jenny does not have dementia, what could she
  do to try to prevent it?

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Dementia will reach epidemic proportions by 2040

• Alzheimer's Disease accounts for the vast
  majority of dementias in the US
• Among people gt65, the prevalence of AD is 6-8
• Among people gt85, the prevalence is 30
• 4 million people in the US currently suffer from
  AD
• By 2040, AD patients will number 14 million

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Alzheimers Disease
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Costs of Dementia

• Decreased quality of life for patient and family
• Loss of independence in ADLs and IADLs
• Need for supervision, outside caregivers
• Financial burdens on family and society
• Lost wages and direct costs for caregivers
• 100 billion spent annually in US on care
• Difficulties obtaining appropriate medical care
• Inability to give accurate history
• Inability to understand and follow directions and
  medical regimens

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A A A, O x 3 is not very helpful

• Dementia, in its early stages, is often missed by
  medical professionals and families
• Up to 50 of moderate dementias are missed by
  physicians
• Patients can remain oriented to person, place and
  time long after they have developed serious
  impairments in other areas of cognitive function

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Screening for dementia can avert many future
problems in diagnosis treatment and management

• Have a high index of suspicion
• Forgetfulness, getting lost, inability to follow
  medical regimen, poor personal hygiene
• Use validated screening tools
• MMSE, animal naming test, clock drawing test
• Look for reversible causes of dementia
• B12 def, sensory def., depression, thyroid
  disease
• Obtain history from other sources

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Clock Drawing Test
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Dementia Prevention
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Dementia Prevention
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Dementia Prevention
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Dementia Prevention
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Conclusion

• Aging presents a unique set of challenges both to
  individuals and to the health care professionals
  who care for them.
• The range in presentation is tremendous there 90
  year olds who are still working and living
  independently in the community while there are 70
  year olds who require institutional care.
• Early signs of serious problems are easy to miss
  on routine examination
• Addressing geriatric issues and syndromes can
  help the elderly maintain function and
  independence
• Even patients without apparent deficits may have
  little functional reserve so that an acute
  illness or insult can lead to disability and
  dependence far more frequently than among younger
  individuals

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Conclusion, continued

• Older people comprise ever increasing portions of
  the general and patient populations and are the
  largest users of health care resources
• Geriatric care is best provided by an
  interdisciplinary team
• The pool of geriatric specialists in all
  disciplines is insufficient to meet current needs
  and is not expected to increase significantly
  despite increasing demands over the next quarter
  century
• All health care professionals, thus, need to
  learn the basic principles of geriatrics and
  acquire core clinical skills in the care of the
  older patient