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The Librarian as Gerontologist Rosanne M Leipzig MD PhD Professor and Vice Chair Departments of Geriatrics and Medicine Mount Sinai School of Medicine.

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Presentation on theme: "The Librarian as Gerontologist Rosanne M Leipzig MD PhD Professor and Vice Chair Departments of Geriatrics and Medicine Mount Sinai School of Medicine."— Presentation transcript:

1 The Librarian as Gerontologist Rosanne M Leipzig MD PhD Professor and Vice Chair Departments of Geriatrics and Medicine Mount Sinai School of Medicine

2 Aging: The Numbers

3 There were 3 million Americans over age 65 in 1900 What’s the estimated number for 2030? A. 10 million B. 30 million C. 50 million D. 70 million ***

4

5 Medical Librarians Are Also Aging Medical Library Association. Hay Group/MLA 2005 salary survey [Web document] [cited 10/12/2007].

6 Projected Population Distribution

7 What percent of those 65+ are high school graduates? A. 10% B. 30% C. 50% D. 70% ***

8 Education level of older population

9 Percentage of all persons over 65 living in nursing homes? A. 5% B. 10% C. 15% D. 20% ***

10 Nursing Home Population By Age: 2000 %

11 Percentage of all persons over 65 living with their spouses? A. 20% B. 35% C. 50% D. 65% ***

12 Living Arrangements of Persons 65+

13 Social Activities

14 Leisure-time Physical Activity % engaged in REGULAR ACTIVITY CDC

15 Reporting Good to Excellent Health

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17 Disability in Aging: The Good News in the U.S. age 65-74: 89% report no disabilities age 85+: 40% report no disabilities In 1999, there were 1.4 million fewer disabled persons than there would have been if health status had not improved since 1982.

18 The Librarian As Gerontologist: What Do You Need To Know How does aging affect one’s health and well- being? What might physicians and other health care professionals be asking you about aging? What might the public be asking about aging?

19 AAMC/John A. Hartford Foundation Consensus Conference on Geriatric Competencies: July, 2007 Rationale: –Almost every graduate of every medical school will be providing care to older adults –Faculty who received little exposure and training in the care for the elderly are uncomfortable teaching geriatrics to students- don’t know where to start –Lists of geriatric curriculum topics exist, but are extensive and imprecise

20 AAMC/John A. Hartford Foundation Consensus Conference on Geriatric Competencies: July, 2007 Goal: Consensus on minimum standards for graduating medical students Input provided by many non-geriatric educators Results –8 content domains identified –26 minimum geriatric competencies identified within these domains

21 Competency Domains Atypical Presentation of Disease Medication Management Cognitive and Behavioral Disorders Falls, Balance, Gait Disorders Self-Care Capacity Health Care Planning and Promotion Palliative Care Hospital Care for Elders

22 Atypical Presentation of Disease

23 Acute MI: 30 Day Mortality Adapted from Mehta RH et al. J Am Coll Cardiol 2001;38: Ref Adjusted ORs %

24 Presentation of MI: Chest Pain < >85 Adapted from Bayer et al JAGS 1986;34:

25 Painless MI in Patients>70 yrs: Presenting Symptoms Syncope Dyspne a Stroke Confusion Weakness Giddiness Vomiting Sweating Palpitations Bayer et al. JAGS 1986;34:

26 Atypical Presentation of Disease Generate a differential diagnosis based on recognition of the unique presentations of common conditions in older adults, including –Acute coronary syndrome –Dehydration –Urinary tract infection –Acute abdomen –Pneumonia.

27 Compensatory Response to Orthostatic Hypotension 1. Compensate for hypovolemia: –Thirst response –ADH secretion –Increase urine concentration 2. Increase heart rate

28 Compensatory Response to Orthostatic Hypotension in Elders 1. Compensate for hypovolemia: –Thirst response –ADH secretion –Increase urine concentration 2. Increase heart rate

29 Atypical Presentation of Disease Identify at least 3 physiologic changes of aging for each organ system and their impact on the patient, including their contribution to homeostenosis (the age- related narrowing of homeostatic reserve mechanisms).

30 Medication Management

31 Medication Management: Drugs to Watch Out For Identify medications, including –Anticholinergic –Psychoactive –Anticoagulant –Analgesic –Hypoglycemic –Cardiovascular drugs that should be avoided or used with caution in older adults and explain the potential problems associated with each.

32 Medication Management Explain impact of age-related changes on drug selection and dose based on knowledge of age- related changes in: –renal and hepatic function –body composition, –and Central Nervous System sensitivity.

33 Why you become a cheaper drunk as you age As you get older, –Higher blood alcohol concentrations –Worse for women than men –Less tolerance for quantities previously enjoyed Brain more sensitive Balance worse even without the alcohol

34 Common Diseases % CDC

35 Medication Management Document a patient’s complete medication list, including: –prescribed, –herbal and –over-the-counter medications, and for each medication provide the dose, frequency, indication, benefit, side effects, and an assessment of adherence.

36 Anti-Aging Medicine

37 Growth Hormone Levels Decline with Age

38 Growth Hormone Review of 18 studies (31 publications) 220 participants; Mean age 69 Positive Results –Fat Mass decreased 2.1 kg –Lean Mass increased 2.1 kg No change: cholesterol, BMD, other lipids Liu H et al. Annals Int Med 2007; 146:

39 Growth Hormone: Down Side Increased –Soft tissue swelling –Joint pain –Carpal tunnel syndrome –Breast swelling –New onset diabetes –Impaired fasting glucose Liu H et al. Annals Int Med 2007; 146:

40 Cognitive and Behavioral Disorders

41 Severe Memory Impairment

42 Severe Depressive Symptoms

43 Cognitive and Behavioral Disorders Define and distinguish among the clinical presentations of delirium, dementia, and depression Perform and interpret a cognitive assessment in older patients for whom there are concerns regarding memory or function. Formulate a differential diagnosis and implement initial evaluation in a patient who exhibits cognitive impairment..

44 Cognitive and Behavioral Disorders Urgently initiate a diagnostic work-up to determine the root cause (etiology) of delirium in an older patient. Develop an evaluation and non-pharmacologic management plan for agitated demented or delirious patients.

45 Falls, Balance, Gait Disorders

46 I Fall To Pieces $200 % of healthy elders in the community that fall annually A.5% B.15% C.30% D.45% ***

47 Falls, Balance, Gait Disorders Ask all patients > 65 y.o., or their caregivers, about falls in the last year, watch the patient rise from a chair and walk (or transfer), then record and interpret the findings.

48 Significant Risk Factors for Falls in Elders Medications Cognitive impairment Lower extremity disabilities Balance and gait abnormalities Poor vision and/or hearing Medical Disorders Previous Falls Level of activity Upper extremity weakness

49 Multiple Falls vs. Number of Risk Factors Percent with Two or More Falls in One Year * White, previous falls, arthritis, parkinsonism, difficulty rising, poor tandem gait. Nevitt JAMA, (n=325) Number of Risk Factors*

50 Falls, Balance, Gait Disorders In a patient who has fallen, construct a differential diagnosis and evaluation plan that addresses the multiple etiologies identified by history, physical examination and functional assessment.

51 Self-Care Capacity

52 Functional Status Impairment

53 Performance Impairment >70 yos Community-dwellers On feet for 2 hrs; sit for 2 hrs; Reach out to shake hands; Use fingers to grasp or handle; Lift or carry 10#s

54 Self-Care Capacity Assess and describe baseline and current functional abilities –instrumental activities of daily living –activities of daily living –special senses in an older patient by collecting historical data from multiple sources and performing a confirmatory physical examination.

55 Functional Status: Activities of Daily Living ADLs –Dressing –Eating –Ambulation –Transfer –Hygiene Bathing Toileting Instrumental ADLS –Telephone use –Getting to places beyond walking distance –Grocery shopping –Preparing meals –Housework/handyman work –Taking medications –Managing money

56 Mobility Disability 1)Unable to walk up and down the stairs to the 2 nd floor without help or 2)Unable to walk half a mile without help Women Men Leveille SG et al. J Gerontology: SOCIAL SCIENCES 2000;55B;s41-50

57 Self-Care Capacity Develop a preliminary management plan for patients presenting with functional deficits, including adaptive interventions and involvement of interdisciplinary team members from appropriate disciplines, such as social work, nursing, rehabilitation, nutrition, and pharmacy.

58 Self-Care Capacity Identify and assess safety risks in the home environment, and make recommendations to mitigate these.

59 Health Care Planning and Promotion

60 Life Expectancy 2003 CDC Years

61 Health Care Planning and Promotion Accurately identify clinical situations where –life expectancy –functional status –patient preference or –goals of care should override standard recommendations for screening tests or for treatment in older adults.

62 Health Care Planning and Promotion Define and differentiate among –types of code status –health care proxies –advanced directives in the state where one is training.

63 Palliative Care

64 Assess and provide initial management of pain and key non-pain symptoms based on patient’s goals of care. Identify the psychological, social, and spiritual needs of patients with advanced illness and their family members, and link these identified needs with the appropriate interdisciplinary team members.

65 Palliative Care Present palliative care (including hospice) as a positive, active treatment option for a patient with advanced disease.

66 Hospital Care for Elders

67 Adults Over 65 years Old

68 Outcomes of Acute Care for Older Adults 31% lose >1 basic ADL at baseline c/w pre- admission (see card) –2/5 of these remained impaired 3 months later 40% have IADL decline at 3 months

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70 Hospital Care for Elders Identify potential hazards of hospitalization for all older adult patients including: –Immobility –Delirium –Medication side effects –Malnutrition –Pressure ulcers –Procedures –Peri and post operative periods –Hospital acquired infections and identify potential prevention strategies.

71 Hospital Care for Elders Explain the risks, indications, alternatives, and contraindications for indwelling (Foley) catheter use in the older adult patient. Explain the risks, indications, alternatives, and contraindications for physical and pharmacological restraint use. Conduct a surveillance examination of areas of the skin at high risk for pressure ulcers and describe existing ulcers.

72 Acute vs Chronic Disease Acute –Short duration –Severe Symptomatology –Singular etiology Infection Injury ‘No matter how you pinch and squeeze……” –Goal of care is cure Return to pre-acute illness functional status Chronic –Longer duration (>3-6 months) –Not always symptomatic Symptoms can exacerbate and remit –Can have multiple etiologies Diabetes and ASCVD Frailty –Goal of care is symptom control and maximizing function Incurable, but ‘manageable’ Unlikely to return to pre-acute illness functional status Require ongoing interactions between patients and healthcare team

73 Hazards of Hospitalization Chronic disease and function decompensate Longer hospitalization Can’t return home without help or subacute admission

74 Which are reasonable discharge destinations for a patient? Hospital Nursing HomeHomeHome with Services Rehab Sub-Acute Rehab Acute Rehab

75 Hospital Care for Elders Communicate the key components of a safe discharge plan (e.g., accurate medication list, plan for follow-up), including comparing/contrasting potential sites for discharge.

76 Managing Chronic Illness Adapting to change Mastery and sense of control Social support network Meaning of life and illness

77 RWJ Chronic Care Model

78 Chronic Care Model Health System –That promotes safe, high quality care Delivery System –Assures effective, efficient clinical care and self-management support Clinical Information Systems –Organize patient and population data to facilitate efficient and effective care Community resources –Mobilize community resources to meet needs of patients Self-Management Support –Empower and prepare patients to manage their health and health care Decision Support –Clinical care that is consistent with scientific evidence and patient preferences

79 The Librarian As Gerontologist: What You Need To Know How does aging affect one’s health and well being ? What might physicians and other health care professionals be asking you about aging? What might the public be asking about aging?

80 The Librarian as Gerontologist What You Need to Know High-quality sources of info on: –Demographics of aging –Age-related changes in function –CAM –Geriatric Drug Dosing –Drug Interactions –Community Resources –Patient self-management –Caregiver support

81 Doris Lessing “The great secret that all old people share is that you really haven't changed in seventy or eighty years. Your body changes, but you don't change at all. And that, of course, causes great confusion.”

82 What is Old Age? “To Me, Old Age is always 15 years older than I am” Bernard M. Baruch Oliver Wendell Holmes, Jr.


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