Presentation on theme: "Geriatrics Overview How are older patients different from all other patients and why does it matter? Richard E. Freeman MD MPH 2013 Lock Haven University."— Presentation transcript:
Geriatrics Overview How are older patients different from all other patients and why does it matter? Richard E. Freeman MD MPH 2013 Lock Haven University A special thanks to Beth Clark MD FACP Geriatrics Dept Bronx VA MC Mt. Sinai Medical Center
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 syndromes can have a profound effect on an older person’s 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
Did you know... Two-thirds of all seniors in the world who have ever lived are alive today.
Geriatrics: –the branch of medicine that focuses on health promotion and the prevention and treatment of disease and disability in later life Gerontology?
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
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
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 –Parkinson’s disease –Dementia
Social Problems More Common with Aging- The Age of LOSS Loss of income Loss of close family Loss of community Loss of physical and mental functions Loss of mobility Social isolation
Functional ReserveTheory Most of the body’s 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
The Challenges of an Aging Population – Why it matters In the 2000 US Census, 12.5% of the US population was >64 By 2030, it is predicted that 20% of the US population will be >64 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
A Little History Lesson Part 1 Pre 1930 – Age of Productivity- New inventions- Industrial revolution Immigration active- European unrest Baby’s born plentiful
Pre care of the elderly Shorter life expectancy EXTENDED FAMILY Alms houses Rest Homes Poor Houses and farms
History Part GREAT Depression, Dust Bowl- famine- internal Migration- Less immigration- European unrest Baby’s less plentiful
Care of the elderly NEW DEAL
History Part World War II Fertile men off to war Fertile women in the work place BIRTH RATE DROPS 418,500 USA lost persons –70 million worldwide
History Part Boys can home from WWII “Healthy, wealthy, & horny” Government subsidies, affluence, mobility, reconstruction- new infrastructure
HISTORY Part 5 BABY BOOMER: born million babies wealthiest, most active, most physically fit generation up to that time, amongst the first to grow up genuinely expecting the world to improve with time. received peak levels of income, reaped the benefits of abundant levels of food, apparel, retirement programs, and sometimes even "midlife crisis" products
Baby Boomers- Characteristics control over 80% of personal financial assets more than half of all consumer spending. Buy 77 % of prescription drugs and 61% of over-the-counter drugs, 80% of all leisure travel. [ they would rather pass on their inheritance as charity than pass it down to their children.
1965- Great society LB Johnson MEDICARE AND MEDICAID
Freeman’s boring statistics
The Challenges of an Aging Population
2000 U.S. Census Data Number of persons (% of population)
HHS Projected cost 2010 data
% US Budget to service Heathcare costs
Geriatric Interdisciplinary Team Medicine Nursing Social Work Psychiatry Psychology Case Management Physical Therapy Occupational Therapy Speech Pathology Pharmacology Chaplaincy Recreation Therapy
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
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 in Scranton, the other lives in California but calls frequently.
Sensory Impairment - Vision
How could the development of macular degeneration or cataracts interfere with Jenny’s ability to monitor and treat her diabetes? What other aspects of Jenny’s 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 Jenny’s 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?
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
Low Vision Aids
Gait Abnormalities and Falls
How could a fall interfere with Jenny’s ability to monitor and treat her diabetes? What other aspects of Jenny’s 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?
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, >50% 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
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 >65 Death rate from falls increases with age –Lifetime cost of falls related injuries for those >65 has been estimated at $12.6 billion –Etiology of falls multifactorial Includes medical, environmental, sensory and postural issues
Gait Abnormalities and Falls
Dementia How could the development of dementia interfere with Jenny’s ability to monitor and treat her diabetes? What other aspects of Jenny’s 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?
Dementia will reach epidemic proportions by 2040 Alzheimer's Disease accounts for the vast majority of dementias in the US Among people >65, the prevalence of AD is 6-8% Among people >85, the prevalence is 30% 4 million people in the US currently suffer from AD By 2040, AD patients will number 14 million
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
“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
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
Clock Drawing Test
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
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