What Every Ophthalmologist Needs to Know about Geriatrics Andrew G. Lee, MD Chair of Ophthalmology The Methodist Hospital, Houston, TX Professor of Ophthalmology, Neurology, and Neurosurgery Weill Cornell Medical College THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. AGS ! See Slides: 12,13,14,15,17,18,22,29,35,36,52,53!

OBJECTIVES Discuss scope of the problem (demographic shift disproportionately affects ophthalmology) Describe comorbidities in elderly  Depression  Dementia  Hearing loss  Fall risk and prevention  Elder abuse Screening tips for elderly eye patients Slide 2

GERIATRICS AS A MODEL FOR THE ACGME COMPETENCIES IN OPHTHALMOLOGY Unique needs of geriatric patients in medical knowledge & patient care domains Professionalism (avoiding ageism) Communication skills (teaming with caregivers and primary care, dealing with hearing loss and dementia) Practice-based learning (age-specific evidence) Systems-based practice (nursing home, comorbidities, fall prevention) Slide 3

COMPETENCIES Patient care Medical knowledge Professionalism Communication and interpersonal skills Practice-based learning Systems-based practice Slide 4

THE COMPETENCIES ALIGN WITH EVOLUTION OF DOCTOR-PATIENT RELATIONSHIP Doctor-patient Patient-doctor Person-doctor Person-person Practice-based learning Medical knowledge Patient care Systems-based learning Communication Professionalism Slide 5

CASE-BASED LEARNING Case vignettes to emphasize key points Platform for discussion of competencies Ophthalmologists do not have to be geriatricians but need to recognize specific geriatric syndromes Slide 6

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GERIATRIC PATIENTS ARE NOT JUST OLDER ADULTS Different responses to disease & treatment Different systems-based issues (transportation, mobility, comorbidities) Different communication needs (hearing loss, dementia, depression, nursing home) Different effects on functional outcome Slide 11

CASE VIGNETTE A 75-year-old man is brought in by his family for “poor vision” Only says very slow “yes” or “no” to questions Blunted affect & seems withdrawn 3 ophthalmologists said “he’s just getting older” Geographic atrophy retinal pigment epithelium Barely able to give visual acuity of 20/70 OU, constricted visual field OU, slow responses Slide 12

COMPETENCY ISSUES Medical knowledge Patient care Communication skills Professionalism Practice-based learning Systems-based practice ??? Slide 13

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SCREENING FOR DEPRESSION Geriatric Depression Scale (15 items) “Do you feel sad or depressed often?” Slide 15

Apfeldorf et al. Principles of Geriatric Medicine and Gerontology. 5th ed. New York: McGraw-Hill, Inc; 2003: Slide 16 IMPORTANT RISK FACTORS FOR SUICIDE IN DEPRESSED ELDERLY PATIENTS Greater severity of depression Symptoms of psychosis Alcoholism Abuse of sedatives Recent loss or bereavement Recent development of disability White male Age over 80

DEPRESSION & VISION LOSS IN THE ELDERLY Elderly patients with depression may present with vision loss (or other somatic symptoms) Depression is a common comorbidity with vision loss (vision loss can cause depression) Depression is under-recognized in the elderly Depression in elderly may lead to suicide Screening by ophthalmologists might help to identify patients at risk Depression is NOT a normal part of aging Slide 17

OUTCOME Patient responded yes to screening depression question (“Do you feel sad or depressed often?”) Referred to primary care service Underwent counseling & pharmacotherapy for depression Returned to ophthalmologist “a different man” 20/20 OU! Full Goldmann visual field OU Slide 18

CASE VIGNETTE 65-year-old woman with age-related macular degeneration Lives in nursing home and doesn’t hear very well During exam, she seems very hard of hearing Technician has to shout to get any response ARMD at 20/200 level OU She is told “nothing more can be done” Slide 19

COMPETENCY ISSUES Medical knowledge Patient care Communication skills Professionalism Practice-based learning Systems-based practice ??? Slide 20

HEARING LOSS Hearing loss = common comorbidity with vision loss in elderly Combination deficits worse than either alone Hearing loss makes it more difficult to test visual acuity Hearing loss makes it difficult to obtain the history (tempting to give up) Many forms of hearing loss are amenable to treatment Slide 21

OUTCOME Hearing assessment with hearing aids Amazingly, her affect & mood improved She became more engaged & active She wrote a wonderful thank-you note to her ophthalmologist for referring her for hearing aids Slide 22

CASE VIGNETTE A 66-year-old college professor is brought in by his wife Chief complaint: “He cant see” (patient is asymptomatic) 20/20 OU Normal eye exam 10 pairs of glasses over last 4 months Slide 23

COMPETENCY ISSUES Medical knowledge Patient care Communication skills Professionalism Practice-based learning Systems-based practice ??? Slide 24

WHAT CAN’T HE SEE? Doesn’t see road signs (wife won’t drive with him anymore) Loses place in lecture (he is tenured) & students complain that he rambles in class Used to write the checks & do the bills but gets confused and writes “date” in “amount” line Gets lost easily on way to class No one wants to tell him because he holds a named professorship & is chair of his department Slide 25

CLOCK DRAW FOR DEMENTIA Instructions to patient: Draw a clock Put in time in numbers (1 through 12 o’clock) Draw hands at 11:10 AM Slide 26

WHEN TO DO CLOCK DRAW TEST Brought in by spouse “Can’t read” despite many new glasses & 20/20 OU Homonymous hemianopsia with negative neuroimaging Loss of executive function & memory (visual variant of Alzheimer’s disease) Slide 27

DEMENTIA & VISION LOSS Vision loss may worsen dementia symptoms (analogous to “sundowning”) Vision loss may be presenting sign of Alzheimer dementia (visual variant) Dementia = common comorbidity with vision loss in elderly Clock draw = easy & fast screening test Treatment may slow progression of dementia (earlier recognition is better) Slide 28

CASE VIGNETTE 70 y/o woman with Fuchs’ corneal dystrophy 20/80 OUStable Glaucoma on 3-drop therapy Stable IOP Glaucomatous cups 0.9 OUStable Glaucomatous field loss OU Stable S/P PKP OU clear grafts OU Stable S/P CE/IOL OUStable Frequent falls (2x in 3 months) Not stable! Slide 29

VISUAL RISK FACTORS FOR FALLS Decreased visual acuity Glare Altered depth perception Decreased night vision Loss of peripheral visual field Slide 30

I HATE FALLING I―Inflammation of joints (or joint deformity) H―Hypotension (orthostatic blood pressure changes) A―Auditory and visual abnormalities T―Tremor (Parkinson's disease or other causes of tremor) E―Equilibrium (balance) F—Foot problems A―Arrhythmia, heart block or valvular disease L―Leg-length discrepancy L―Lack of conditioning (generalized weakness) I—Illness N―Nutrition (weight loss) G―Gait disturbance Sloan JP. Mobility failure. In: Protocols in primary care geriatrics. New York: Springer, 1997:33-8. Slide 31

FALLS ARE BAD IN ELDERLY Falls = leading cause of injury deaths & disabilities among persons aged >65 years US: 1 in 3 older adults falls each year 1997: 9,000 (aged >65 years) died from falls 20%-30%: moderate to severe injuries that reduce mobility & independence Hospitalized for falls 5x more than for other causes Women: 3x more likely than men to be hospitalized for a fall-related injury Slide 32

FALLS & FRACTURES 1988  1996: hip fx increased from 230,000 to 340,000 Hip fracture hospitalization rates are substantially higher for white women Cost of hip fracture: $16,300  $18, : hip fractures = $2.9 billion for Medicare Could reach $82 billion  $240 billion by 2040 Slide 33

FALL RATE PER 100,000 PEOPLE Slide 34 MMWR 2006

TAKE-HOME MESSAGES Vision loss increases risk for falling Ask about falls Fall prevention is superior to fall treatment Fall  fracture  hospitalization  loss of mobility & independence  nursing home or death Fall checklist for all vision-impaired elders Stable eye exam ≠ stable patient (Unstable patient at risk for falls) Slide 35

CASE VIGNETTE 75-year-old woman with Alzheimer’s disease She is brought in by her pastor (but son has power of attorney) for “falling” & hitting her eye She has ecchymoses OD, a hyphema, and a retinal detachment OD She appears disheveled & unkempt Pastor is concerned about her health The patient tells you she is afraid to go home Slide 36

COMPETENCY ISSUES Medical knowledge Patient care Communication skills Professionalism Practice-based learning Systems-based practice ??? Slide 37

CASE VIGNETTE When you call the son regarding your concerns, he tells you to “mind your own business” Son tells you that he is in charge of his mother and how he treats her is his own business The pastor feels that she might be neglected or the victim of abuse, & he believes the son might be taking her Social Security check Slide 38

ELDER ABUSE (UMBRELLA TERM) Physical abuse: inflict or threat to inflict harm Sexual abuse: non-consensual sexual contact Emotional or psychological abuse: verbal or nonverbal Exploitation: financial or material Neglect: refusal or failure to provide food, shelter, health care, or protection Abandonment: desertion of a vulnerable elder Slide 39

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REPORTING ELDER ABUSE Legislatures in all 50 states have passed some form of elder abuse prevention laws All states have set up reporting systems Adult protective services (APS) investigates reports of suspected elder abuse Slide 42

ELDER ABUSE: A GROWING PROBLEM 19.7% increase in reports from 2000– % increase in substantiated cases from 2000–2004 Two in 5 victims (42.8%) are >80 years Slide 43

TAKE-HOME MESSAGES Beware elder abuse As in child abuse, suspect if story doesn’t match Adult Protective Services = equivalent of Child Protective Services Physical abuse is not the only type of abuse Neglect is a form of abuse Slide 44

SUMMARY (1 of 2) Demographic shift disproportionately affects ophthalmology Geriatric patients are not just older adults ACGME competencies (model for implementation) Recognize, triage, & refer comorbidities in the elderly  Depression  Dementia  Hearing loss Slide 45

SUMMARY (2 of 2) Screening tips for elderly ophthalmology patients  Whether they look depressed or not, ask about depression  If you have to shout, they need a hearing assessment  Clock draw test for dementia  If they have fallen or are at risk of falling, provide fall checklist  Think about elder abuse (especially if story doesn’t add up) Slide 46

Visit us at: Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics THANK YOU FOR YOUR TIME! linkedin.com/company/american-geriatrics- society Slide 47