Introduction to Geriatric Medicine

Introduction to Geriatric Medicine
Carolyn Clevenger, DNP, GNP-BC Assistant Professor, NHW School of Nursing VA Geriatric Research, Education, & Clinical Center Jonathan Flacker, MD AGSF Chief, Section of Geriatrics and Gerotology Associate Professor Emory University School of Medicine

Industry Disclosures- CKC
I believe none of the following industry relationships are relevant to the current educational activity: Consultancies (within last 3 years)- None Research funding- None Speakers’ bureaus, stocks, patents, family employment by industry- None

Industry Disclosures- JMF
External Industry Relationships * Company Name(s) Role Equity, stock, or options in biomedical industry companies or publishers** JNJ Stock Board of Directors or officer Nope Royalties from Emory or from external entity Industry funds to Emory for my research Other

Learning Objectives Understand important demographic trends in aging
Be able to explain the concept of functional status Learn a framework for understanding basic principles affect either recovery from, or treatment during, acute illness in older patients

The American Geriatrics Society
What is Geriatrics? Geriatrics is the branch of medical science that focuses on health promotion and the treatment of disease and disability in later life. The American Geriatrics Society

The American Geriatrics Society
What is a Geriatrician? A Geriatrician is a physician who is specially trained to prevent and manage the unique and often multiple health problems of older adults. The American Geriatrics Society

What is a GNP? Gerontological Nurse Practitioners (GNPs) are advanced practice nurses with specialized education in the diagnosis, treatment and management of acute and chronic conditions often found among older adults and generally associated with aging. Gerontological Advanced Practice Nurses Association

Age Distribution of US Population

Aging in Georgia

The Emory University Reynolds Program
Strengthening Physician Training in Geriatrics

Basic Principles of Geriatrics
1. Aging is not a disease Disease happens to some, but aging is not optional Aging does not generally cause symptoms Successful aging is common

Physiologic Reserve Physiologic Reserve Symptomatic Edge
Homeostasis Physiologic Reserve Symptomatic Edge AGE 

Years Remaining When You Are Already “Old”
At age 85 - have more years to live. At age 75, have roughly 9-12 more years to live. At age 65, have roughly more years to live.

2. Medical conditions in geriatric patients are commonly chronic and multiple, and multi-factorial in origin Acute illnesses are superimposed on existing chronic conditions Treatment of one condition can affect another Geriatric conditions usually have multiple contributing factors

Juanita 86 year-old female comes to the clinic for refill for thyroid med Gait speed is slow and appears out of breath History of: Hypothyroidism, hypertension, osteoarthritis, atrial fibrillation Potentially new: heart failure, angina, anemia, lung disease, spinal stenosis

Older Americans: Key Indicators of Well-Being 2012 (agingstats.gov)
Geriatric Conditions are Usually Chronic and Multiple Older Americans: Key Indicators of Well-Being 2012 (agingstats.gov)

Geriatric Conditions are Often Multi-factorial
Multiple Morbidities Clinical Presentation Infection Dehydration Medication effects Delirium Sensory impairment Sleep disturbance

3. Reversible and treatable conditions are often under-diagnosed and under-treated in geriatric patients

Case Ms J is in your clinic
She is 80 years old and has hypertension and stage II CKD You should of course ask her about?

Examples of Common, Treatable Geriatric Syndromes That are Often Overlooked
Constipation Incontinence Fatigue Dizziness Sleep disorders Gait instability

4. Functional ability and quality of life are critical outcomes in the geriatric population

John 84 year-old male with vascular disease including dementia, diabetes, veinous insufficiency, obesity Hospitalized for cellulitis/sepsis Could no longer walk independently after prolonged bedrest Moved to assisted living Profoundly depressed

Measurement of Health Outcomes
Biological Clinician-Reported Patient-Reported Blood tests Physical exam Symptoms EKG/MRI Alertness/Orientation Well-being Biopsies Diagnosis Functioning Blood pressure Vitality

5. Social history, social circumstances, and available social support are essential aspects of managing geriatric patients

Case Ms Malone is an 85 year old female admitted to the hospital from home for a pneumonia Once he is better she should go __________

LIVING ARRANGEMENTS ARE IMPORTANT! Living Arrangements of Older Men
1 minutes Point out -That most older men live with spouses -Older women are as likely to live with spouse as live alone -This is pretty similar in all races in men, less so in women Interesting epidemiologic fact to throw in: Married men generally live longer than unmarried men Married women generally die sooner than unmarried women Draw your own conclusions! Living Arrangements of Older Women

Hazards of Living at Home Alone
Isolation Poor nutrition Environmental hazards and accidents Behavioral hazards

6. Geriatric care is commonly multidisciplinary Multiple disciplines work together as an interprofessional team

MaryEllen 76-year old female with stroke; great improvements in mobility, less so in cognition Goals of care: to return to home to live independently Structured family meeting on day 5 Patient and son MD and NP Physical and occupational therapy Social work and chaplain Psychologist

Interdisciplinary Geriatric Care
Team Members Physicians NPs, PAs Nurses Nurse’s Aides Rehab therapists Social workers Dieticians Psychologists Pharmacists Housekeepers Engineers Pastoral care IT support Administration & Patient and Family

Principles of High-Functioning Teams
Clear roles and responsibilities Who does what? Who will take the lead in a given situation? Shared mental model Same goal and general idea of how to achieve it Mutual trust To back-up and monitor performance Team orientation Believe that team based care is better than alone Honest and clear communication Including negative feedback

7. Cognitive and affective disorders are highly prevalent and commonly undiagnosed at early stages

Case Mr Tam is a 79 year old male brought to the clinic by his children who are concerned about weight loss What must you consider?

Cognitive and Affective Disorders
Early cognitive impairment is commonly hidden and overlooked Depression is commonly undiagnosed and under - treated Behavioral symptoms such as agitation and aggression are very distressing and difficult to manage for family members

Depression is in the U.S.

8. Iatrogenic illness are common and many are preventable Iatro = physician Genesis = origin Medications, diagnostic tests, and hospitalizations can be hazardous in older people

Betty Admitted to nursing home from hospital following heart failure exacerbation Unintentionally losing weight Treated with Marinol (dronabinol) Side effect: munchies One bag of Cheetos later…readmitted with HF exacerbation

Common Iatrogenic Illnesses in Geriatric Patients
Risk Factors Adverse drug reactions Delirium Falls and injuries Incontinence Immobility Deconditioning Pressure ulcers Contractures Normal age-related changes Atypical presentation of disease High prevalence of chronic disease and comorbidity Provider beliefs and attitudes Inadequate geriatric training of healthcare providers

9. Geriatric care is provided in a variety of settings

Case - Sites of Geriatric Care
Acute Care Facility Personal Care Home Assisted Living Facility Home with home health Home Outpatient/ Facility Long Term Care Facility Sub Acute Rehab

Geriatric care is provided in a variety of settings ranging from the home to long-term care institutions Criteria for levels of care Financing Care transitions and coordination

Sites Geriatric Care Acute Hospital Outpatient Clinics Nursing Home
Assisted Living Facilities Home Care is not generally well coordinated

10. Ethical issues and end-of-life care are critical aspects of the practice of geriatrics Not all people who live into extreme old age have to die in a hospital

May 73-year old with leukemia
Burdensome side effects from chemo, ready to stop treatments and go home from hospital Son disagreed with plan “This meeting is not to reach consensus, it is to hear what your mother wants”

Anticipatory Guidance

Advance Directives In Georgia, a large proportion of terminally ill older people in nursing homes do not have advance directives

Learning Objectives Understand important demographic trends in aging
Be able to explain the concept of functional status Learn a framework for understanding basic principles affect either recovery from, or treatment during, acute illness in older patients

What goes up, what goes down: the physiology of aging

Manuel A. Eskildsen, MD, MPH Financial Relationships w Industry Disclosures
External Industry Relationships * Company Name(s) Role Equity, stock, or options in biomedical industry companies or publishers** None Board of Directors or officer Royalties from Emory or from external entity Industry funds to Emory for my research Other

Objectives Understand the physiologic changes that occur with aging.
Differentiate the normal aging process from disease.

Outline Discuss changes across different organ systems
Body compositions Cardiac Pulmonary Gastrointestinal Renal Endocrine Reproductive Nervous System Sensory Skin Discuss your assigned cases

Aging is not a disease

What is normal aging, and what is disease?
Is an expected part of getting older However, it may be variable A direct consequence of the physiologic aging process Disease Represents a pathological change in the tissues involved Aging may make the system vulnerable– but not a direct consequence of aging

Examples of cellular changes
Activation or suppression of aging genes Telomeres Damage by free radicals to mitochondria

The Consequences of Aging
Lack of adaptability to stress Decreasing reserves Makes it more likely to see symptoms and disease in organ far from primary problem Homeostenosis

Physiologic Changes

Body composition changes with aging
Less More At age 30, total body water is 60% At age 75, total body water is 50% Total body fat rises with age

Effects on Medications
Likely the most important to consider Lipophilic medications (e.g., diazepam) Larger volume of distribution Stays in body longer Hydrophilic medications (e.g., digoxin) Smaller volume of distribution Comparatively, may achieve higher plasma concentrations

Cardiac Changes - Overview
Little difference at rest Structurally, muscle thickness and heart weight increase Functional changes: Decreased maximal heart rate Increased dependence on “atrial kick”

Cardiac Structural Changes
Thickened heart muscle Hardening and thickening of arteries Both are involved in elevated BP with aging This thickened cardiac muscle may result in a normal S4 in an older person

Cardiac Functional Changes
Resting heart rate and cardiac output don’t change However… Maximal heart rate decreases Maximal cardiac output decrease Thickened left atrium Decreased atrial kick More susceptible to complications like heart failure

Maximal heart rate Male Female Maximal HR = 220 – age
Maximal HR = 220 – (0.6 x age)

Atrial Kick In the younger heart, diastolic filling is easier.
Thicker heart depends more on active filling due to atrial kick Atrial fibrillation takes away that atrial kick

Pulmonary and Lungs - Overview
Also, few changes evident at rest Structurally, generally tissues are stiffer Maximal reserve decreases

Pulmonary Structural Changes
Alveolar surface decreases overall Lungs are stiffer Airway flow is decreased Diaphragm is weaker Ciliary action less effective Decreased alveolar surface= decreased diffusion capacity (DLCO)

Pulmonary Function Decreased vital capacity (amount of air that can be maximally inspired) Increased residual volume (air trapping) Ventilation/Perfusion (V/Q) mismatch

Arterial O2 changes with age
PaO2= 100 – (age/3) Age 17 Age 87 PaO2= 94 mm Hg PaO2= 71 mm Hg

Question An 85-year-old man has had increasingly severe shortness of breath on exertion over the past 3 months. For the past 20 years, he has walked 30 minutes three times weekly at a fairly rapid pace without symptoms. He has no chest pain, wheezing, or cough. Blood pressure is 140/85 mm Hg. On examination, the lungs are clear and there is no evidence of wheezing. Radiographs of the chest and an electrocardiogram show normal findings. Which of the following additional findings would require further evaluation? (A) Arterial PO2 of 80 mm Hg (B) Decreased cardiac output on ultrasonography (C) Decreased maximum heart rate on stress testing (D) Decreased vital capacity on pulmonary function testing (E) Presence of an S4 gallop

Gastrointestinal/Hepatic

Gastrointestinal Changes (Potential Disease Consequences)
Decreased salivary production (oral ulcers) Gastric mucosal atrophy, impaired acid clearance (GERD) Slower transit times (constipation) Decreased calcium absorption (bone loss)

Constipation Constipation is not normal aging, but aging predisposes to it Slower transit time plus… Low fiber Poor mobility Effects of medications (narcotics) Equals constipation

Hepatic Changes Phase I metabolism (oxidation/reduction)
Cytochrome P450 system Significant declines with aging Careful with diazepam (valium) Phase II reactions (conjugation) Like glucuronidation Facilitates renal excretion Less affected with aging Example: Lorazepam (ativan)

Renal Changes - Overview
Decrease in renal mass, especially cortical Overall decreases in function Electrolyte changes

Renal Changes Decrease in size, especially at the expense of the cortex Decrease in renovascular bed 30% of glomeruli lost by age 75 Decreased creatinine clearance --- serum creatinine is less of an important indicator Decrease in concentrating capacity --- tendency toward dehydration

Renal Elimination Cockcroft-Gault Equation
Changes variable, but can be guesstimated: CCr = (140-AGE) x (Wt in KG) (72 x Cr in mg/dl) x 0.85 for women

Creatinine Clearance Comparison
Age 30 130 lbs Creatinine= 1.5 Age 85 120 lbs Creatinine= 1.5 CrCl = 51 CrCl = 24

Implications of Aging Changes on Kidney
Need to know whether drugs are excreted renally And whether dose needs to be adjusted Example The 80-year old woman in the example above has CrCl of 24 ml/min She has a DVT and her MD decides to treat with enoxaparin. Ordinary dosing is 1 mg/kg BID For CrCl < 30, dose is 1 mg/kg Qday Dose is 55 mg Qday

Endocrine Changes - Overview
Changes in Glucose Tolerance Decrease in GH, Testosterone, Estrogen Ovarian failure (menopause) already happened in 50s

Glucose and Insulin SEDENTARY LIFESTYLE contributes
Clinically insignificant increases in fasting glucose after age 20 (1% per decade) Decreased response of peripheral tissues to insulin SEDENTARY LIFESTYLE contributes much more to poor glucose tolerance than age

Reproductive/Genitourinary

Female – GU and Breast Best known change – menopause
Permanent end to menstrual periods (around age 50) Vagina thinner, drier, less elastic Intercourse may be more difficult Breasts less firm  tend to sag

Male Changes Fewer sperm and decreased sex drive over time
Hormone changes are more gradual Blood flow to penis tends to decrease Erections may not last as long; also less rigid Erectile dysfunction more common (but not part of normal aging) Prostate enlarges Older men may urinate with less force, take more time to initiate stream

Central Nervous System
Structure ↓ Brain Weight ↓ no. of nerve cells in brain ↓ cerebral blood flow (20%) ↑ neurofibrillary tangles and scattered senile plaques

Central Nervous System - Function
Intellect Maintained until at least age 80 Slowing in central processing → Tasks take longer to perform Verbal skills Maintained until age 70 Gradually ↓ in vocabulary, ↑ semantic errors and abnormal prosody Mentation Difficulty learning, especially languages and forgetfulness in non-critical areas – doesn’t impair recall of important memories or affect function

Dementia vs. Normal Aging
Difficulty naming common words Forgetting names of known places, family members Example: putting sweater in microwave Normal Aging Occasional word-finding difficulty Difficulty learning new languages Example: Forgetting your keys

Peripheral Nervous System
↓ spinal motor neurons Nerve conduction slows ↓ vibratory sensation – especially feet ↓ thermal sensitivity (warm-cool) ↓ size of large myelinated fibers

Musculoskeletal - Bone
Decreased bone density Increased bone loss Decreased Vitamin D absorption, decreased bone formation Implications: Loss of height (women > men) Osteoporosis is not normal aging

Musculoskeletal - Muscle
Muscle mass decreases by 30 – 40 % linear acceleration with age Fewer motor units (so decrease power) Produce less heat per KG Decreased transfer ability Decreased stair climbing ability Decreased gait speed Activity makes a big difference!

Sensory Changes Visual Auditory Smell Taste

Visual Changes Hardening of lens  Difficulty with accommodation
Presbyopia After age 40; part of normal aging Yellowing of lens Eventually can lead to cataracts (not normal aging) Impaired dark adaptation and contrast sensitivity Implications for night driving

Auditory Changes Result: Loss of high >> low frequency hearing
Thickens Result: Loss of high >> low frequency hearing

Hearing – Clinical Implications
Clinical Question: Describe a Strategy for Communicating With Older Patients Who Have Hearing Loss? Clinical Question: What easy physical exam component should you carry out before referring a patient to an ENT? Speaking at a lower frequency Rule out cerumen impaction

Taste & Smell Changes # of taste buds and responses are unchanged
Olfaction ↓↓↓ significantly Detection thresholds increase 50% by age 80 Smell recognition decreases by 15% Decreased Smell leads to Decreased taste May predispose to malnutrition

Skin Changes Loss of subcutaneous fat Atrophy of sweat glands
Impaired vasoconstictor/vasodilator response in skin arterioles Decreased temperature discrimination Ineffective DNA repair

Skin Changes-Implications
Less fat over bony prominences (pressure ulcers) Temp discrimination impairments; Less efficient shivering; less muscle activity Hypothermia Higher temperature for sweating, less production Hyperthermia Ineffective DNA repair Carcinogenesis

Summary Changes in multiple organ systems are a part of normal aging
They may predisposed to disease but are not in of themselves pathologic Have clinical implications which may necessitate adjustment of treatment

Chronic Disease Management
Ugochi Ohuabunwa MD Division of General Medicine and Geriatrics Emory University School of Medicine

Ugochi Ohuabunwa, M.D. Personal/Professional Financial Relationships with Industry
External Industry Relationships * Company Name Role Equity, stock, or options in biomedical industry companies or publishers None Board of Directors or officer Royalties from Emory or from external entity Industry funds to Emory for my research Other

Learning Objectives Discuss the definition and epidemiology of chronic diseases Describe models of care in management of chronic diseases Compare and contrast acute and chronic disease management modalities Discuss effective inter-professional team collaborative practice in chronic disease management Describe the steps of management of a patient with Heart Failure using the Chronic Care Model

You as a patient…………. What would you consider to be excellent medical care if you had a chronic medical condition? How best would you like your disease managed? How do you think the medical practice where you are cared for should be best organized to provide excellent patient care?

You as a physician…………. What would you consider to be excellent medical care provided to your patients? How would you like your medical practice organized to facilitate provision of excellent patient care? What measures can your practice put in place to ensure that your patients are doing well and have good outcomes?

Mr. Smith – History of Present Illness
A 78-year-old man admitted to Emory University Hospital with three days of nausea and vomiting, shortness of breath, cough, and leg swelling. He had a heart attack in January Since then, he has had worsening symptoms of heart failure, necessitating five hospital admissions over the last six months

Past Medical History Coronary Artery Disease with Acute Heart Attack January 2013 Congestive Heart Failure High Blood Pressure High Cholesterol Diabetes Dementia

Medications on Admission
Furosemide 20mg once daily Clopidogrel 75mg once daily Aspirin 325mg once daily Simvastatin 20mg at night Metoprolol 25mg twice daily Lisinopril 20mg once daily Donepezil 10mg once daily Glipizide XL 10mg once daily

Social History Widowed and lives alone in an independent living senior high rise Has 2 living children both of whom live out of state Has a niece who checks in on him 3 times a week Does not drink alcohol, smoke or use recreational drugs

Functional History Able to complete his activities of daily living
Bathing Toileting Grooming Has had increasing difficulty in performing some instrumental activities of daily living due to his increasing shortness of breath Cooking Cleaning

Questions What do you think is going on with Mr. Smith?
Why the very frequent re-hospitalizations? As Mr. Smith’s physician, how best can you manage his acute and chronic medical problems? What do you think is going on with Mr. Smith? How are his medical, social situation and functional needs contributing to the recurrence of disease? Why the very frequent re-hospitalizations? Disease progression Inadequate medication treatment Inappropriate diet As Mr. Smith’s physician, how best can you manage his acute and chronic medical problems Treat the acute medical problem For the chronic medical problems, complete a comprehensive assessment of medical, social and functional problems that may be contributory to disease recurrence: Medical – Optimize medications and ensure patient is at goal - Ensure appropriate diet - Educate patient about disease process and medications and make sure he is engaged to care for himself Social: Evaluate home situation and harness resources to help patient with social needs such as medication supervision by a home health nurse Functional: Evaluate functional needs and harness resources to help patient – Home health aide to help with IADLS and medication supervision

Definition Chronic conditions are "any conditions that require ongoing adjustments by the affected person and interactions with the health care system." (Improving chronic illness care, 2008) Examples Asthma Diabetes Heart disease Hypertension High Cholesterol

Epidemiology 133 million people - almost half of all Americans, live with a chronic condition That number is projected to increase by more than one percent per year by 2030, resulting in an estimated chronically ill population of 171 million." Conditions such as asthma, diabetes, heart disease, obesity and tobacco are considered to be chronic conditions. Chronic conditions are continuing to increase; therefore developing innovative and impactful methods to deliver quality patient care are essential. It is suggested that:

Epidemiology 80% of persons over 65 have one or more chronic conditions Chronic conditions contribute to ¾ of the healthcare budget Need for development of innovative and impactful methods to deliver quality patient care

Epidemiologic Transition
Non-Communicable Disease Mortality Rates I would like to begin by talking about the Epidemiologic Transition. This picture shows the epidemiologic transition of disease patterns where a long-term shift has occured in mortality and disease patterns where pandemics of infection are replaced by non-communicable diseases including diabetes and cardiovascular disease. In developing countries, deaths due to infectious disease continue to decline and as Omran coins the…man-made diseases including diabetes continue to increase Infectious Disease Epidemiologic Transition Omran, A. The Epidemiologic Transition: A theory of the epidemiology of a population change. Milbank Q. 1971:49:

Transition in Health Care
PARADIGM SHIFT ACUTE CARE CHRONIC CARE With this shift in disease patterns, there should have emerged a transition in health care, however, at least in the United States, this did not occur. We still exist in an acute care model of health care deliver where care is more fragmented and reactionary. We need to change health care delivery to accommodate the epidemiologic transition to one that is more prevention focused and where care is coordinated and planned. Clearly the only acceptable alternative is to change. Focus: illness Care: fragmented Focus: prevention Care: coordinated

Current State of Primary Care Practice Acute Disease Management
Primary care practice largely designed To provide ready access and care to patients with acute problems Emphasis on triage and patient flow Short appointments Diagnosis and treatment of symptoms and signs Reliance on laboratory investigations and prescriptions Brief, didactic patient education Patient-initiated follow-up Can you fault this system

Current State of Primary Care Practice
Care is not necessarily based on evidence, but experience and training Seldom is there a team approach…care is mainly driven by the physician alone Paternalistic and directive approach with little attention to patients’ behavioral needs

Current State of Primary Care Practice
Limited access Insurer limitations Reluctance of primary care referral Fragmented access Poor information systems Poor tracking

Is the Current System Working?
Patients and families struggling with chronic illness have different needs These needs are unlikely to be met by an acute care organization and culture They require planned, regular interactions with their caregivers Need for focus on function and prevention of exacerbations and complications

Ideal Healthcare System
Evidence-based, planned care Systematic assessments Attention to treatment guidelines Reorganization of practice (team approach) Includes ancillary professionals with the patient as the most important member Attention to patient needs (information) Counseling, education, information feedback Behaviorally sophisticated support for the patient's role as self- manager

Ideal Healthcare System
Access to clinical expertise Patient and provider education, access to specialists Supportive information systems Patient registries Provider feedback on preventive service utilization

Models of Care in Chronic Disease Management
Chronic Care Model Guided Care Model Innovative Care for Chronic Diseases Model (World Health Organization) Stanford Self-Management Program Fennell Four Phase Model of chronic illness

Chronic Care Model (CCM)
CCM summarizes the basic elements for improving care in health systems on different levels The community The health system Self-management support Delivery system design Decision support Clinical information systems

The Chronic Care Model creates a more informed activated patient and a prepared proactive practice team working together in a partnership to improve functions and clinical outcomes. This model incorporates the paradigm shift from our current model of heath care delivery that is problem-based designed to handle acute patient problems to a system that is prevention based to avoid long-term problems such as diabetes complications. This however, is not done in isolation, it takes community resources, self-management support (diabetes education classes), decision support (clinical guidelines), Delivery system support which means designing the medical care environment to support preventive care to accommodate the patients physical, psychological/psychosocial and educational needs.

Guided Care Model In Guided Care, a specially-educated registered Guided Care Nurse, based in a primary care practice, works in partnership with 2-5 primary care physicians and other members of the health care team in providing 8 processes to chronically ill patients.

Guided Care Processes Assessing the patient and primary caregiver at home Creating an evidence-based comprehensive "Care Guide" (care plan) for providers and a patient-friendly "Action Plan" for patients and caregivers Promoting patient self-management Monitoring patient's conditions monthly The 8 inter-related clinical of combine scientific evidence with patients' preferences, priorities, and values:

Guided Care Processes Coordinating the efforts of all health care providers, healthcare facilities, rehab facilities, home care agencies, hospice programs, and social service agencies Smoothing transitions between sites of care, focusing more intensively on transitions into and out of hospitals Educating and supporting family caregivers Facilitating access to community resources

Back to Mr. Smith How best can we manage his illnesses?
Which model of care would be best suited for him? How will the model work?

A Review of His Chronic Medical Conditions
Coronary Artery Disease with Acute Heart Attack January 2013 Congestive Heart Failure High Blood Pressure High Cholesterol Diabetes Dementia

His Social History Widowed and lives alone in an independent living senior high rise Has 2 living children both of whom live out of state Has a niece who checks in on him 3 times a week Does not drink alcohol, smoke or use recreational drugs

His Functional History
Able to complete his activities of daily living Bathing Toileting Grooming Has had increasing difficulty in performing some instrumental activities of daily living due to his increasing shortness of breath Cooking Cleaning

Mr. Smith Based on this history, can you summarize the needs of Mr. Smith? Which of these needs would you like to address as Mr. Smith’s physician? How best can you organize your practice and harness resources to meet these needs?

Needs of Mr. Smith Medical Needs
Multiple medical diseases with frequent exacerbations Need for optimal medication management Need to ensure that these diseases are well controlled and are at goal Need to ensure that he is well informed and compliant

Needs of Mr. Smith Social Needs Functional Needs
Lives alone, only checked on 3ce a week by niece Has dementia and may be unable to manage his medications May also be forgetful of dietary needs and other self management measures Functional Needs Increasing difficulty with completing IADLs such as cooking May be eating the wrong things

Mr. Smith Which of these needs would you like to address as Mr. Smith’s physician? Medical needs? Social needs? Functional needs As a Clinician, which of these needs are your responsibility to meet? How best can you organize your practice and harness resources to meet these needs?

Mr. Smith Applying the Chronic Care Model to the management of his chronic medical conditions

Chronic Care Model Components
The community The health system Self-management support Delivery system design Decision support Clinical information systems

Linkages with community- based resources
1. The Community Linkages with community- based resources Exercise programs Senior centers Self-help groups Patient education classes Home care agencies

1. The Community Which community resources would Mr. Smith benefit from? Based on his Medical History Based on his Social History Based on his Functional History

2. Self-management Support
Involves collaboratively helping patients and their families acquire skills and confidence to manage their chronic illnesses through: Education on management of illnesses including - diet, exercise, medication use, self measurement Provision of self-management tools e.g, blood pressure cuffs, glucometers, bathroom scales Referrals to community resources Routinely assessing problems and accomplishment of goals

2. Self-management support
How can we help Mr. Smith acquire skills and confidence to manage his chronic illnesses? What should be the content of his education? What self-management tools can we provide Mr. Smith?

4. Delivery System Design
Redesign of the medical practice, creating practice teams with a clear division of labor Non physician personnel are trained to support Patient self-management Arrange for routine periodic tasks (e.g, laboratory tests, eye examinations, and foot examinations) Ensure appropriate follow-up Pre - planned visits are an important feature of practice redesign

4. Delivery System Design
Which members of the healthcare team should be involved in the care of Mr. Smith? Define the role of each member of the healthcare team and what services they should provide?

5. Decision Support Use of evidence-based clinical practice guidelines for optimal chronic care Guidelines integrated into daily practice through physician reminders Guidelines reinforced by physician “champions” leading educational sessions for practice teams Prompt access to specialists for expert evaluation

5. Decision Support You are the physician champion of the clinic
How can you ensure that members of the practice team are well equipped to provide up to date evidence based care to Mr. Smith? What systems can you create to ensure that Mr. Smith’s physician integrates evidence based practice guidelines into his routine management ? How can we coordinate his care to ensure ease of specialist referral?

6. Clinical Information Systems
Presence of computerized information system Has 3 important roles: As reminder systems that help primary care teams comply with practice guidelines As feedback to physicians, showing how each is performing on chronic illness measures such as HbA1c and lipid levels As registries for planning individual patient care and conducting population-based care

6. Clinical Information Systems
How can we incorporate the clinical information system into the management of Mr. Smith? Based on Mr. Smith’s medical history, what chronic illness measures would best be used for providing feedback to Mr. Smith’s doctor about his care? How best can we plan Mr. Smith’s care prior to and during each visit based on the information received from the computerized system?

Mr. Smith Summarize your goals and care plan for the management of Mr. Smith’s chronic medical illnesses Medical Functional Psychosocial

Conclusions Chronic Disease Management should not be problem-based, designed to handle only acute patient problems Should be a system that is prevention based to avoid long-term complications Should adopt a wholesome approach, taking into account the medical, psychosocial, functional and educational needs of a patient in order to harness available resources to meet these needs

Conclusions Should involve a well prepared proactive practice team with appropriately defined roles, operating with the support of clinical information systems to provide evidence based care Should collaboratively help patients and their families acquire skills and confidence to manage their chronic illnesses A successful chronic disease management model would result in a more informed activated patient and a prepared proactive practice team working together in a partnership to improve functions and clinical outcomes.

Division of general medicine & geriatrics
Appetite for Life Aging Week 2013 Camille Vaughan, MD, MS Assistant professor Division of general medicine & geriatrics Tuesday, November 12th, 2013

Camille Vaughan, MD, MS Personal/Professional Financial Relationships with Industry within the past year External Industry Relationships * Company Name(s) Role Equity, stock, or options in biomedical industry companies or publishers** None N/A Board of Directors or officer Royalties from Emory or from external entity Industry funds to Emory for my research Astellas Pharma, Inc Investigator Initiated Trial Other Kimberly-Clark, Corp. Spouse is full-time employee *Consulting, scientific advisory board, industry-sponsored CME, expert witness for company, FDA representative for company, publishing contract, etc. **Does not include stock in publicly-traded companies in retirement funds and other pooled investment accounts managed by others.

Learning Objectives Factors impacting the nutritional status of older adults Physiologic changes of aging which impact nutrient requirements Nutrients – which ones are most important? Health benefits and risks of weight loss in overweight and obese older adults The role of medical nutrition therapy Programs to enhance nutrition in community dwelling older adults

Role of Food/Nutrition in Aging
Physiologic well-being Quality of Life Social Cultural Psychological Promotes health and functionality Medical Nutrition Therapy (MNT) Disease management Lessen chronic disease risk Slow progression Lessen disease symptoms Position Paper, J Acad of Nutrition & Dietetics, 2012

Role of Food/Nutrition in Aging
Nurses’ Health Study ~ 10,000 women Healthy diet & Mediterranean Diet in mid-life associated with healthy aging (15 yrs later) Samieri et al. Ann Int Med 2013

Factors influencing nutritional status
Medical/Health Status Chronic/Acute illness Medications Sensory changes Oral health Cognition/Psychological Change in mental status Depression or emotional needs Habitual food intake Health/nutrition beliefs Advertising Nutritional Status Aging Process Environment Living situation Economics Cultural beliefs & traditions Religious beliefs & traditions Lifestyle Access to food & food prep Socialization Physical/Functional Status Physical limitations Balance Physical strength & endurance Physical activity Adapted from Bernstein and Luggen, Nutrition for Older Adults, 2010, Jones & Bartlett Learning

Medical & Health Status Factors
Medical conditions – acute & chronic Diabetes, infection, head injury Medications Common culprits Dysgeusia: Lithium, ACE inhibitors, some antibiotics, cancer drugs, chlorhexadine mouthwash, thyroid medications, metformin Xerostomia: Anticholinergics, diuretics Constipation: Anticholinergics, antiparkinsonian meds Altered absorption/metabolism: proton pump inhibitors, metformin Diminished smell/taste with advancing age Oral health – less saliva

Physical & Functional Status
Less physical activity is common Diminished ability to chew/swallow Ability to prepare food impacted by functional status Reduction in energy needs impacts ability to meet nutrient requirements Eating ‘nutritionally dense’ foods even more important

Cognition/Psychological Impact
Impacts ability to prepare foods Food choices may be impacted by habits (good/bad) Depression Labeling/advertising readability Nutrition beliefs

Environment Living situation Economics
Independent Assisted living Safety Economics Cultural/Religious beliefs/traditions Access to food – food security Availability of nutritionally adequate and safe food Socialization

Defining Food Insecurity
USDA defines based on questionnaire The three least severe conditions that result in a household being classified as food insecure: Worried whether food would run out before having money to buy more Food purchased didn't last, and didn't have money to get more Couldn't afford to eat balanced meals

Food Insecurity in Dekalb Cty

Food Insecurity Risk factors for food insecurity among older adults
Income below poverty line Population subgroups – ethnic minorities/rural Lower educational level Disabled Living with a grandchild Supplemental Nutrition Assistance Program (SNAP)

Nutrient Requirements
Physiologic changes of aging Total energy requirements decrease with aging Primarily due to decreased physical activity Loss of skeletal muscle mass Loss of 15% of fat free mass between age 30 and age 80 Increase in body fat and visceral fat Renal function Diminished ability to concentrate urine Blunted thirst sensation Most vitamin and mineral needs remain constant or increase despite need for lower caloric intake

Decline in Total Energy Expenditure with Aging
Basal Metabolic Rate Total Energy Expenditure Physical Activity Level Roberts & Dallal. Public Health Nutr 2005

Nutrients Requirements
Reference standards developed by the IOM Recommended Dietary Allowance (RDA) Started in 1941 Intake which is adequate for about 97-98% of healthy persons Dietary Reference Intakes (DRI) Started in early 1990’s by FDA More comprehensive – subsets for different age groups/men/women Include RDAs as well as other measures (like Adequate Intake [AI] when RDA is not established)

Fluid (includes high moisture foods) DRI for men ≥ 19 yrs = 3.7 L/day (no change for > 70 yrs) DRI for women ≥ 19 yrs = 2.7 L/day (no change for > 70 yrs) General recommendations in the clinic: 6-8 eight oz glasses of fluid daily Dehydration is a major problem in older adults Increases risk of constipation, impaction Increases risk of kidney injury in the event of an acute event like infection/fall

Fiber DRI for women ≥ 50 yrs = 21 g/day DRI for men ≥ 50 yrs = 30 g/day May be difficult to meet DRI without choosing fiber-rich foods Foods low in fiber Usually have inferior nutrient composition Contribute to discretionary energy intake (increase risk of obesity) In patients with poor appetite – high-fiber foods may lead to early satiety Adequate fluid intake is essential with fiber recommendations High fiber foods: pears, bran, whole grains, prunes, walnuts Fiber helps with bowel regularity, reduces risk of CHD, assists in glucose regulation

Protein RDA women & men ≥ 19 yrs = 0.8 g/kg/day 56 g/day for men, 46 g/day for women May be difficult with limited resources, reduced appetite Role of protein in the prevention of sarcopenia - unclear Troyer et al. Am J Clin Nutr 2010

Sodium DRI for women & men ≥ 70 yrs = 1,200 mg/day Upper Limit = 2,300 mg/day Most Americans consume 3,000 – 4,000 mg/day Delivering meals meeting DASH guidelines can improve adherence among older adults High sodium foods to avoid: white breads, chips, soups, processed foods Troyer et al. Am J Clin Nutr 2010

Vitamin D Vit D RDA for men & women ≥ 70 = 800 IU/day Classically recommended to prevent osteoporosis Vitamin D levels insufficient in most and deficient in many older adults At least 800 IU/day associated with decreased risk of falling Good sources: sun exposure, salmon, fortified foods Holick et al. NEJM 2007

Calcium Calcium RDA for men & women ≥ 70 = 1200 mg/day Calcium supplements (not dietary Ca) linked to increased risk of MI (regardless of dose) Good sources: broccoli, low-fat yogurt/cheese/milk Li et al. Heart 2012

B12 RDA for women & men ≥ 19 = 2.4 mcg/day Estimated 6-15% of older adults are deficient Causes: pernicious anemia, atrophic gastritis, associated with some drugs – metformin, lack of intrinsic factor No mandated fortification Complications of B12 deficiency: neurocognitive, peripheral neuropathy, macrocytic anemia, elevated homocysteine

Folate (fortification since 1998) RDA for women & men ≥ 19 = 400 mcg/day Excessive folic acid intake could mask B12 deficiency

Antioxidants Vitamin E, C, beta carotene, lutein, selenium, others Inconclusive research regarding antioxidant effects on vision (macular degeneration) and cognition Recent meta-analysis: omega-3 showed modest benefit to reduce MI risk Vitamin K AI for women ≥ 19 yrs = 90 mcg/day AI for men ≥ 19 yrs = 120 mcg/day Important for blood clotting, bone health Rizos et al. JAMA 2012

Overweight & Obesity in Older Adults
Weight management complicated in older adults Loss of excess fat mass can accelerate loss of muscle  risk factor for decrease functional capacity Combining with exercise may help prevent muscle loss Weight loss (even 5-10%) in overweight/obese older adults can result in improvements: Improved quality of Life Reduced medical complications Lower CVD/diabetes risk factors Reduced disability Less mechanical strain on joints Frimel et al. Med Sci Sports Exercise 2008

Overweight & Obesity in Older Adults
Sarcopenic obesity Coexistence of age-related loss of muscle mass/function and excess body fat Identification based on grip strength and BMI Likely potentiates effects on disability, morbidity, and mortality Prevalence ranges from 3.0% % depending on the definition used Stemholm et al. Curr Opin Clin Nutr Met Care 2008

Medical Nutrition Therapy
Provided by a Registered Dietician (RD) or Dietetic Technicians, registered (DTR) Medical Nutrition Therapy can include: Nutrition assessments Individualized interventions Counseling Management of parenteral feedings End-of-life care Covered by Medicare for diabetes and renal disease Also can be bundled in some home health services Screening Tool: Mini-Nutritional Assessment

Community-based Resources
Older Americans Act Nutrition Services Title III program started in 1965 Provides congregate and home-delivered meals In 2009, million meals were delivered to 880,135 individuals In 2008, 61% of meals delivered to homebound older adults In the Atlanta area – Senior Connections serves about 700,000 meals per year (Meals on Wheels) Delivery of meals within DASH guidelines increases adherence to dietary recommendations for older adults with CVD Troyer et al. Am J Clin Nutr 2010

USDA Food and Nutrition Programs Supplemental Nutrition Assistance Program (SNAP) Coupons or electronic benefits for nutritionally adequate food Bread, fruit/vegetables, meats, fish, poultry, dairy products, seeds, or plants that produce food US citizens and legal residents Gross income ≤130% federal poverty level Seniors’ Farmers Market Nutrition Program Coupons/vouchers to exchange at local farmer’s markets

How to access or assess eligibility? Atlanta Area Agency on Aging 24-hour referral line: Senior Connections (eligibility varies by county) Emory Dept of Medicine supports

Paying Homage Julia Child Remixed

Preparedness: “The Elephant in the Room”
BEFORE SCENE 1 Death and the dying process is complex and challenging for a number of reasons: 1) we do not like to think about it 2) most of our training if focused on diagnosis and treatment to prolong life and acknowledging death and dying may feel like ‘failing’ 3) patients don’t bring up the topic (although most have though about death and dying at some point in there life) but do want to talk about it,and 4) we (as physicians) are not taught how to talk about it. Thus far, today’s activities have introduced us to physical changes and symptoms, individual preferences and cultural issues, and how knowing about dying may impact one’s approach to physical changes, symptoms, and priorities. It has been about preparing you and your patients for the dying process and death. I hope it has been enlightening and has challenged you to think about these issues. One vital step remains… actually bringing up the topic with patients and families. Without this step no context for suffering, no reflection, no planning, no priorities can be set by your patients…. The final and key step to preparedness is communication with your patients. Jonathan M. Flacker MD AGSF Associate Professor Division of General Medicine and Geriatrics (with thanks to Dr. Adam Herman)

Dr. Jonathan Flacker Personal/Professional Financial Relationships with Industry within the past year External Industry Relationships * Company Name(s) Role Equity, stock, or options in biomedical industry companies or publishers** Stock (JNJ) Board of Directors or officer No Royalties from Emory or from external entity Nope Industry funds to Emory for my research Absolutely not Other Nah *Consulting, scientific advisory board, industry-sponsored CME, expert witness for company, FDA representative for company, publishing contract, etc. **Does not include stock in publicly-traded companies in retirement funds and other pooled investment accounts managed by others.

Learning Objectives By the end of this session the student will be able to: Describe 3 ways to make the environment conducive to a discussion about bad news Demonstrate how to begin a discussion of bad news Compare and contrast effective techniques for delivering bad news with good techniques

Preparedness An iterative process
All components revolve around knowledge and communication Common symptoms Individual preferences Cultural beliefs and values Recognized and communicate to patients that they are dying #1 - being prepared is a dynamic process, we have to educate and re-educate and reevaluate where our patients and families are at #2 - knowledge of the doctor, the patient and their families #3 - without communication patients and families cannot prepare and we cannot know there preferences and values

(Nicholas Christakis MD)
Preparedness Communication is key Ethical obligation to discuss dying with patients “Physicians have the DUTY to inform their patients about their illness and patients have a RIGHT to know.“ (Nicholas Christakis MD) Why? Why? Patients do not know what to expect They may have individual and cultural preferences that you do not know about …but this is not easy

If you are not prepared you can not plan
Preparedness If you are not prepared you can not plan For a game For a school For a baby For a death Must we must tell our patients (and families?) How can they prepare otherwise? Imagine not telling a patient that they were pregnant Not knowing why their sick in the morning, gaining weight, etc… Would not know they need to get a pediatrician, know what hospital to go to, why their having contractions

… not discussing death and dying is the elephant in the room
Preparedness So how do you broach such a sensitive topic? You know they are dying Patients and family often know Every one’s afraid to talk about it … not discussing death and dying is the elephant in the room You know they are dying Patients and families often sense that things are happening and often have though about dying We have to acknowledge to elephant in the room How do we do this…

Preparedness Components: Actors Setting/environment
Communication (language) Who Where and How

Scenario Mrs. Benford is here today to discuss tests results
She knows she Has cancer Is weak, in pain, and has lost 20 lbs Doctor knows Despite treatment cancer has spread There is no curative therapies We will have ‘time-outs’ to discuss key points in discussing death and dying Let’s see how thing go… Go to SCENE 1

What do you think?

Actors Who should be present? Doctor Patient Family Other
Doctor - not a responsibility you can delegate Patient - ALWAYS if at all possible Family - spouses, son’s daughters, the primary caregivers Other - Important Friends, Community Pastor, Other doctors involved with care.

Setting/Environment What is appropriate environment? Quiet
Undivided attention (no interruptions) Focus on patient and family (body language) Limit topics Kleenex Let’s fix what’s happened and watch some more… What was wrong with scene 1 GO TO SCENE 2

What do you think?

Communication Rule #1: Attentive Listening Listen
Corollary : Avoid information overload - they won’t hear it anyway Let them tell you what they understand and what they want to know #1 Very simple - open ears, keep your mouth closed - bite your tongue do what ever it takes #2 They may not be able to tell you technically what’s happening, but most patient and families understand the changes happening and see the decline in a palpable fashion #3 We often hide behind a veil of vocabulary because it’s hard, and we fear the things we need to say

Communication The one minute managing test

Communication Rule #2: Open ended questions
More information in less time Allows patient and family to prioritize Listen and reflect concerns Corollary to Rule #2: Close ended questions assumes the doctor knows the priorities of patient and family #1 Open ended questions that less time and provide more information and closed questioning and a ‘led’ conversation #2 Example of closed ended questions… anything that can be answered with a ‘yes’ or a ‘no’. The act of asking closed questions creates a clear dominance structure between patient and physician and assumes the physician knows the priorities of the patient and family. Unless you can read minds, don’t do this. More over never start with close ended questions - you may end up there to clarify details but they are never a starting point.

Communication Examples: “What changes have you noticed… ?” “What has changed for you… ? How?” “What do you understand about your illness(es)? “How has it changed recently?”

Communication Examples (cont): “What do you think is happening to you”
“… Tell me more about that…” Let’s watch some more… GO TO SCENE 3

What do you think? What is NOT being said?

Communication Say the words Let it lie… Allow time for response
Rule #3: Acknowledge the elephant in the room Say the words Let it lie… Allow time for response Corollary : Avoiding the elephant prevents you from fulfilling your duty as a physician If accomplished, you have the ability to move forward and set priorities and goals of care

Communication Rule #4: Give patient (and family) some wiggle room
Absolutes lead to polarization and confrontation Allows patient and family to talk ‘hypothetically’ Corollary : People put in a corner may become defensive, angry, and distrustful

Communication Rule #5: Silence is your friend
Let your statement and questions hang Let your statement and questions sink in Corollary : If there is no silence, you forgot Rule #1 and your patient can’t process Practice Don’t just do something…sit there…..

Communication How do we acknowledge the elephant? First…
Combine direct language (“death”, “dying”) WITH… ambiguous modifiers (“might”, “possible”) This allows ‘wiggle’ room Second… Silence is your friend This allows time to consider your statement

Acknowledging the Elephant
Examples: “Have you ever thought that you might be dying?” “Have you ever thought about your own death?” (let it hang…)

“No one can know for sure exactly what’s going to happen. But it’s possible you might be dying. So, it’s important to be prepared. That way all the bases are covered and you and your family will be ready whenever it occurs.” (silence…)

“All of us need to be prepared for death so that when it happens nothing is left unsaid or undone. Whether you die today or 10 years from now, it’s good to be prepared…” “If (hypothetically) you died today, what would be left unsaid or undone…” (let it lie…)

“No matter what you choose (treatment or no treatment), your life is limited. The task is still to get prepared for your death so you will be ready and that’s a good thing.” (let it hang out there…)

“Every day from today until the day you die is very precious. The fact that you have this __(insert condition/illness)_ means you may have even fewer days, which makes each day even more precious… How do you want to spend that time?” (silence…)

“Pretend like you knew you were going to die today. What hopes would you have? What is your idea of a ‘peaceful’ death…” (let it hang out there…)

“…I’m a bit hesitant to bring this up, yet I know it can be very important to patients in your situation to talk about. Most patients tell me they think about death as they are growing older and getting weaker. That’s a healthy thing to do…so we can be prepared for it…” (silence…)

What is the goal? … … to acknowledge death and dying and allow patients and their families to set priorities and goals of care with this knowledge in hand. Let’s see what happens… GO TO SCENE 4

Advanced Care Planning
Two major ways: The Living Will Power of Attorney for Health Care

The Living Will Usually covers specific directives course of treatment
forbidding treatment Effective ONLY if the person can’t give informed consent

Power of Attorney Appoints individual (a proxy) to direct health care decisions Effective ONLY if the person can’t give informed consent

Hospice Care Recognizes that: Dying is a normal process of living
Affirms life - neither hastens nor postpones death Belief that through appropriate care, individuals and their families will attain a degree of satisfaction in preparation for death

Relationship with Palliative Care
Hospice is a formalized way to deliver palliative care HOSPICE

Wrap -up Acknowledge the elephant Tell patients what to expect Act as a guide through the dying process Continue to be their doctor (do not abandon) Let’s see what happens… GO TO SCENE 5

Learning Objectives By the end of this session the student will be able to: Describe 3 ways to make the environment conducive to a discussion about bad news Demonstrate how to begin a discussion of bad news Compare and contrast effective techniques for delivering bad news with good techniques

Introduction to Geriatric Medicine

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