Introduction to Geriatrics in Anatomy: Cadavers, Cases and Careers

1. ALPERT MEDICAL SCHOOL Introduction to Geriatrics in Anatomy: Cadavers, Cases and Careers Richard W. Besdine, MD,FACP Professor of Medicine Greer Professor of Geriatric Medicine • Director, Division of Geriatrics • Director, Center for Gerontology and Health Care Research

2. Maybe Aging isn’t so Bad Photo by Frank Fournier Foofie Harlan; age 75 (or 80?)

3. Learning Objectives Today To be able to answer the following questions: • What is geriatrics? • Who are geriatricians and what do we do? • Why are your cadavers ideal for learning about aging of the human body? • Why did your cadavers die, and what are the common causes of death in America?

4. Goals of Geriatrics Care SUCCESSFUL AGING Patient-centered care – preferences, well being Prevent or reduce disability, maximize physical and cognitive function Anticipate and prevent clinical catastrophes – no iatrogenic harm Evidence-based treatment of disease Manage complexity Palliative care principles Appropriate long-term care

5. Your Future Patients U.S. Birth Cohort 1946-64 - “Baby Boomers” 76 million - most will make it to Medicare (1/1/11) Best educated and wealthiest Americans ever Grew up in health care of the 1960s They saw their grandparents’ lives enhanced by Medicare via $, access, outcomes – expectations! This is the population which will bankrupt Medicare (Unless we change healthcare delivery in America) Seems sensible to learn about geriatrics

6. What is Geriatrics? The health professions discipline devoted to clinical care, teaching and research related to aging, as well as health and disease in older persons A major emphasis in geriatrics is to measure physical and cognitive function, then intervene in order to preserve and restore those functions Gerontology refers to research about aging Most care for older persons is delivered by generalist or specialist physicians, for whom enrichment in geriatrics care is essential

7. What is a Geriatrician? In medicine, a physician with expert knowledge of pure aging changes, and how these changes interact with disease in older adults to alter evaluation, treatment and outcomes of disease Also requires special expertise regarding diseases and sites of care especially common and important for older persons Most are internists or family physicians with fellowship training or extensive CME in geriatrics – can also be specialist consultants

8. My Career Path to Geriatrics • I began as a bench scientist in immunochemistry, with clinical training and certification in IM and ID • But I found the greatest professional satisfaction in managing the complexity and challenge of older patients with multiple diseases and medications • In 1972, no US academic programs; trained in UK • Returned to Harvard, determined to build the first US academic geriatrics program – we did • U CT in 1986, HCFA 1995-99, Brown in 2000 • Interim dean 2002-5; Reynolds Grant 2006

9. What’s it Like to be a Geriatrician? • Burning and answerable research questions; funding for scientists who pose them • Enormous opportunity for careers; clinical and academic positions nationwide – Brown a leader • Great sense of worth, satisfaction; but also frustration with a system that is inadequate • Practice rarely routine; patients are complicated, challenging and endlessly interesting • Highest job satisfaction of all specialties!

10. Physician Career Satisfaction by Specialty Data collected from 12,474 MDs in the late 1990s; spanning 33 specialties 5 variables: “very satisfied” - “very dissatisfied” Very satisfying or satisfying Normalized to family medicine = 1 Ger >2X; Neonat 1.9; Derm 1.5; Peds 1.3; Oto 1.8; OBG 1.6; Ophth 1.5; Ortho 1.4; IM 1.2 Leigh JP et al. Arch Intern Med. 2002;162:1577-84

11. Anatomical Changes of Pure Aging Does anything stay the same from 18 to 80? Skin – Thinner, hair loss, drier (wrinkles) CNS – Brain weight, mass  – function? Heart – LV stiffness, valve thickening, atheromatous deposition Lungs – Stiffening, less compliance Kidneys, Liver – Smaller, less blood flow, less clearance and detoxification Prostate – Bigger, but that’s not good Genitalia – wrinkles, but functional

12. Data on Your Cadavers 25 cadavers; 5>90, 13>80, 3 <70 Mean age = 81; median = 85 Why are they so old? Everyone is! Modern era of organ donation Elders more likely think of anatomical gift What did they die of? Death certificates are not reliable Nearly all died of age-disease interaction

13. BMS Class of 2012 Cadavers

14. BMS Class of 2012 Cadavers2 Mean age 81, median age 85

15. Your Cadavers’ Diseases (vs. 2011,10) Cardiac or respiratory arrest = 25! (24,24) Cancer = 10 (10,11) CAD/CHF = 9 (8,9) COPD/respiratory failure = 7 (3,4) Stroke 2 (3,1) Dementia/AD = 5 (3,3) Pneumonia = 3 (1,2) Renal Failure = 3 (1,0) DM, trauma, sepsis, pancreatitis, shock

16. Causes of Death in America 2006 Rate 3% from ’05 to ’06 – 4% >85 1. Heart disease (CAD/CHF) - 629,191 (9,8,9) 2. Cancer - 560,102 (10,10,11) 3. Stroke – 137,265 (2,3,1) 4. COPD 124,614 (7,4,4) 5. Unintentional injury - 117,748(1,0,1) 6. Alzheimer’s disease/dementia – 72,914(5,3,3) 7. Diabetes – 68,664 (1,1,1) 8. Flu/pneumonia – 54,095 (3,1,7)

17. BMS Class of 2012 Cadavers - Heart

18. BMS Class of 2012 Cadavers2 - Heart Mean age 81, median age 85

19. 1. Heart Disease (CAD/CHF/AMI) Commonest cause of death in America, and of death in older Americans Half of cardiac deaths due to tobacco use Of the remainder, another half estimated to be preventable by exercise and diet modification 9 of your 25 cadavers, but likely present in all Heart failure in older persons most often failure to relax, not failure to contract Thick, stiff LV; slow, inadequate diastolic filling – contractility normal – more next year

20. Prevalence of CVD by Age and Gender among Americans Men Women

21. BMS Class of 2012 Cadavers - Cancer

22. BMS Class of 2012 Cadavers2 - Cancer Mean age 81, median age 85

23. 2. Cancer Second commonest cause of death in America; large majority of cancer occurs in older persons 10 of your 25 cadavers, but not always cause; some can be biologically indolent (prostate, CLL) Many cancers are chronic diseases with modern chemo- and radiation therapy (colon, breast, lung), but still usually contribute to death Adequate chemotherapy often denied to elders based only on age – presumption of frailty; should be decided by functional status measurement and physiologic assessment

24. BMS Class of 2012 Cadavers - Stroke

25. BMS Class of 2012 Cadavers2 - Stroke Mean age 81, median age 85

26. 3. Stroke 3rd commonest cause of death in America 2 of your 25 cadavers; virtually always a major disability Most often a result of atrial fibrillation or long-standing HTN, hyperlipidemia, vascular disease, DM, tobacco Half the strokes that occur are deemed preventable (medication, behavior change)

27. BMS Class of 2012 Cadavers - COPD

28. BMS Class of 2012 Cadavers2 - COPD Mean age 81, median age 85

29. 4. COPD 4th commonest cause of death in America, and 4th among your cadavers - 7 of your 25 Large majority due to tobacco use, and thus preventable – counseling, patches work in elders; they are most likely to remain abstinent after quitting An especially bad way to die Treatment once established is only palliative

30. 5. Unintentional Injury (Table 2) 5th commonest cause of death in America and among elders; only one of your cadavers’ death certificates, but falls and fractures very common, and often the precipitant of a downward spiral Large majority preventable – interventions to bone density (exercise, Ca++, vitamin D) and falls (strength & balance training, meds, home safety) proven effective in elders Fatal vehicular crashes greatest/mile driven >65; greatest risk is dementia (usually AD)

31. BMS Class of 2012 Cadavers - Dementia

32. BMS Class of 2012 Cadavers2 - Dementia Mean age 81, median age 85

33. 6. Dementia AD is 6th leading cause of death in America; not in top 50 in first ¾ of 20th century “Epidemic” due to discovery of pathology in late 20th century and population aging, not disease  5 of your 25 cadavers; usually causal (3/4) when listed, but indirectly – how do AD patients die? ~5 million Americans; why so few deaths? Among commonest causes of disability Classic model of caregiver stress – dangerous to health of caregiver

34. Life Expectancy in Years Year We And Many Of Our Patients Will Live Long Enough To Develop AD Median survival of women in the longest-lived countries has increased 3 months/year since 1840 Oeppen J et al. Science. 2002;296:1029-1031

36. NORMAL ALZHEIMER’S DISEASE Source: Unknown

37. Source: Unknown

38. Alzheimer’s Disease I have spent my entire career in geriatrics evaluating, diagnosing and managing AD patients Treatment options have been primarily palliative, other than reducing impact of co-morbidities We now stand on the threshold of discovery of effective therapies; even better, prevention I predict the virtual eradication of AD in some populations of elders during your practice lifetimes Brown is a leader in research on aging– biology, epidemiology, clinical - including AD

39. BMS Class of 2012 Cadavers - Pneumonia

40. BMS Class of 2012 Cadavers2 - Pneumonia Mean age 81, median age 85

41. 8. Pneumonia With flu, 8th leading cause of death in America; number one in the first quarter of 20th century 3 of your 25 cadavers; usually causal if listed Although once a major killer of young adults, now a large majority of pneumonia deaths in elders with major chronic disease burden – “old man’s friend” Commonest infectious cause of hospitalization Classic cause of non-specific disease presentation in older adults – e.g., confusion, falls, incontinence, fainting, dizziness, weight loss (geriatrics syndromes; more later this year)

42. Goals for Prosection Session I and several other geriatricians will be visiting your tables for an afternoon in January Stimulated by today’s discussion and by a list you will get later in the year, we expect that you will identify anatomical findings in your cadavers relevant to older adults – both disease- and aging-related As your geriatricians walk the tables and spend time with each of you, our job will be to provide clinical context and correlation to the anatomical findings in your cadavers It should be enjoyable for all of us

43. Examples of Findings for Prosection CNS – brain atrophy, stroke or tumor; spinal stenosis BPH; shrunken kidneys; renal artery atheroma Hip fracture; joint replacement; osteoarthritic joints; carpal tunnel; cervical stenosis; compression fractures Solid cancers (gastric, colon, liver, lung, breast) Diverticulitis, gallstones Lymph nodes; skin cancers; LVH; aortic stenosis Foreign bodies - pessaries, stents, pacemakers, penile implants, valves, grafts, IVC filters; prior surgery (staples, sutures, scar tissue)

44. Jeanne Louise Calment Born in Arles, France 2/21/1875; died at 122 in Arles, 8/4/1997. She met Van Gogh in her father's shop. Her mother at died 86, father at 94,. She rode a bicycle until age 100. She ate 2 pounds of dark chocolate each week until she turned 119. “A kind God forgot me” Photo by N'geen Tien-Gamma Liasion