Richard E. Freeman MD MPH 2013 Lock Haven University A special thanks to Beth Clark MD FACP

1. Geriatrics OverviewHow 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

3. 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

7. Did you know...Two-thirds of all seniors in the world who have ever lived are alive today.

8. Geriatrics: • the branch of medicine that focuses on health promotion and the prevention and treatment of disease and disability in later life • Gerontology?

9. 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

10. 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

11. 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

12. 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

13. Geriatric Syndromes • Sensory Impairment (Visual and Hearing) • Gait Impairment • Falls • Incontinence • Dementia • Depression • Delirium • Poly-pharmacy • Sleep Problems • Pressure Ulcers

14. 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

15. Functional Reserve

16. 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

17. WHYWW

19. A Little History LessonPart 1 • Pre 1930 • – Age of Productivity- • New inventions- • Industrial revolution • Immigration active- European unrest • Baby’s born plentiful

20. Pre- 1930 care of the elderly • Shorter life expectancy • EXTENDED FAMILY • Alms houses • Rest Homes • Poor Houses and farms

22. History Part 2 • 1930-1940- • GREAT Depression, • Dust Bowl- famine- internal Migration- • Less immigration- European unrest • Baby’s less plentiful

23. 1930-1940 Care of the elderlyNEW DEAL

24. History Part 3 • 1940-1945 • 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

25. History Part 4 • 1946-1964 • Boys can home from WWII • “Healthy, wealthy, & horny” • Government subsidies, affluence, mobility, reconstruction- new infrastructure

26. Baby Boomers

27. HISTORY Part 5 • BABY BOOMER: born 1946-1964 • 76 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

28. 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.

29. 1965- Great societyLB JohnsonMEDICARE AND MEDICAID

30. Freeman’s boring statistics

31. 15.5 9.0 117.4 4

33. The Challenges of an Aging Population

35. 2000 U.S. Census DataNumber of persons (% of population)

36. HHS Projected cost 2010 data

37. % US Budget to service Heathcare costs

38. Medicine Nursing Social Work Psychiatry Psychology Case Management Physical Therapy Occupational Therapy Speech Pathology Pharmacology Chaplaincy Recreation Therapy Geriatric Interdisciplinary Team

39. 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

40. 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.

41. Sensory Impairment - Vision

42. 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?

43. 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

44. Cataracts

45. Glaucoma

46. Macular Degeneration

47. Diabetic Retinopthy

48. Low Vision Aids

49. Low Vision Aids

50. Gait Abnormalities and Falls