Demographics of Aging and Geriatric Syndromes

1. Gerry Gleich M. D. Geriatrics Interclerkship April 26, 2013 Demographics of Aging and Geriatric Syndromes

2. Demographic Trends for Older Adults • 13% of the U.S. population is currently over 65 • By 2030 it is expected there will be 68 million Americans older than 65 or 20% of the population

3. Old Age Ain’t for Sissies

5. Life expectancy • In 1900 life expectancy was 47.3 years • By 1950 life expectancy was up to 68.2 years • 2010 life expectancy was 78.7 years

6. Gender and aging • Older women outnumber older men at 23.0 million older women to 17.5 million older men. • Current life expectancy for women is 81.1 years for men it is 76.2 years

7. Life expectancy • At age 65 life expectancy is about 19 more years • At age 75 life expectancy is about 12 more years • At age 85 life expectancy is about 7 more years

9. Race and aging • The geriatric population is becoming more ethnically diverse in the U.S. • Currently the non-hispanic white are 73.6 % of the elderly but expected to decline to 60.5% by the year 2030 • Increases in the Hispanic-American and Asian-American populations are expected

10. Marital status and aging • In the community 75% of men over 65 are likely to be married and living with their spouse • 41% of women over 65 are married and living with their spouse • 47% of women over 65 are widows • 13% of men over 65 are widowers

11. Living arrangements • Likelihood of living alone increases with aging • Options for living • Independent with or without assistance • Retirement communities • Group settings • Foster care • Assisted living • Long-term care

12. Patient needs Resources ADLs Spouse/Family IADLs Friends Physical Community Emotional Church Spiritual Financial Determinants of location of care and living arrangements

13. Independent Living Own home or apartment Congregate or senior housing may have: help with some household upkeep congregate meals activities staff specific home health services available through outside agencies Naturally Occurring Retirement Communities (NORC)

14. Assisted Living “A type of living arrangement in which personal care services such as meals, housekeeping, transportation, and assistance with ADLs are available as needed to people who still live on their own in a residential facility” Center for Medicare and Medicaid Services

15. 2007 975,000 residents 38,000 facilities (25-120 units) 2009 $3022/mo ave cost for pvt unit ($10K-$50K/yr range) Assisted Living Facilities of America National Center for Assisted Living Assisted Living

16. Most Assisted Living Facilities will provide: Health care management and monitoring Help with activities of daily living such as bathing, dressing, and eating Housekeeping and laundry Medication reminders and/or help with medications Recreational and social activities Security Transportation Emergency call system in each unit Assisted Living

17. Assisted Living Half the price of a nursing home, but what services are you getting? Liability is hurting development of the industry Much less regulation than nursing homes right now Aging in place is a big issue

18. 2010 15,622 facilities (MA 429) 1.66 million beds (MA 48,484) 1.4 million residents Av LOS 875 days Av cost $198/day (Alaska $687, MA $329) %≥65 yo in NH? www.longtermcare.gov www.statehealthfacts.org Long Term Care in Nursing Homes

19. Long Term Care in Nursing Homes Abuse in 1960s, 1970sled to Reforms in 1980s (OBRA ’87) led to Government regulation

20. Can Nursing Homes Be the Best Alternative?

21. Long Term Care in Nursing Homes How is it changing? Can we make it a more positive alternative? Resident-centered care

22. Health Care Costs

23. US Health Expenditures 2010

28. We Are About to Break the Bank

29. What’s next?

31. Some Features of “ACA” • Expanding access to insurance • Reducing administrative costs • Payment reform • Incentivize Electronic Health Records • Incentivize prevention and primary care • Accountable Care Organizations • Bundled payments • Payment for quality of care

32. Some Effects of ACA on Seniors • Improvements in Prescription Drug benefits • Premium increases for more wealthy seniors • Preventive services covered

33. Goals of Geriatrics • Respond to Changing Demographics and Economics • Improve quality of life and care • Minimize morbidity • Maximize function

34. How to meet our goals • Normal age-related changes vs. pathologic • Biopsychosocial model of care • Patient-centered Goal-Oriented Care

35. Geriatrics is Challenging • Age is not an accurate predictor of condition or function • Co-morbidities are common • Presentation of illness is altered (non-specific) • Homeostatic control is less efficient

36. Homeostenosis Less functional reserve. A Chain is only as strong as its weakest link

37. Cognitive Medical Polypharmacy Nutrition Functional Decline Social support Special senses Incontinence Environmental

39. Functional Status • The single best predictor of institutionalization is impaired functional status • Self-reported function is an accurate predictor of health risks and costs • 23% of older adults report some functional limitation in either ADLs or IADLs much higher percentage for the oldest segments

40. Predictive Value of Function Lubitz. NEJM 2003; 349:1048-55

41. ADL: Activities of Daily Living • Bathing • Dressing • Transferring • Toileting • Grooming • Feeding • Mobility

42. IADL: Instrumental Activities of Daily Living • Telephone • Meal preparation • Managing finances • Taking medications • Doing laundry • Doing housework • Shopping • Managing transportation

43. Geriatric Syndromes Common presenting complaints should make alarms sound in your head to think comprehensively. These presenting complaints are likely to have multifactorial causes including the effects of age-related changes and chronic disease mediated changes

44. Some Common Geriatric Syndromes • Frailty and failure to thrive • Dizziness • Syncope • Osteoporosis • Falls • Malnutrition • Urinary incontinence • Pressure ulcers • Dementia • Delirium • Polypharmacy More on some of these syndromes…

45. Contribution of Changes in Special Senses to Syndromes • Visual impairment • Hearing impairment

46. Cataracts Incidence is about 20% of those older than 65 and 50% of those older than 75 90% success with surgery (vision improved to at least 20/40) Surgery is safe taking less than 30 minutes: breakdown of old lens, and new lens implant About 15% of patients need addition laser capsulotomy after lens implant

47. Cataract Vision

48. Age Related Macular Degeneration Central vision is affected

49. Glaucoma- Los of peripheral vision

50. Hearing Impairment Affects 10% of adults over age 65 and 25% over age 75 Can contribute to social isolation, anger, depression, family arguments