The Librarian as Gerontologist

1. The Librarian as Gerontologist Rosanne M Leipzig MD PhD Professor and Vice Chair Departments of Geriatrics and Medicine Mount Sinai School of Medicine

2. Aging: The Numbers

3. There were 3 million Americans over age 65 in 1900 • What’s the estimated number for 2030? A. 10 million B. 30 million C. 50 million D. 70 million ***

5. Medical Librarians Are Also Aging Medical Library Association. Hay Group/MLA 2005 salary survey [Web document]. 2005 [cited 10/12/2007].

6. Projected Population Distribution

7. What percent of those 65+ are high school graduates? A. 10% B. 30% C. 50% D. 70% ***

8. Education level of older population

9. Percentage of all persons over 65 living in nursing homes? A. 5% B. 10% C. 15% D. 20% ***

10. Nursing Home Population By Age: 2000 %

11. Percentage of all persons over 65 living with their spouses? A. 20% B. 35% C. 50% D. 65% ***

12. Living Arrangements of Persons 65+

13. Social Activities

14. Leisure-time Physical Activity 65+2004-5 % engaged in REGULAR ACTIVITY CDC http://209.217.72.34/aging/TableViewer/tableView.aspx?ReportId=383

15. Reporting Good to Excellent Health

17. Disability in Aging: The Good News in the U.S. • age 65-74: 89% report no disabilities • age 85+: 40% report no disabilities • In 1999, there were 1.4 million fewer disabled persons than there would have been if health status had not improved since 1982.

18. The Librarian As Gerontologist:What Do You Need To Know • How does aging affect one’s health and well-being? • What might physicians and other health care professionals be asking you about aging? • What might the public be asking about aging?

19. AAMC/John A. Hartford Foundation Consensus Conference on Geriatric Competencies: July, 2007 • Rationale: • Almost every graduate of every medical school will be providing care to older adults • Faculty who received little exposure and training in the care for the elderly are uncomfortable teaching geriatrics to students- don’t know where to start • Lists of geriatric curriculum topics exist, but are extensive and imprecise

20. AAMC/John A. Hartford Foundation Consensus Conference on Geriatric Competencies: July, 2007 • Goal: Consensus on minimum standards for graduating medical students • Input provided by many non-geriatric educators • Results • 8 content domains identified • 26 minimum geriatric competencies identified within these domains

21. Competency Domains • Atypical Presentation of Disease • Medication Management • Cognitive and Behavioral Disorders • Falls, Balance, Gait Disorders • Self-Care Capacity • Health Care Planning and Promotion • Palliative Care • Hospital Care for Elders

22. Atypical Presentation of Disease

23. Acute MI: 30 Day Mortality Adjusted ORs % 2.00 1.69 1.49 1.21 Ref Adapted from Mehta RH et al. J Am Coll Cardiol 2001;38:736-41

24. Presentation of MI:Chest Pain 80 70 60 50 40 30 20 10 0 <70 70-74 75-79 80-84 >85 Adapted from Bayer et al JAGS 1986;34:263-266

25. Painless MI in Patients>70 yrs: Presenting Symptoms Dyspnea Syncope Stroke Confusion Weakness Giddiness Vomiting Sweating Palpitations Bayer et al. JAGS 1986;34:263-266

26. Atypical Presentation of Disease • Generate a differential diagnosis based on recognition of the unique presentations of common conditions in older adults, including • Acute coronary syndrome • Dehydration • Urinary tract infection • Acute abdomen • Pneumonia.

27. Compensatory Response to Orthostatic Hypotension 1. Compensate for hypovolemia: • Thirst response • ADH secretion • Increase urine concentration 2. Increase heart rate

28. Compensatory Response to Orthostatic Hypotension in Elders 1. Compensate for hypovolemia: • Thirst response • ADH secretion • Increase urine concentration 2. Increase heart rate

29. Atypical Presentation of Disease • Identify at least 3 physiologic changes of aging for each organ system and their impact on the patient, including their contribution to homeostenosis (the age-related narrowing of homeostatic reserve mechanisms).

30. Medication Management

31. Medication Management:Drugs to Watch Out For • Identify medications, including • Anticholinergic • Psychoactive • Anticoagulant • Analgesic • Hypoglycemic • Cardiovascular drugs that should be avoided or used with caution in older adults and explain the potential problems associated with each.

32. Medication Management • Explain impact of age-related changes on drug selection and dose based on knowledge of age-related changes in: • renal and hepatic function • body composition, • and Central Nervous System sensitivity.

33. Why you become a cheaper drunk as you age • As you get older, • Higher blood alcohol concentrations • Worse for women than men • Less tolerance for quantities previously enjoyed • Brain more sensitive • Balance worse even without the alcohol

34. Common Diseases 65+2004-5 % CDC http://209.217.72.34/aging/TableViewer/tableView.aspx

35. Medication Management • Document a patient’s complete medication list, including: • prescribed, • herbal and • over-the-counter medications, and for each medication provide the dose, frequency, indication, benefit, side effects, and an assessment of adherence.

36. Anti-Aging Medicine

37. Growth Hormone Levels Decline with Age

38. Growth Hormone • Review of 18 studies (31 publications) • 220 participants; Mean age 69 • Positive Results • Fat Mass decreased 2.1 kg • Lean Mass increased 2.1 kg • No change: cholesterol, BMD, other lipids Liu H et al. Annals Int Med 2007; 146:104-115

39. Growth Hormone: Down Side • Increased • Soft tissue swelling • Joint pain • Carpal tunnel syndrome • Breast swelling • New onset diabetes • Impaired fasting glucose Liu H et al. Annals Int Med 2007; 146:104-115

40. Cognitive and Behavioral Disorders

41. Severe Memory Impairment

42. Severe Depressive Symptoms

43. Cognitive and Behavioral Disorders • Define and distinguish among the clinical presentations of delirium, dementia, and depression • Perform and interpret a cognitive assessment in older patients for whom there are concerns regarding memory or function . • Formulate a differential diagnosis and implement initial evaluation in a patient who exhibits cognitive impairment. • .

44. Cognitive and Behavioral Disorders • Urgently initiate a diagnostic work-up to determine the root cause (etiology) of delirium in an older patient. • Develop an evaluation and non-pharmacologic management plan for agitated demented or delirious patients.

45. Falls, Balance, Gait Disorders

46. I Fall To Pieces $200% of healthy elders in the community that fall annually • 5% • 15% • 30% • 45% ***

47. Falls, Balance, Gait Disorders • Ask all patients > 65 y.o., or their caregivers, about falls in the last year, watch the patient rise from a chair and walk (or transfer), then record and interpret the findings.

48. Significant Risk Factors for Falls in Elders • Medications • Cognitive impairment • Lower extremity disabilities • Balance and gait abnormalities • Poor vision and/or hearing • Medical Disorders • Previous Falls • Level of activity • Upper extremity weakness

49. Multiple Falls vs. Number of Risk Factors Percent with Two or More Falls in One Year Number of Risk Factors* * White, previous falls, arthritis, parkinsonism, difficulty rising, poor tandem gait. Nevitt JAMA, 1989. (n=325)

50. Falls, Balance, Gait Disorders • In a patient who has fallen, construct a differential diagnosis and evaluation plan that addresses the multiple etiologies identified by history, physical examination and functional assessment.