1 An Overview of Geriatric Health Care Dr. M.L. Donnelly Division of Community Geriatrics Vancouver-Fraser Medical Program Department of Family Practice University of British Columbia

2 Today’s Schedule 1:00 – 2:001:00 – 2:00 –An Overview of Geriatric Health Care Dr. M.L. Donnelly (VFMP)Dr. M.L. Donnelly (VFMP) 2:15 – 3:152:15 – 3:15 –local site: Geriatric Health Care resources VFMP: Dr. M.L. DonnellyVFMP: Dr. M.L. Donnelly IMP: Dr. David Evans, Clinical Instructor, UBC Dept. of Family PracticeIMP: Dr. David Evans, Clinical Instructor, UBC Dept. of Family Practice –Division of Geriatric Psychiatry – VIHA »Medical Consultant to Seniors Mental Health and Addictions Programs NMP: Dr. Ian SchokkingNMP: Dr. Ian Schokking –Clinical Associate Professor – UBC Dept. Family Practice

3 Asking questions in today’s lecture “ 4 words or less” otherwise use the mike

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5 An Overview of Geriatric Health Care 1.Demography 2.Normal aging 3.Disability and frailty 4.Values (theirs & ours) 5.Epidemiology

6 An Overview of Geriatric Health Care (cont’d) 6.Comprehensive geriatric assessment 7.Caregiver issues 8.Health promotion & prevention for seniors

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9 Health, illness and disease may overlap, but they are uniquely different facets of experience. Labonte, 1993

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15 Statistic Canada’s 1986 Health and Activity Limitation Survey 83% of those 75 to 84 and 89% of those 85+ reported mobility and agility related disabilities 47% of those 75 to 84 and 65% of those 85+ reported hearing disabilities

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17 The CSHA Clinical Frailty Scale 1.Very fit – robust, active, energetic, well motivated and fit; these people commonly exercise regularly and are in the most fit group for their age. 2.Well – without active disease, but less fit than people in category 1 3.Well, with treated comorbid disease – disease symptoms controlled compared with those in category 4.

18 The CSHA Clinical Frailty Scale 4.Apparently vulnerable – although not frankly dependent, these people commonly complain of being ‘slowed up’ or have disease symptoms 5.Mildly frail – with limited dependence on others for instrumental activities of daily living. 6.Moderately frail – help is needed with both instrumental and noninstrumental activities of daily living 7.Severely frail – completely dependent on others for the activities of daily living or terminally ill

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20 Three Greatest Fears of Seniors 1.Poor health 2.Loss of independence 3.Inadequate income

21 Determinants of Independence Determinants of Independence Marshall, 1995 Health Wealth Social integration

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23 Predictors of Institutionalization Availability of long-term care beds Absence of caregiver Functional incapacity Advancing age Presence of dementia Recent hospital admission Physical health deterioration Note: lack of informal support is main predictor

24 The average age of admission into a long- term care facility rose from 75 in 1977 to 85 in 1997

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26 Geriatric Giants 1.Delirium 2.Dementia 3.Depression 4.Incontinence 5.Falling 6.Medications 7.Illness interactions 8.Atypical presentations in the elderly

27 Incidence of Delirium in the Acute Care Hospital > Francis25.4% med 1992Francis22% med 1995 Chonchubhair 10% elderly gen/sx 20% elderly ortho/sx 1991Levkoffup to 51% med/sx

28 Canadian Study of Health and Aging Prevalence of Dementia

29 Common Causes of Dementia Alzheimer’s disease Vascular dementia Frontal temporal dementia Dementia with Lewy Bodies Parkinson’s disease with dementia

30 Prevalence of Depression

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32 Typical Altered Presentations of Specific Illness in the Elderly Depression without sadness Infectious disease without leukocytosis, fever, or tachycardia Silent surgical abdomen Silent malignancy (“mass without symptoms”) Nondyspneic pulmonary edema Apathetic thyrotoxicosis

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36 Comprehensive Geriatric Assessment

37 Comprehensive Geriatric Assessment HX Collateral Fe Pex Msex

38 Comprehensive Geriatric Assessment Comprehensive Geriatric Assessment (cont’d) Functional assessment Informal supports Formal supports DRUG review Nutritional review

39 Activities of Daily Living Instrumental ADL Scale Ability to use telephone Mode of transportation Responsibility of own medications Ability to handle finances Shopping Food preparation Housekeeping Laundry

40 Activities of Daily Living Physical Self-Maintenance Scale Toileting Feeding Dressing Physical ambulation Bathing Hobbies, leisure activities

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43 Comprehensive Geriatric Assessment Comprehensive Geriatric Assessment (cont’d) Investigations HOME assessment Risk assessment Health prevention/ promotion issues Advance directives

44 Information obtained from a home visit Suitability and safety of home for patient’s functional level Attitudes and presence of other persons at home Proximity and helpfulness of neighbors and relatives Emergency assistance arrangements

45 Information obtained from a home visit (cont’d) Nutritional and alcohol habits Actual and required daily living skills Hygiene habits Safety and convenience modifications needed Problems in getting to local stores and service picture

46 RISK

47 Comprehensive Geriatric Assessment Comprehensive Geriatric Assessment (cont’d) 1.Problems 2.Priorities 3.Goals 4.Care Plan

48 Quality of Life

49 Informal Caregiving 80% of care provided for seniors is informal care by family and friends Government policies shifting care to the community increase caregiver responsibilities The majority of informal caregivers are women (most are either the spouse or daughters)

50 Informal caregiving (cont’d) Women find caregiving more stressful than men Most caregivers are over 60 themselves and suffer from their own health care problems Care for the caregiver” “talk or action”

51 Informal Caregiving (cont’d) In a US study 52% of caregivers were under significant strain (Marchi-Jones 1996) Caregiver groups and education Respite care

52 Prevention and Health Promotion for Seniors 1.Health Enhancement exercise diet coping skills (eg. stress reduction techniques, assertiveness skills) Socialization 2.Risk Avoidance oral health driving competency assessments flu shots, pneumococcal vaccines powers of attorney, advanced directives, levels of intervention foot care falls risk assessment

53 Prevention and Health Promotion for Seniors (cont’d) 3.Risk Reduction smoking alcohol medication knowledge, management mobility aids home safety sun screens optimize sensory input (sigh, hearing) incontinence osteoporosis management

54 Prevention and Health Promotion for Seniors (cont’d) 4.Early Identification pap smears mammograms rectal examinations blood pressure thyroid status 5.Complication reduction

55 Friend or Enemy I can look At my body As an old friend Who needs my help Or an enemy who frustrates me In every way With its frailty And inability to cope. Old friend, I shall try To be of comfort to you To the end. May Sarton, Coming into Eighty

56 Geriatrics Mentoring Group Interested? Contact Martha Donnelly or Jacquie Bailey