1. Emory Reynolds Program PGY-1 Workshop Created by: Jonathan M. Flacker, M.D. jflacke@emory.edu

2. Objectives Warm-up Describe Traditional Medical Thinking Identify Important Principles of a Geriatric Medicine Approach (BIG 10) Have fun

3. What’s Different? So, what’s different about taking care of older patients? What’s different about Geriatrics?

4. Case Study(ies) in Geriatrics Describe the last senior patient you saw What are the key important points of this patient’s care?

5. Key Medical Issues? Pick a Disease, Any Disease…. –Epidemiology –Pathophysiology –Approach Testing Medications Interventions

6. TREATMENT SUCCESS!! Interventions Testing Medication Age Appropriate Expectations Identification of Problem Impact of Comorbidities Cognitive Affective Issues Collaborators Quality of Life Appropriate Site Social Situation Prevention Of Iatrogenesis Ethically Appropriate

7. THE MOST "AGED" NATION (HIGHEST % OVER AGE 65) IS_______________? SWEDEN Gerontology Quiz Adapted From Sokolovsky's Comparative Gerontology Quiz; by Jay Sokolovsky, Professor of Anthropology, University of South Florida

8. WHAT IS THE ONLY COUNTRY IN THE WORLD (PERHAPS IN HISTORY) WHERE THERE ARE MORE PEOPLE OVER 60 THAN UNDER 20? ITALY Gerontology Quiz Adapted From Sokolovsky's Comparative Gerontology Quiz; by Jay Sokolovsky, Professor of Anthropology, University of South Florida

9. NAME THE TWO COUNTRIES WHICH ARE CURRENTLY AGING THE FASTEST: JAPAN and CHINA Gerontology Quiz

10. IN THIRD WORLD COUNTRIES, BETWEEN NOW AND THE YEAR 2020 THE POPULATIONS OVER AGE 60 WILL GROW TWICE AS FAST AS THE PART OF THE POPULATION BETWEEN 5 AND 15. [True or False] TRUE Gerontology Quiz

11. THE SOCIETY WITH THE HIGHEST LONGEVITY IS __________? JAPAN Gerontology Quiz Adapted From Sokolovsky's Comparative Gerontology Quiz; by Jay Sokolovsky. Professor of Anthropology, University of South Florida

12. THE MAJORITY OF THE WORLD'S AGED POPULATION, OVER 65 YEARS OF AGE, LIVE IN THE INDUSTRIALIZED NATIONS OF NORTH AMERICA, EUROPE, JAPAN AND THE FORMER SOVIET UNION. [True or False] FALSE Gerontology Quiz Adapted From Sokolovsky's Comparative Gerontology Quiz; by Jay Sokolovsky, Professor of Anthropology, University of South Florida

13. THE AVERAGE MARRIED COUPLE, IN THE U.S. NOW HAS MORE PARENTS ALIVE THAN CHILDREN IN THEIR FAMILY. [True or False] TRUE Gerontology Quiz Adapted From Sokolovsky's Comparative Gerontology Quiz; by Jay Sokolovsky, Professor of Anthropology, University of South Florida

14. Intro to the Basics in Geriatrics 10 (“BIG” 10) Developed by the Emory Reynolds Program

16. SO, WHAT DO YOU THINK?

17. The BIG 10 1.Aging is not a disease

18. Peripheral Vascular Disease Newman: J Am Geriatr Soc, Volume 48(9).September 2000.1157-1162

19. But, What Does Happen With Aging?

20. Homeostenosis The depletion in physiologic reserves or diminished responsiveness to external stimuli with aging

21. The Average Younger Person Lungs REQUIRED LEVEL OF FUNCTION RESERVE Brain Muscles Balance Bladder

22. Older Person: Illness=Delirium Lungs REQUIRED LEVEL OF FUNCTION RESERVE Brain Muscles Balance Bladder

24. SO, WHAT DO YOU THINK?

25. The BIG 10 1.Aging is not a disease 2. Medical conditions in older patients are commonly chronic, multiple, and multifactorial

26. Specific Morbid Process Multiple Phenomenologies Cortisol Excess “Moon facies” “Buffalo Hump” Truncal obesity Skin thinning Easy bruisability Proximal muscle weakness Osteoporosis Traditional Medical Syndrome Flacker J. J Am Geriatr Soc 2003

27. Multiple Morbid ProcessesSpecific Phenomenology Delirium Syndrome Older age Severity of illness Dementia Medication effects Dehydration Sensory impairment Sleep disturbance The Geriatric Syndrome Flacker J. J Am Geriatr Soc 2003

28. Multifactorial Health Conditions Falls Depression Dizziness Delirium Incontinence

30. SO, WHAT DO YOU THINK?

31. The BIG 10 1.Aging is not a disease 2. Medical conditions in older patients are commonly chronic, multiple, and multifactorial 3. Reversible and treatable conditions are often underdiagnosed and under treated in older patients

32. Put In Order (Low to high) A.% Hospitalized Elderly Patients That Experience Delirium B.% Elderly Patients After Surgical Repair Of Hip Fracture Who Were Discharged With Delirium C.% Delirious Elderly Patients That Is Not Recognized By Physicians And Nurses D.% Elderly Patients Admitted To A Nursing Home Suffering From Some Degree Of Delirium

33. Put In Order A.% Hospitalized Elderly Patients That Experience Delirium (20%) B.% Elderly Patients After Surgical Repair Of Hip Fracture Who Were Discharged With Delirium (29%) C.% Delirious Elderly Patients Not Recognized By Physicians And Nurses (54%) D.% Elderly Patients Admitted To A Nursing Home Suffering From Some Degree Of Delirium (46%)

34. More To Put In Order (Low to high) A.%Prevalence Rate Of Osteoporosis In USA B.% Of Men Over 50 In The USA Who Will Have An Osteoporosis Related Fracture During Their Lifetime C.% Prevalence Of Undiagnosed Osteoporosis In Seniors In USA D.% Of White Women Over 50 Who Have Osteoporosis In The USA

35. More To Put In Order A.% Prevalence Rate Of Osteoporosis In USA (10%) B.% Of Men Over 50 In The USA Who Will Have An Osteoporosis Related Fracture During Their Lifetime (25%) C.% Prevalence Of Undiagnosed Osteoporosis In Seniors In USA (6.6%) D.% Of White Women Over 50 Who Have Osteoporosis In The USA (15%)

36. Still More To Put In Order (Low to High) A.% Prevalence Of Isolated Systolic Hypertension in Women > 65 Years Old in USA B.% Prevalence Of Isolated Systolic Hypertension in Men > 65 Years Old in USA C.% Reduction In Occurrence Of Congestive Heart Failure As A Result Of HTN Treatment For 3-5 Years D.% Reduction in Occurrence Of Strokes Among Treated Older Patients With Blood Pressure Reductions Of 12 to 14 mm Hg Systolic and 5 to 6 mm Hg Diastolic

37. Still More To Put In Order A.% Prevalence Of Isolated Systolic Hypertension in Women > 65 Years Old in USA (30%) B.% Prevalence Of Isolated Systolic Hypertension in Men > 65 Years Old in USA (20%) C.% Reduction In Occurrence Of Congestive Heart Failure As A Result Of HTN Treatment For 3-5 Years (48%) D.% Reduction in Occurrence Of Strokes Among Treated Older Patients With Blood Pressure Reductions Of 12 to 14 mm Hg Systolic and 5 to 6 mm Hg Diastolic (30%)

38. What Else?

40. SO, WHAT DO YOU THINK?

41. The BIG 10 1.Aging is not a disease 4. Functional ability and quality of life are critical outcomes in the geriatric population 2. Medical conditions in older patients are commonly chronic, multiple, and multifactorial 3. Reversible and treatable conditions are often underdiagnosed and under treated in older patients

42. ADL OR IADL? EATING ADL

43. ADL OR IADL? HOUSEKEEPING IADL

44. ADL OR IADL? TELEVISION REMOTE USE OK, Neither

45. ADL OR IADL? SHOPPING IADL

46. ADL OR IADL? DRESSING ADL

47. ADL OR IADL? BABYSITTING OK, Neither

48. ADL OR IADL? HYGEINE ADL

49. ADL OR IADL? ACCOUNTING IADL

50. ADL OR IADL? TRANSPORTATION IADL

51. ADL OR IADL? TOILETING ADL

52. ADL OR IADL? PET CARE OK, Neither

53. ADL OR IADL? FOOD PREPARATION IADL

54. ADL OR IADL? AMBULATING ADL

55. FUNCTIONAL ASSESMENT Dressing Eating Ambulating Toileting Hygiene Shopping Housekeeping Accounting Food Preparation Transportation ADLsIADLs

57. SO, WHAT DO YOU THINK?

58. The BIG 10 1.Aging is not a disease 4. Functional ability and quality of life are critical outcomes in the geriatric population 2. Medical conditions in older patients are commonly chronic, multiple, and multifactorial 5. Social history, social support, and patient preferences are essential aspects of managing geriatric patients 3. Reversible and treatable conditions are often underdiagnosed and under treated in older patients

59. Living Arrangements of Older Men Living Arrangements of Older Women LIVING ARRANGEMENTS ARE IMPORTANT!

60. Caregiver Burden Any examples?

61. Source: Administration on Aging. Achieving Cultural Competence: A Guidebook for Providers of Services to Older Americans and Their Families. www.aoa.gov www.aoa.gov Aging Quick Fact # 2 Question: What Ethnic Group Is Estimated To Have The Largest Percent Population Of Older Persons Living In Poverty?

62. What Are The Leading Causes of Death for Persons Age 65 and Over? How Do They Differ By Ethnicity? WHITEBLACKAMERICAN INDIAN ASIAN OR PACIFIC IS. HISPANIC 1Heart Disease 2Cancer 3Stroke DiabetesStroke 4COPDDiabetesStroke Pneumonia / Influenza COPD 5 Pneumonia / Influenza COPD Pneumonia / Influenza Source: Administration on Aging. Achieving Cultural Competence: A Guidebook for Providers of Services to Older Americans and Their Families. www.aoa.gov www.aoa.gov Aging Quick Fact # 3

64. SO, WHAT DO YOU THINK?

65. The BIG 10 1.Aging is not a disease 4. Functional ability and quality of life are critical outcomes in the geriatric population 2. Medical conditions in older patients are commonly chronic, multiple, and multifactorial 5. Social history, social support, and patient preferences are essential aspects of managing geriatric patients 10.Ethical issues and end-of- life care are critical aspects of the practice of geriatrics 3. Reversible and treatable conditions are often underdiagnosed and under treated in older patients

66. MOCK COURT: Can She Make This Decision?

67. Group 1 Explain why the Doctor was WRONG to allow Mrs. Dubois to make this decision

68. Group 2 Explain why the Doctor was RIGHT to allow Mrs. Dubois to make this decision

69. Group 3 Decide which arguments are compelling and reasonable

70. GO

71. Competency Competence is presumed unless a court has determined that an individual is incompetent A judicial declaration of incompetence may be global or limited (e.g., to financial matters, personal care, or medical decisions)

72. Decision-Making Capacity A clinical term that is task-specific In order to make valid treatment decisions, a person must be able to: –Recognize there is a decision to be made –Understand The needed information The treatment options The likely consequences of each option (i.e. risks, burdens, and benefits) –Rationally manipulate the information to come up with a decision consistent with his or her values.

73. PRACTICE TOOL Aid To Capacity Evaluation (ACE) Etchells et al. Assessment of patient capacity to consent to treatment. J Gen Intern Med. 1999;14(1):27-34

74. “ASK THE DOCTOR”

75. Question #1 WHAT IS A HEALTH CARE PROXY? –Under most state laws a competent person can authorize another person, to make health care decisions if the patient is unable to do so –Done by completing the state-specific standard health care proxy form

76. Question #2 WHY DO I NEED A HEALTH CARE PROXY? –Without a health care proxy a doctor may be required to provide medical treatment that you would have refused if you were able to do so

77. Question #3 WHEN DOES IT TAKE EFFECT? –The health care proxy becomes effective only when the patient is unable to make decisions, as determined by a physician –Until then, the patient continues to be in charge of making their own health care decisions – It can be revoked orally, and one always have the right while competent to sign a new health care proxy

78. Question #4 HOW IS A HEALTH CARE PROXY DIFFERENT THAN A POWER OF ATTORNEY? –A power of attorney primarily authorizes the person designated to make financial decisions but it cannot be used to make health care decisions –A health care proxy must be completed for an agent to make health care decisions when one is not able

79. Question #5 WHAT IS THE DIFFERENCE BETWEEN A HEALTH CARE PROXY AND A LIVING WILL? –A living will is a document signed in advance in which one specifically sets forth decisions about health care treatment – Unlike the health care proxy, however, it does not authorize one to appoint an agent to make decisions that were not anticipated when you completed the living will

80. Practice Tool Georgia Health Care Proxy Form Georgia Durable Power of Attorney for Health Care

82. SO, WHAT DO YOU THINK?

83. The BIG 10 1.Aging is not a disease 4. Functional ability and quality of life are critical outcomes in the geriatric population 2. Medical conditions in older patients are commonly chronic, multiple, and multifactorial 5. Social history, social support, and patient preferences are essential aspects of managing geriatric patients 10.Ethical issues and end-of- life care are critical aspects of the practice of geriatrics 3. Reversible and treatable conditions are often underdiagnosed and under treated in older patients 9. Geriatric care is provided in a variety of settings ranging from the home to long-term care institutions

84. Personal Care Homes (PCHs) PCHs provide: –Lodging –Food –Some Support Services Elderly or Mental or Physical Disabilities –Unable to care for themselves –Do not require 24 hour nursing services –Need help with IADLs and ADLs

85. Assisted Living Designed for older people who cannot live on their own Specially constructed for care of seniors Generally apartment style with wheelchair access, emergency call pull cords, etc. Typically, assistance with bathing and dressing, supervision of medications, assistance with toileting, management of bladder and bowel incontinency, and special diets Typically intermittent skilled nursing services such as diabetic insulin injections or colostomy care can are handled by outside licensed home health agencies Private Pay

86. Skilled Nursing Facility (SNF) SNF Rehab Provides: –Transitional step between hospital stay, another level of care, or home –Rehabilitation program for those lacking endurance/need for an acute rehabilitation program –Plan of care focused on stabilizing patients following acute illness or injury Payment => Medicare –Only pays while receiving actual medical services for 100 days –Only pay for the first 20 days for skilled care –For days 21-100, for skilled care, Medicare will pay for all allowable costs over $97 a day. The patient will have to pay up to $97 a day.

87. Acute Rehabilitation Hospital Acute rehabilitation program is a highly structured Intensive interdisciplinary program intended for patients with significant functional impairments Must follow “75% rule” and “3 hour rule” Provides patients with a supportive, structured and coordinated rehab program designed to improve the ability to perform daily living tasks Medicare Payment based on RUGs

88. Where Else ?

90. SO, WHAT DO YOU THINK?

91. The BIG 10 1.Aging is not a disease 4. Functional ability and quality of life are critical outcomes in the geriatric population 2. Medical conditions in older patients are commonly chronic, multiple, and multifactorial 5. Social history, social support, and patient preferences are essential aspects of managing geriatric patients 10.Ethical issues and end-of- life care are critical aspects of the practice of geriatrics 3. Reversible and treatable conditions are often underdiagnosed and under treated in older patients 8. Iatrogenic illnesses are common and many are preventable 9. Geriatric care is provided in a variety of settings ranging from the home to long-term care institutions

92. Are Hospitals Good For Your Health? Deconditioning Incontinence Falls Delirium Malnutrition Dehydration Etcetera, Etcetera, Etcetera…..

93. Hazards of Hospitalization in Older Persons Creditor, Ann Intern Med 1993;118:219-223

95. SO, WHAT DO YOU THINK?

96. The BIG 10 1.Aging is not a disease 4. Functional ability and quality of life are critical outcomes in the geriatric population 2. Medical conditions in older patients are commonly chronic, multiple, and multifactorial 5. Social history, social support, and patient preferences are essential aspects of managing geriatric patients 10.Ethical issues and end-of- life care are critical aspects of the practice of geriatrics 3. Reversible and treatable conditions are often underdiagnosed and under treated in older patients 8. Iatrogenic illnesses are common and many are preventable 9. Geriatric care is provided in a variety of settings ranging from the home to long-term care institutions 7. Cognitive and affective disorders are prevalent and commonly undiagnosed at early stages

97. Q & A Do you screen for cognitive impairment? How? Do you screen for depression? How?

99. The BIG 10 1.Aging is not a disease 4. Functional ability and quality of life are critical outcomes in the geriatric population 2. Medical conditions in older patients are commonly chronic, multiple, and multifactorial 5. Social history, social support, and patient preferences are essential aspects of managing geriatric patients 6.Geriatric care is multidisciplinary 3. Reversible and treatable conditions are often underdiagnosed and under treated in older patients 10.Ethical issues and end-of- life care are critical aspects of the practice of geriatrics 8. Iatrogenic illnesses are common and many are preventable 9. Geriatric care is provided in a variety of settings ranging from the home to long-term care institutions 7. Cognitive and affective disorders are prevalent and commonly undiagnosed at early stages

100. SO, WHAT DO YOU THINK?

101. Multidisciplinary “Survivor” Hypothetical Scenario: The new CEO of a large public hospital is forced to make significant budget cuts. As the head of your department you must explain the importance of you discipline to the multidisciplinary care of patients In the Health Care System

102. Multidisciplinary Survivor You have 5 minutes to present your case. Don’t be surprised if the CEO asks some tough questions At the end the department heads will each complete a list in order of from who should be cut the most to who should be cut the least The area targeted for the least budget cuts wins!

103. GO

104. The BIG 10 1.Aging is not a disease 2.Medical conditions in older patients are commonly chronic, multiple, and multifactorial 3.Reversible and treatable conditions are often underdiagnosed and under treated in older patients 4.Functional ability and quality of life are critical outcomes in the geriatric population 5.Social history, social support, and patient preferences are essential aspects of managing geriatric patients 6.Geriatric care is multidisciplinary 7.Cognitive and affective disorders are prevalent and commonly undiagnosed at early stages 8.Iatrogenic illnesses are common and many are preventable 9.Geriatric care is provided in a variety of settings ranging from the home to long-term care institutions 10.Ethical issues and end-of- life care are critical aspects of the practice of geriatrics

105. Objectives Warm-up Describe Traditional Medical Thinking Identify Important Principles of a Geriatric Medicine Approach (BIG 10) Have fun

106. The videos used in this presentation were developed by the University of Wisconsin Reynolds Program for educational use only. The remainder of the presentation was developed by the Emory University Reynolds Program. For more information contact jflacke@emory.edu.