1. Geriatrics 101: How are older patients different from all other patients and why does it matter? Elizabeth Clark, MD, FACP Associate Director/Clinical, VISN 3 GRECC Bronx VA Medical Center Associate Professor of Geriatrics Mount Sinai School of Medicine

2. 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 syndrome 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

6. 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

7. 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

8. 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

9. Social Problems More Common with Aging Loss of income Loss of close family Loss of community Social isolation

10. Geriatric Syndromes Sensory Impairment (Visual and Hearing) Gait Impairment Falls Incontinence Dementia Depression Delirium Polypharmacy Sleep Problems Pressure Ulcers

11. Functional Reserve 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

12. Functional Reserve

13. 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

14. The Challenges of an Aging Population

15. 2000 U.S. Census Data Number of persons (% of population) Total< 65>6465-7475-84>85 USA 273,643,274 (100) 240,529,940 (87.9) 33,113,334 (12.1) 18,108,981 (6.6) 11,708,844 (4.3) 3,295,509 (1.2) NY State 18,395,995 (100) 16,058,189 (87.3) 2,337,806 (12.7) 1,253,232 (6.8) 834,532 (4.5) 250,042 (1.4) NY City 7,825,848 (100) 6,913,082 (88.4) 912,766 (11.6) 493,874 (6.2) 319,936 (4.1) 99,956 (1.3) NY County 1,477,358 (100) 1,294,714 (87.6) 182,644 (12.4) 92,857 (6.3) 65,301 (4.4) 24,486 (1.7) Bronx County 1,327,690 (100) 1,093,593 (89.9) 134,097 (10.1)

16. VISN 3 Primary Care Patients Age Distribution of Unique SSNs seen in FY2007

18. VISN 3 FY2007 Med./Surg. Discharges

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

22. 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

23. 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 on the Upper West Side, the other lives in California but calls frequently.

24. Sensory Impairment - Vision

25. 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?

26. 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

27. Cataracts

28. Glaucoma

29. Macular Degeneration

30. Diabetic Retinopthy

31. Low Vision Aids

33. Gait Abnormalities and Falls

34. How could a fall interfere with Jenny’s ability to monitor and treat her diabetes? What other aspects of Jenny’s life could be affected by gait disturbance or a fall? What are some of the barriers to diagnosis and treatment of gait abnormalities and falls risk in the elderly? What roles can the different members of the interdisciplinary team play help Jenny to address her recent fall so that it does not lead to additional functional decline?

35. Gait Abnormalities and Falls Gait disorders are common in the elderly – At least 20% of community dwelling seniors report gait problems requiring assistance –In one study, >50% of those 85 and older reported difficulty walking –The presence of a gait disorder often heralds functional decline –The etiology of gait disorders is usually multifactorial

36. Gait Abnormalities and Falls Falls –30-40% of community dwelling seniors fall each year –Falls often result in decreased independence Decreased functional status Increased rate of NH placement Increased use of medical services Increased fear of falling –Falls result in injury and death Most result in soft tissue injury, 10-15% in fracture Complications from falls are the leading cause of death from injury among those >65 Death rate from falls increases with age –Lifetime cost of falls related injuries for those >65 has been estimated at $12.6 billion –Etiology of falls multifactorial Includes medical, environmental, sensory and postural issues

37. Gait Abnormalities and Falls

43. Dementia

44. How could the development of dementia interfere with Jenny’s ability to monitor and treat her diabetes? What other aspects of Jenny’s life could be affected by dementia? What are some of the barriers to diagnosis and treatment of dementia in the elderly? How can the different members of the interdisciplinary team help Jenny and her family in addressing her dementia and maintaining independence and function for as long as possible? What are some of the key issues that need to be addressed as she faces this progressively debilitating and life limiting illness? If Jenny does not have dementia, what could she do to try to prevent it?

45. Dementia will reach epidemic proportions by 2040 Alzheimer's Disease accounts for the vast majority of dementias in the US Among people >65, the prevalence of AD is 6-8% Among people >85, the prevalence is 30% 4 million people in the US currently suffer from AD By 2040, AD patients will number 14 million

46. Alzheimer’s Disease

47. Costs of Dementia Decreased quality of life for patient and family –Loss of independence in ADLs and IADLs –Need for supervision, outside caregivers Financial burdens on family and society –Lost wages and direct costs for caregivers –$100 billion spent annually in US on care Difficulties obtaining appropriate medical care –Inability to give accurate history –Inability to understand and follow directions and medical regimens

48. “A A A, O x 3” is not very helpful Dementia, in its early stages, is often missed by medical professionals and families Up to 50% of moderate dementias are missed by physicians Patients can remain oriented to person, place and time long after they have developed serious impairments in other areas of cognitive function

49. Screening for dementia can avert many future problems in diagnosis treatment and management Have a high index of suspicion –Forgetfulness, getting lost, inability to follow medical regimen, poor personal hygiene Use validated screening tools –MMSE, animal naming test, clock drawing test Look for reversible causes of dementia –B12 def, sensory def., depression, thyroid disease Obtain history from other sources

50. Clock Drawing Test

52. Dementia Prevention

58. Conclusion Aging presents a unique set of challenges both to individuals and to the health care professionals who care for them. The range in presentation is tremendous: there 90 year olds who are still working and living independently in the community while there are 70 year olds who require institutional care. Early signs of serious problems are easy to miss on routine examination Addressing geriatric issues and syndromes can help the elderly maintain function and independence Even patients without apparent deficits may have little functional reserve so that an acute illness or insult can lead to disability and dependence far more frequently than among younger individuals

59. Conclusion, continued Older people comprise ever increasing portions of the general and patient populations and are the largest users of health care resources Geriatric care is best provided by an interdisciplinary team The pool of geriatric specialists in all disciplines is insufficient to meet current needs and is not expected to increase significantly despite increasing demands over the next quarter century All health care professionals, thus, need to learn the basic principles of geriatrics and acquire core clinical skills in the care of the older patient