1. INTRODUCTION TO GERIATRIC MEDICINE

2. DEMOGRAPHICS 1900 – Life expectancy 47 years in US 1900 – Life expectancy 47 years in US 4% over the age of 65 Mid 1990’s – Life expectancy 65 years in US Mid 1990’s – Life expectancy 65 years in US 12.6% over the age of 65 By 2020 - % over the age of 65 By 2020 - % over the age of 65 By 2040 - % over the age of 65 By 2040 - % over the age of 65

3. DEMOGRAPHICS 1900 – Life expectancy 47 years in US 1900 – Life expectancy 47 years in US 4% over the age of 65 Mid 1990’s – Life expectancy 65 years in US Mid 1990’s – Life expectancy 65 years in US 12.6% over the age of 65 By 2020 – 17% over the age of 65 By 2020 – 17% over the age of 65 By 2040 – 22% over the age of 65 By 2040 – 22% over the age of 65 1/3 women live to 85; 15% men live to 85 1/3 women live to 85; 15% men live to 85 Causes of death: heart, cancer, stroke, lung Causes of death: heart, cancer, stroke, lung

4. DEMOGRAPHICS More than 70% of people now live to 65 (3 times that of 1900) More than 70% of people now live to 65 (3 times that of 1900) Life expectancy at age 65 is now >17 years Life expectancy at age 65 is now >17 years Population of US increased 3 fold in the 20 th century; 11 fold for those over 65 Population of US increased 3 fold in the 20 th century; 11 fold for those over 65 1900 – 19% of those who died over age 65 1900 – 19% of those who died over age 65 2000 – 75% of those who die over age 65 2000 – 75% of those who die over age 65 Death rates changed from childhood and middle age Death rates changed from childhood and middle age

5. CENTENARIANS 1900 – rare 1900 – rare 2000 – 60,000 2000 – 60,000 2050- >1,000,000 2050- >1,000,000

6. CENTENARIANS

7. DEMOGRAPHICS 85% over age 65 have one chronic illness 85% over age 65 have one chronic illness 60% over age 65 have 2 or more chronic illnesses 60% over age 65 have 2 or more chronic illnesses 17% age 65-74 functional limitations 17% age 65-74 functional limitations 29% age 75-84 functional limitations 29% age 75-84 functional limitations

8. FLORIDA DEMOGRAPHICS 1995 – 19% over age 65 1995 – 19% over age 65 2025 – 26% over age 65 2025 – 26% over age 65 Four surrounding counties with mean age over 55 years Four surrounding counties with mean age over 55 years Tampa Bay area has over half the skilled nursing units in the state and the two largest hospice organizations in US Tampa Bay area has over half the skilled nursing units in the state and the two largest hospice organizations in US

9. THE MYTHS OF AGING Sick, demented, frail, weak, disabled, powerless, sexless, passive, alone, unhappy Sick, demented, frail, weak, disabled, powerless, sexless, passive, alone, unhappy Holding back society Holding back society Scientific reality or not? Scientific reality or not?

10. MYTH # 1 TO BE OLD IS TO BE SICK Are the new seniors very sick/old or healthier? Past: Infectious illnesses Mid century: Arthritis, HTN, heart disease Now: Decrease prevalence arthritis, HTN, stroke, lung disease Compression of morbidity; less institutionalized 1994: 39% over 65 health very good or excellent with 29% fair or poor

11. MYTH #2 YOU CAN’T TEACH AN OLD DOG NEW TRICKS Fear of developing Fear of developing Alzheimer’s disease Even those with short Even those with short term memory problems have been shown to improve recall Deficits can be overcome Deficits can be overcome with proper training (lists, etc.)

12. MYTH #3 THE HORSE IS OUT OF THE BARN Risky behaviors – no point in changing Risky behaviors – no point in changing Not too late for no smoking, exercise and diet Not too late for no smoking, exercise and diet

13. MYTH #4 THE SECRET TO SUCCESSFUL AGING IS TO CHOOSE YOUR PARENTS WISELY Is the role of genetics overstated? Is the role of genetics overstated? Increased longevity of offspring of those who died at much Increased longevity of offspring of those who died at much earlier ages

14. MYTH #5 THE LIGHTS MAY BE ON BUT THE VOLTAGE IS LOW Inadequate physical/mental/sexual abilities Inadequate physical/mental/sexual abilities Sexual activity decreases in old age Sexual activity decreases in old age

15. MYTH #6 THE ELDERLY DON’T PULL THEIR OWN WEIGHT One third of elderly continue to work One third of elderly continue to work One third of elderly volunteer One third of elderly volunteer Others provide informal caregiving Others provide informal caregiving Many more are willing and able to work Many more are willing and able to work

16. SUCCESSFUL AGING* Low probability of disease and Low probability of disease and disease related disability High cognitive and High cognitive and functional capacity Active engagement with LIFE Active engagement with LIFE *Rowe and Kahn, Gerontologist, 1997

17. HEALTH WHO: More than absence of disease WHO: More than absence of disease WHO: Presence of physical, mental and social well being; perceived in the context of each individual’s experiences, beliefs, and expectations. WHO: Presence of physical, mental and social well being; perceived in the context of each individual’s experiences, beliefs, and expectations. Can 2 individuals with same objective measures of health status have different perceptions of health related quality of life? Can 2 individuals with same objective measures of health status have different perceptions of health related quality of life?

18. GERIATRIC RX Functionally oriented biopsychosocial model fostering comprehensive, multidimensional approach to health assessment Functionally oriented biopsychosocial model fostering comprehensive, multidimensional approach to health assessment Context of patient’s beliefs and values Context of patient’s beliefs and values Must elicit values of patients to determine benefits and burdens of interventions Must elicit values of patients to determine benefits and burdens of interventions

19. ELEMENTS OF ASSESSMENTS Biomedical: acute/chronic diseases, physical function, ADLs, IADLs Biomedical: acute/chronic diseases, physical function, ADLs, IADLs Psychological: Intellect. function, personality, mood, sensorium, psych history/symptoms Psychological: Intellect. function, personality, mood, sensorium, psych history/symptoms Social: Family structure/involvement, friends, co- workers, neighbors, church, community, work history, financial resources, health insurance, living arrangements, life-style Social: Family structure/involvement, friends, co- workers, neighbors, church, community, work history, financial resources, health insurance, living arrangements, life-style Values: Personal, cultural, ethnic, religious, spiritual Values: Personal, cultural, ethnic, religious, spiritual

20. PRINCIPLES OF GERIATRIC ASSESSMENT GoalPromote wellness, independence FocusFunction, performance ScopePhysical, cognitive, psychol, social ApproachMultidisciplinary EfficiencyPerform rapid screens to identify target areas SuccessMaintaining/improving quality of life

21. STEPS TO ESTABLISH GOALS OF HEALTH CARE FOR ELDERLY 1. Use biopsychosocial-values model to develop functionally oriented comprehensive health assessment 2. Develop all feasible options for care with benefits/burdens/risks and projected outcomes. 3. Acknowledge uncertainty where present 4. Relieve suffering 5. Communicate effectively to patients and significant others; become patient advocate

22. PHYSICIAN ROLE “The physician who enters the patient’s universe and understands the patient’s perceptions, assumptions, values and beliefs is a tremendous advantage.” Peabody, 1927 Care of the Patient, JAMA “It is therapeutic for the patient to feel that the physician cares enough about the individual to understand his life, particularly the meaning and purpose of his present existence.” Frankl 1959 (Man’s Search for Meaning)