INTRODUCTION TO GERIATRIC MEDICINE

DEMOGRAPHICS

1900 – Life expectancy 47 years in US1900 – Life expectancy 47 years in US

4% over the age of 654% over the age of 65 Mid 1990’s – Life expectancy 65 years in USMid 1990’s – Life expectancy 65 years in US

12.6% over the age of 6512.6% over the age of 65 By 2020 - % over the age of 65By 2020 - % over the age of 65 By 2040 - % over the age of 65By 2040 - % over the age of 65

DEMOGRAPHICS

1900 – Life expectancy 47 years in US1900 – Life expectancy 47 years in US4% over the age of 654% over the age of 65

Mid 1990’s – Life expectancy 65 years in USMid 1990’s – Life expectancy 65 years in US12.6% over the age of 6512.6% over the age of 65

By 2020 – 17% over the age of 65By 2020 – 17% over the age of 65 By 2040 – 22% over the age of 65By 2040 – 22% over the age of 65 1/3 women live to 85; 15% men live to 851/3 women live to 85; 15% men live to 85 Causes of death: heart, cancer, stroke, lungCauses of death: heart, cancer, stroke, lung

DEMOGRAPHICS

More than 70% of people now live to 65 (3 More than 70% of people now live to 65 (3 times that of 1900)times that of 1900)

Life expectancy at age 65 is now >17 yearsLife expectancy at age 65 is now >17 years Population of US increased 3 fold in the Population of US increased 3 fold in the

2020thth century; 11 fold for those over 65 century; 11 fold for those over 65 1900 – 19% of those who died over age 651900 – 19% of those who died over age 65 2000 – 75% of those who die over age 652000 – 75% of those who die over age 65 Death rates changed from childhood and Death rates changed from childhood and

middle agemiddle age

CENTENARIANS

1900 – rare1900 – rare 2000 – 60,0002000 – 60,000 2050- >1,000,0002050- >1,000,000

CENTENARIANS

                                                                                                                

                                                                                                                                                                                        

DEMOGRAPHICS

85% over age 65 have one chronic illness85% over age 65 have one chronic illness 60% over age 65 have 2 or more chronic 60% over age 65 have 2 or more chronic

illnessesillnesses 17% age 65-74 functional limitations17% age 65-74 functional limitations 29% age 75-84 functional limitations29% age 75-84 functional limitations

FLORIDA DEMOGRAPHICS

1995 – 19% over age 651995 – 19% over age 65 2025 – 26% over age 652025 – 26% over age 65 Four surrounding Four surrounding

counties with mean age counties with mean age over 55 yearsover 55 years

Tampa Bay area has over Tampa Bay area has over half the skilled nursing half the skilled nursing units in the state and the units in the state and the two largest hospice two largest hospice organizations in USorganizations in US

THE MYTHS OF AGING

Sick, demented, frail, weak, disabled, Sick, demented, frail, weak, disabled, powerless, sexless, passive, alone, unhappypowerless, sexless, passive, alone, unhappy

Holding back societyHolding back society Scientific reality or not? Scientific reality or not?

MYTH # 1TO BE OLD IS TO BE SICK

Are the new seniors very sick/old or healthier?Are the new seniors very sick/old or healthier?Past: Infectious illnessesPast: Infectious illnessesMid century: Arthritis, HTN, heart diseaseMid century: Arthritis, HTN, heart diseaseNow: Decrease prevalence arthritis, HTN, Now: Decrease prevalence arthritis, HTN,

stroke, lung diseasestroke, lung diseaseCompression of morbidity; less institutionalizedCompression of morbidity; less institutionalized1994: 39% over 65 health very good or 1994: 39% over 65 health very good or

excellent with 29% fair or poorexcellent with 29% fair or poor

MYTH #2YOU CAN’T TEACH AN OLD DOG NEW TRICKS Fear of developing Fear of developing

Alzheimer’s diseaseAlzheimer’s disease Even those with short Even those with short

term memory problems term memory problems have been shown to have been shown to improve recallimprove recall

Deficits can be overcome Deficits can be overcome with proper training (lists, etc.)with proper training (lists, etc.)

MYTH #3 THE HORSE IS OUT OF THE BARN

Risky behaviors – no point in changingRisky behaviors – no point in changing Not too late for no smoking, exercise and Not too late for no smoking, exercise and

dietdiet

MYTH #4THE 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 Increased longevity of offspring of those

who died at much who died at much

earlier agesearlier ages

MYTH #5THE LIGHTS MAY BE ON BUT THE VOLTAGE IS LOW

Inadequate physical/mental/sexual abilitiesInadequate physical/mental/sexual abilities Sexual activity decreases in old ageSexual activity decreases in old age

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

SUCCESSFUL AGING*

Low probability of disease and Low probability of disease and disease related disabilitydisease related disability

High cognitive and High cognitive and functional capacityfunctional capacity

Active engagement with LIFEActive engagement with LIFE

*Rowe and Kahn, Gerontologist, 1997*Rowe and Kahn, Gerontologist, 1997

HEALTH

WHO: More than absence of diseaseWHO: More than absence of disease WHO: Presence of physical, mental and WHO: Presence of physical, mental and

social well being; perceived in the context social well being; perceived in the context of each individual’s experiences, beliefs, of each individual’s experiences, beliefs, and expectations. and expectations.

Can 2 individuals with same objective Can 2 individuals with same objective measures of health status have different measures of health status have different perceptions of health related quality of life?perceptions of health related quality of life?

GERIATRIC RX

Functionally oriented biopsychosocial model Functionally oriented biopsychosocial model fostering comprehensive, multidimensional fostering comprehensive, multidimensional approach to health assessmentapproach to health assessment

Context of patient’s beliefs and valuesContext of patient’s beliefs and values Must elicit values of patients to determine Must elicit values of patients to determine

benefits and burdens of interventionsbenefits and burdens of interventions

ELEMENTS OF ASSESSMENTS

Biomedical: acute/chronic diseases, physical Biomedical: acute/chronic diseases, physical function, ADLs, IADLsfunction, ADLs, IADLs

Psychological: Intellect. function, personality, mood, Psychological: Intellect. function, personality, mood, sensorium, psych history/symptomssensorium, psych history/symptoms

Social: Family structure/involvement, friends, co-Social: Family structure/involvement, friends, co-workers, neighbors, church, community, work workers, neighbors, church, community, work history, financial resources, health insurance, living history, financial resources, health insurance, living arrangements, life-stylearrangements, life-style

Values: Personal, cultural, ethnic, religious, spiritualValues: Personal, cultural, ethnic, religious, spiritual

PRINCIPLES OF GERIATRIC ASSESSMENT

GoalGoal Promote wellness, independencePromote wellness, independence

FocusFocus Function, performanceFunction, performance

ScopeScope Physical, cognitive, psychol, socialPhysical, cognitive, psychol, social

ApproachApproach MultidisciplinaryMultidisciplinary

EfficiencyEfficiency Perform rapid screens to identify Perform rapid screens to identify target areastarget areas

SuccessSuccess Maintaining/improving quality of Maintaining/improving quality of lifelife

STEPS TO ESTABLISH GOALS OF HEALTH CARE FOR ELDERLY1.1. Use biopsychosocial-values model to develop Use biopsychosocial-values model to develop

functionally oriented comprehensive health functionally oriented comprehensive health assessmentassessment

2.2. Develop all feasible options for care with Develop all feasible options for care with benefits/burdens/risks and projected outcomes.benefits/burdens/risks and projected outcomes.

3.3. Acknowledge uncertainty where presentAcknowledge uncertainty where present4.4. Relieve sufferingRelieve suffering5.5. Communicate effectively to patients and Communicate effectively to patients and

significant others; become patient advocatesignificant others; become patient advocate

PHYSICIAN ROLE

““The physician who enters the patient’s The physician who enters the patient’s universe and understands the universe and understands the patient’s perceptions, assumptions, patient’s perceptions, assumptions, values and beliefs is a tremendous values and beliefs is a tremendous advantage.”advantage.”

Peabody, 1927 Care of the Patient, Peabody, 1927 Care of the Patient, JAMAJAMA

““It is therapeutic for the patient to feel It is therapeutic for the patient to feel that the physician cares enough that the physician cares enough about the individual to understand about the individual to understand his life, particularly the meaning and his life, particularly the meaning and purpose of his present existence.”purpose of his present existence.”

Frankl 1959 (Man’s Search for Frankl 1959 (Man’s Search for Meaning) Meaning)