Gerry Gleich M. D.Geriatrics Interclerkship April 26, 2013
13% of the U.S. population is currently over 65
By 2030 it is expected there will be 68 million Americans older than 65 or 20% of the population
In 1900 life expectancy was 47.3 years
By 1950 life expectancy was up to 68.2 years
2010 life expectancy was 78.7 years
Older women outnumber older men at 23.0 million older women to 17.5 million older men.
Current life expectancy for women is 81.1 years for men it is 76.2 years
At age 65 life expectancy is about 19 more years
At age 75 life expectancy is about 12 more years
At age 85 life expectancy is about 7 more years
The geriatric population is becoming more ethnically diverse in the U.S.
Currently the non-hispanic white are 73.6 % of the elderly but expected to decline to 60.5% by the year 2030
Increases in the Hispanic-American and Asian-American populations are expected
In the community 75% of men over 65 are likely to be married and living with their spouse
41% of women over 65 are married and living with their spouse
47% of women over 65 are widows13% of men over 65 are widowers
Likelihood of living alone increases with aging
Options for living Independent with or without assistance Retirement communities Group settings Foster care Assisted living Long-term care
Patient needs Resources
ADLs Spouse/FamilyIADLs FriendsPhysicalCommunityEmotional ChurchSpiritual Financial
Own home or apartment Congregate or senior housing
may have: help with some household upkeep congregate meals activities staff
specific home health services available through outside agencies
Naturally Occurring Retirement Communities (NORC)
“A type of living arrangement in which personal care services such as meals, housekeeping, transportation, and assistance with ADLs are available as needed to people who still live on their own in a residential facility”
▪ Center for Medicare and Medicaid Services
2007 975,000 residents 38,000 facilities (25-120 units)
2009 $3022/mo ave cost for pvt unit ($10K-$50K/yr range)
Assisted Living Facilities of America National Center for Assisted Living
Most Assisted Living Facilities will provide:
Health care management and monitoring Help with activities of daily living such as bathing, dressing, and eating Housekeeping and laundry Medication reminders and/or help with medications Recreational and social activities Security TransportationEmergency call system in each unit
Half the price of a nursing home, but what services are you getting?
Liability is hurting development of the industry
Much less regulation than nursing homes right now
Aging in place is a big issue
201015,622 facilities (MA 429)1.66 million beds (MA 48,484)1.4 million residentsAv LOS 875 daysAv cost $198/day
(Alaska $687, MA $329) %≥65 yo in NH? www.longtermcare.gov www.statehealthfacts.org
Abuse in 1960s, 1970s led to
Reforms in 1980s (OBRA ’87) led to
Government regulation
How is it changing?Can we make it a more positive
alternative?Resident-centered care
Expanding access to insuranceReducing administrative costs Payment reform Incentivize Electronic Health Records Incentivize prevention and primary
careAccountable Care OrganizationsBundled paymentsPayment for quality of care
Improvements in Prescription Drug benefits
Premium increases for more wealthy seniors
Preventive services covered
Respond to Changing Demographics and Economics
Improve quality of life and careMinimize morbidityMaximize function
Normal age-related changes vs. pathologic
Biopsychosocial model of carePatient-centered Goal-Oriented Care
Age is not an accurate predictor of condition or function
Co-morbidities are commonPresentation of illness is altered
(non-specific)Homeostatic control is less efficient
Less functional reserve. A Chain is only as strong as its weakest link
Functional Decline
Cognitive
Medical
Nutrition
IncontinenceEnvironmental
Special senses
Social support
Polypharmacy
The single best predictor of institutionalization is impaired functional status
Self-reported function is an accurate predictor of health risks and costs
23% of older adults report some functional limitation in either ADLs or IADLs much higher percentage for the oldest segments
Functional Status at Age 70
Life Expectancy (in years)
Annual Health Care Costs
Independent 14.3 $4,600
IADL Deficit Only 12.4 $8,500
1 + ADL Deficit 11.6 $14,000Lubitz. NEJM 2003; 349:1048-55
BathingDressingTransferringToiletingGroomingFeedingMobility
TelephoneMeal preparationManaging financesTaking medicationsDoing laundryDoing houseworkShoppingManaging transportation
Common presenting complaints should make alarms sound in your head to think comprehensively.
These presenting complaints are likely to have multifactorial causes including the effects of age-related changes and chronic disease mediated changes
Frailty and failure to thrive
Dizziness Syncope Osteoporosis Falls
Malnutrition Urinary
incontinence Pressure ulcers Dementia Delirium Polypharmacy
More on some of these syndromes…
Visual impairmentHearing impairment
Incidence is about 20% of those older than 65 and 50% of those older than 75
90% success with surgery (vision improved to at least 20/40)
Surgery is safe taking less than 30 minutes: breakdown of old lens, and new lens implant
About 15% of patients need addition laser capsulotomy after lens implant
Central vision is affected
Affects 10% of adults over age 65 and 25% over age 75
Can contribute to social isolation, anger, depression, family arguments
Cerumen drier and thickerTympanic membrane thickerOssicular joints degenerateCochlear changes
loss of hair cells stiffening of basilar membrane neuronal loss
Decreased central auditory processing
Ask the listener preferred way to communicate with them
Obtain listener’s attention before speaking Eliminate background noise Make sure the listener can see your lips Speak slowly and clearly avoid shouting Speak to the better ear Change phrasing if listener doesn’t seem to
understand Spell, use gestures or write down words Ask the listener to repeat what they heard
Complications of falls are the leading cause of death from injury in adults over age 65
33% of adults over age 65 report falling within the past year
Most result in minor soft tissue injuries 10-15% result in fractures 5% result in more serious soft tissue injury
or head trauma Cost is considerable – ED visits, admission
surgery etc.
Age related changesDisease related effectsMedication effectsEnvironmental
Visual declineVestibular loss of hair cells, ganglion
cellsPostural control declinesMuscle mass declinesBaroreceptor and autonomic nervous
system efficiency decline
Acute systemic illnessParkinson’sCVAOsteoarthritisNeuropathyVisual impairments
Psychotropic Medications Benzodiazepines SSRIs Antipsychotics
Cardiac – orthostatic hypotensionHypoglycemic agentsAnticholinergics
Minimize medications Prescribe exercise strength training Treat visual impairments Manage postural hypotension Supplement Vitamin D 800IU/day Manage foot and footwear issues Assistive devices and supervision as
needed Modify home environment
Affects 6-8% over age 65 and 30% over age 85
As baby boomers age this will be more and more common
Risk factors: Age, Family History, Down’s Syndrome, Head trauma, Fewer years of education, CV risk factors
Patients with mild cognitive impairment progress to Alzheimer’s at a rate of 12% per year
Alzheimer’s Disease –Gradual Progression 8-10 years, memory, language, visuospatial, and later apraxia
Vascular Dementia –Step-wise progression related to small vessel disease
Lewy Body Dementia- Gradual progression with Parkinson’s symptoms and hallucinations
Frontotemporal Dementia-may be more rapid and presenting with disinhibition
Maximize functionAssess goals and advance directives
earlyAssess caregiver resources,
understanding, and stress
Assess contribution of other medical conditions, environment and medications to overall picture
Could delirium or depression be present Metabolic profile Selective use of imaging
Onset at a young age <65 Sudden onset Focal neurologic findings Normal Pressure Hydrocephalus suspicion Recent fall or head trauma
Support function Physical activity Family and caregiver education and
support Environmental modification Attention to safety Advance directives Medications
May slow decline Can manage behavioral symptoms
Affects 15-30% of adults over age 65Affects 60-70% of long term care
residentsCan lead to cellulitis, ulcerations,
social isolation, falls, institutionalization
Improvements can be made with an organized approach
Urge Detrusor hyperactivity
Stress Pelvic floor relaxation and increased intra-
abdominal pressure Mixed Incomplete emptying
Dilated bladder with impaired contractility may also have detrusor hyperactivity with impaired contractility
Multifactorial Assess comorbidities, functional status
and medication effects U/A for hematuria and pyuria No routine culture. Positive culture may
reflect asymptomatic bacteriuria Consider post void residual
PVR >300 should lead to assessment of renal function and urology referral within 2 months
PVR 200-300 evaluate renal function within 3 months
PVR <200 maximize overall medical status
Behavioral Incontinence supplies
SurgicalPharmacologicCatheters
Extremely common in community dwelling older adults Difficulty falling asleep 40% Nighttime awakening 30% Early morning awakening 20% Daytime sleepiness 20%
At least one half of community dwelling older adults use OTC or prescription sleep medications
Total sleep time decreasesTime to fall asleep (latency) increase
or no changeSleep efficiency decreasesDaytime napping increasesPercent REM sleep decreasesWake after sleep onset increases
30-60% associated with psychiatric disorders (depression, anxiety)
Pain GE Reflux Nocturia Periodic Limb Movements Sleep related breathing disorders Dementia Medication effects
Sleep hygiene measures Regular times for sleep Bed for sleep only Exercise daily Relax before bed Limit food intake, stimulants, alcohol
before bed Dark quiet environment, comfortable
temperature for sleep Exposure to bright light during the day
Behavioral techniques to emphasize sleep hygiene Relaxation techniques Cognitive interventions Bright light therapy to correct circadian
rhythm disturbance
Try non-pharmacologic measures Avoid benzodiazepines
Associated with falls Rebound insomnia Sedation into the daytime Tolerance and withdrawal syndrome
Short acting nonbenzodiazepine-benzodiazepine receptor agonists NBRA’s (zaleplon, zolpidem, eszopiclone) Rapid onset take right before bed No rebound Only use 2-3 nights per week
Sedating antidepressants (mirtazapine, trazodone) for patients with depression
OTC Sleep Agents Avoid antihistamines - anticholinergic effects Melatonin – may be helpful Valerian no good evidence of efficacy Kava – risk of hepatotoxicity
The elderly account for 33% of drug costs in the U.S.
The average elderly person is on 4.5 prescription drugs and 3.5 OTC drugs at any given time
The risk of an adverse drug reaction is proportional to the number of drugs a person is taking
“Any new symptom should be considered a drug side effect until proven otherwise”
Reconcile medications at each visitStop unnecessary medications Weigh risk vs. benefit for any new
medConsider the big picture - functional
statusMonitor for adverse effectsAvoid the prescribing cascade
Goals change as overall level of function and health changes
Knowledge of natural history of diseases is important in helping to prognosticate
Knowledge of functional status is even more important
Keep the big picture in focus It can be a moving target so remain
flexible Do no harm and you can do a lot of good
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