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