College of Physicians and Surgeons of OntarioQUALITY PROFESSIONALS | HEALTHY SYSTEM | PUBLIC TRUST

The Grey Tsunami: The Regulation of Aging

Professionals

Angela BatesManager, Committee Support

Compliance & Monitoring (CPSO)

“I have reached an age when, if someone tells me to wear socks, I don’t have to.”- Albert Einstein

College of Physicians

and Surgeons of Ontario

Key Themes Our Aging Population“Normal” Aging, “Successful” AgingThe Cognitive ContinuumRegulatory Approaches

College of Physicians

and Surgeons of Ontario

Our Aging PopulationStatistics Canada:

College of Physicians

and Surgeons of Ontario

Our Aging Population

College of Physicians

and Surgeons of Ontario

Our Aging PopulationAs the general

population ages, so does the professional population.

Should this worry regulators?

College of Physicians

and Surgeons of Ontario

“Normal” AgingEffects of normal aging on the body:

Sensory organsReflexes SkinBonesMetabolism and hormone production

College of Physicians

and Surgeons of Ontario

“Normal” AgingEffects of aging on the mind (cognition):

“Fluid” intelligence declinesDecline in recent memory/new memory formationAttention changesProcessing speed slows

*Effects vary considerably among individuals

College of Physicians

and Surgeons of Ontario

“Normal” AgingSome aspects of cognition tend to remain stable or improve with age:

Language, conversation skills“Crystallized” intelligence is stableRemote memory is preservedNew brain cells can still be formed

College of Physicians

and Surgeons of Ontario

Successful AgingRowe & Kahn, 1998

College of Physicians

and Surgeons of Ontario

The Cognitive Continuum

College of Physicians

and Surgeons of Ontario

Mild Cognitive Impairment (MCI)

More serious cognitive declineSubjective and objective indicatorsHigher risk of developing dementiaAble to function with adaptations

College of Physicians

and Surgeons of Ontario

Mild Cognitive Impairment (MCI)

Amnestic vs. non-amnesticThorough assessments necessary to determine underlying causeCan be compensated for (e.g., reminder lists) and does not necessarily interfere with daily living MCI may be early stage of Alzheimer’s

College of Physicians

and Surgeons of Ontario

Mild Cognitive Impairment (MCI)

Can an individual with MCI safely practise as a professional?

College of Physicians

and Surgeons of Ontario

DementiaMost common causes of age-related dementia:

Alzheimer’s DiseaseVascular (Blood Vessel) DementiaParkinson’s Disease

College of Physicians

and Surgeons of Ontario

Alzheimer’s DiseaseAccounts for 60-70% of all cases of dementiaMore prevalent at age 65 and older, but can begin in 40s and 50s.Slow onset: makes it difficult at first to distinguish normal “forgetfulness” from pathological condition.

College of Physicians

and Surgeons of Ontario

Alzheimer’s Disease

Progressive illness: worsens over time, to point where patient may not be able to respond to environment or remember loved ones.Treatment aimed at symptom

stabilization; no cure.

College of Physicians

and Surgeons of Ontario

Alzheimer’s Disease: Assessment & Diagnosis

Preferably conducted by neurologist and/or geriatricianNo definitive diagnostic test; e.g., no x-ray or scan or blood test but brain imaging may be used:

Single Photon Emission Computerized Tomography (SPECT) ScanPositron Emission Tomography (PET) Scan

College of Physicians

and Surgeons of Ontario

Vascular (Blood Vessel) Dementia

Second most common cause of dementiaNot a single disease, but a group of syndromes relating to different vascular mechanisms.May be caused by:

Stroke (CVA, or cerebrovascular accident): but all strokes do not necessarily cause dementiaNarrow or damaged blood vessels in the brain

College of Physicians

and Surgeons of Ontario

Vascular Dementia: Assessment & Diagnosis

Neurological examinationBrain imagingCarotid ultrasoundNeuropsychological testing

College of Physicians

and Surgeons of Ontario

Parkinson’s DiseaseProgressive disorder of the nervous system marked by impaired movement, coordination, cognition and affectCaused by impaired dopamine-producing cells in the substantia nigra portion of the brainDopamine is a neurotransmitter involved in regulation of movement and pleasure

College of Physicians

and Surgeons of Ontario

Parkinson’s Disease:Assessment & Diagnosis

Clinical history and observation:Tremor, slow movement, muscle rigidityOnset on one side of bodyResting tremorResponsiveness to dopamine

Neurological examination

College of Physicians

and Surgeons of Ontario

Capacity (Health) AssessmentsThreshold for triggering assessment?

Assessments are invasiveCannot be directed by regulator capriciously; must meet statutory threshold (if governing legislation articulates one); and take into account considerations of procedural fairness and privacy

College of Physicians

and Surgeons of Ontario

Capacity (Health) AssessmentsNeuropsychological

Assessment of functional capacityNeurological

Brain imaging (CT, MRI)GeriatricOccupational

College of Physicians

and Surgeons of Ontario

AdaptationMost professionals will adapt their practices as they age; e.g., limit tasks, hours of workIssues:

Professionals with financial issuesProfessionals who lack insight into health issues and potential impact of same

College of Physicians

and Surgeons of Ontario

Regulatory Approaches to MCI

The grey area: What options are there for addressing health assessments which indicate MCI, but which do not contain a clear statement of risk to public?

College of Physicians

and Surgeons of Ontario

Regulatory Approaches to MCIAvoid solo practiceClose practice supervision, with regular reportsRegular follow-up with

Family physicianGeriatricianNeuropsychological testing (repeat)Neurological examination (repeat)

College of Physicians

and Surgeons of Ontario

Regulatory Assessments

Competence (Quality Assurance)

Random?Age-targeted?

College of Physicians

and Surgeons of Ontario

ReferencesAging and Cognitive Decline:

Adler, R., Constantinou, C. (2008). “Knowing – or not knowing – when to stop: cognitive decline in doctors”. The Medical Journal of Australia 189 (11/12): 622-624.

Salthouse, T., Atkinson, T., Berish, D. (2003). “Executive functioning as a potential mediator of age-related cognitive decline in normal adults”. Journal of Experimental Psychology: General 132 (4): 566-594.

Salthouse, T. (2009). “When does age-related cognitive decline begin?”. Neurobiological Aging 30(4): 507-514.

Singer, T., Verhaegehn, P., Ghisletta, P., Baltes, P. (2003) “The fate of cognition in very old age: six-year longitudinal findings in the Berlin Aging Study”. Psychology and Aging 18 (2): 318-331.

College of Physicians

and Surgeons of Ontario

ReferencesSuccessful Aging:•Baltes, Paul B.; Baltes, Margret M. (1990). "Psychological perspectives on successful aging: The model of selective optimization with compensation". In Baltes, Paul B.; Baltes, Margret M. Successful Aging. pp. 1–3

•Depp, Colin A.; Jeste, Dilip V. (2009). “Definitions and predictors of successful aging: a comprehensive review of larger quantitative studies”. FOCUS 7 (1): 137–50.

•Jeste, D. V.; Harris, J. C. (2010). "Wisdom--A Neuroscience Perspective". JAMA: the Journal of the American Medical Association 304 (14): 1602

Rowe, J. W.; Kahn, R. L. (1997). "Successful Aging". The Gerontologist 37 (4): 433–40.

College of Physicians

and Surgeons of Ontario

ReferencesMild Cognitive Impairment:•Troyer, A., Murphy, K., Anderson, M., Moscovitch, M., Craik, F. (2008) “Changing everyday memory behaviour in amnestic mild cognitive impairment: A randomised controlled trial”. Neuropsychological Rehabilitation: An International Journal (8) 1: 65-68.

•Anderson, N., Murphy, K., Troyer, A. (2012). Living with MCI Oxford University Press: Toronto.

•Whitwell JL, Shiung MM, Przybelski SA, et al. (2008). “MRI patterns of atrophy associated with progression to AD in amnestic mild cognitive impairment”. Neurology 70 (7): 512–20

College of Physicians

and Surgeons of Ontario

Contact

Angela BatesManager, Committee SupportCompliance Monitoring & SupervisionCollege of Physicians and Surgeons of Ontarioabates@cpso.on.ca

College of Physicians

and Surgeons of Ontario

www.cpso.on.ca

8,884,383 visits