Overview of Geriatry and the common elderly problems. Suitable for most health sciences courses.

1. Geriatrics Overview
How are older patients different from all other
patients and why does it matter?
Richard E. Freeman MD MPH
2013
Lock Haven University
A special thanks to
Beth Clark MD FACP
Geriatrics Dept
Bronx VA MC
Mt. Sinai Medical Center

3. Learning Objectives
• Understand some of the unique issues and challenges
that face older people and the healthcare professionals
who care for them
• Understand the demographic imperative for all health
care professionals to learn basic principles of geriatrics
• Understand how the presence of one or more geriatric
syndromes can have a profound effect on an older
person’s ability to meet a new medical challenge and
maintain function and independence, even where there
is no prior history of disability or functional decline
• Understand how different members of the
interdisciplinary team work collaboratively to address
geriatric syndromes and issues and so improve the
health and independent function of older patients

7. • Did you know...
Two-thirds of all seniors in the world who
have ever lived are alive today.

8. Geriatrics:
– the branch of medicine that focuses on health
promotion and the prevention and treatment
of disease and disability in later life
• Gerontology?

9. The Challenges of Aging –
How older patients are different from all other patients
• As people age, some physiologic changes are
inevitable
•
• Other changes, while not universal, are far more
common than among younger people
• Older people also face unique psycho-social
challenges
• These changes and challenges can lead to a
variety of geriatric syndromes and issues
• These in turn can lead to poor health outcomes,
functional decline, frailty, disability and
dependence

10. Physiologic Changes Associated
with Aging
• Examples of universal changes
– Decreased night vision
– Decreased muscle mass
– Loss of hair pigment
– Decreased lung vital capacity
– Decreased height
– Decreased gait speed

11. Physiologic Changes Associated
with Aging
• Examples of changes (including diseases) that
are increasingly common, though not inevitable,
as people age
– Hearing loss
– Macular degeneration
– Hypertension
– Heart disease
– Cancer
– Parkinson’s disease
– Dementia

12. Social Problems More Common
with Aging-
The Age of LOSS
• Loss of income
• Loss of close family
• Loss of community
• Loss of physical and mental functions
• Loss of mobility
•Social isolation

13. Geriatric Syndromes
• Sensory Impairment (Visual and Hearing)
• Gait Impairment
• Falls
• Incontinence
• Dementia
• Depression
• Delirium
• Poly-pharmacy
• Sleep Problems
• Pressure Ulcers

14. Functional ReserveTheory
• Most of the body’s organ systems have some
degree of redundancy – for instance, there are
more kidney cells than absolutely needed so
that kidney function can continue even if cells
are lost to disease or other insult
• As people age, functional reserve diminishes so
that an acute insult can have much more severe
consequences, whether it is in kidney function or
cognitive function or even social function

15. Functional Reserve

16. The Challenges of an Aging
Population – Why it matters
• In the 2000 US Census, 12.5% of the US
population was >64
• By 2030, it is predicted that 20% of the US
population will be >64
• As the elderly population increases the
care needs and expenditures for that care
will increase
• The geriatric workforce is not predicted to
increase to meet this demand

17. WHY
WW

19. A Little History Lesson
Part 1
• Pre 1930
• – Age of Productivity-
• New inventions-
• Industrial revolution
• Immigration active- European unrest
• Baby’s born plentiful

20. Pre- 1930 care of the elderly
• Shorter life expectancy
• EXTENDED FAMILY
• Alms houses
• Rest Homes
• Poor Houses and farms

22. History Part 2
• 1930-1940-
• GREAT Depression,
• Dust Bowl- famine- internal Migration-
• Less immigration- European unrest
• Baby’s less plentiful

23. 1930-1940 Care of the elderly
NEW DEAL

24. History Part 3
• 1940-1945
• World War II
• Fertile men off to war
• Fertile women in the work place
• BIRTH RATE DROPS
• 418,500 USA lost persons
– 70 million worldwide

25. History Part 4
• 1946-1964
• Boys came home from WWII
• “Healthy, wealthy, & horny”
• Government subsidies,
affluence, mobility,
reconstruction- new
infrastructure

26. Baby Boomers

27. HISTORY Part 5
• BABY BOOMER: born 1946-1964
• 76 million babies
• wealthiest,
• most active,
• most physically fit generation up to that time,
• amongst the first to grow up genuinely expecting
the world to improve with time.
• received peak levels of income, reaped the
benefits of abundant levels of food, apparel,
retirement programs, and sometimes even
"midlife crisis" products

28. Baby Boomers- Characteristics
• control over 80% of personal financial
assets
• more than half of all consumer spending.
• Buy 77 % of prescription drugs and 61% of
over-the-counter drugs,
• 80% of all leisure travel.[
• they would rather pass on their inheritance
as charity than pass it down to their
children.

29. 1965- Great society
LB Johnson
MEDICARE AND MEDICAID

30. Geriatric Interdisciplinary Team
• Medicine
• Nursing
• Social Work
• Psychiatry
• Psychology
• Case Management
• Physical Therapy
• Occupational Therapy
• Speech Pathology
• Pharmacology
• Chaplaincy
• Recreation Therapy

31. Case Discussion
• We will look at the case of a highly functional
and independent senior citizen who has recently
been diagnosed with diabetes
• We will discuss 3 geriatric syndromes (visual
impairment, falls and dementia) and see how
these could have a deleterious effect on her
ability to manage this new diagnosis, maintain
her ADLs and IADLs and ultimately to remain in
the community.
• We will also discuss how different members of
the interdisciplinary team can contribute to her
care

32. The Case of Jenny Smith
• Jenny Smith is an 83 year old woman with hypertension
and osteoporosis for which she is on appropriate
medication and follows a diet and exercise program. Her
doctor recently diagnosed her with diabetes.
• She was initially treated with oral agents but now has
started taking insulin
• Jenny retired from her job as a high school English
teacher 15 years ago but keeps herself busy with
volunteer work as a tutor, church activities and exercise
classes at the Y.
• Jenny was widowed 5 years ago. She has 2 grown
daughters – one lives near her in Scranton, the other
lives in California but calls frequently.

33. Sensory Impairment - Vision

34. Sensory Impairment - Vision
• How could the development of macular
degeneration or cataracts interfere with Jenny’s
ability to monitor and treat her diabetes?
• What other aspects of Jenny’s life could be
affected by visual loss?
• What are some of the barriers to diagnosis and
treatment of visual loss in the elderly?
• In addition to the ophthalmologist who examines
Jenny’s eyes, how can the different members of
the interdisciplinary team help Jenny to learn to
cope with her visual impairment so that it does
not lead to additional functional decline?

35. Sensory Impairment - Vision
• Visual impairment affects 20-30% of
people over the age of 75.
• Visual impairments that occur with greater
frequency as people age include
– Refractive error
– Cataracts
– Glaucoma
– Macular degeneration
– Diabetic retinopathy
– Blindness

36. Cataracts

37. Glaucoma

38. Macular Degeneration

39. Diabetic Retinopthy

40. Low Vision Aids

41. Low Vision Aids

42. Gait Abnormalities and Falls

43. Gait Abnormalities and Falls
• How could a fall interfere with Jenny’s ability to
monitor and treat her diabetes?
• What other aspects of Jenny’s life could be
affected by gait disturbance or a fall?
• What are some of the barriers to diagnosis and
treatment of gait abnormalities and falls risk in
the elderly?
• What roles can the different members of the
interdisciplinary team play help Jenny to address
her recent fall so that it does not lead to
additional functional decline?

44. Gait Abnormalities and Falls
• Gait disorders are common in the elderly
– At least 20% of community dwelling seniors
report gait problems requiring assistance
– In one study, >50% of those 85 and older
reported difficulty walking
– The presence of a gait disorder often heralds
functional decline
– The etiology of gait disorders is usually
multifactorial

45. Gait Abnormalities and Falls
• Falls
– 30-40% of community dwelling seniors fall each year
– Falls often result in decreased independence
• Decreased functional status
• Increased rate of NH placement
• Increased use of medical services
• Increased fear of falling
– Falls result in injury and death
• Most result in soft tissue injury, 10-15% in fracture
• Complications from falls are the leading cause of death from injury
among those >65
• Death rate from falls increases with age
– Lifetime cost of falls related injuries for those >65 has been
estimated at $12.6 billion
– Etiology of falls multifactorial
• Includes medical, environmental, sensory and postural issues

46. Gait Abnormalities and Falls

47. Gait Abnormalities and Falls

48. Gait Abnormalities and Falls

49. Gait Abnormalities and Falls

50. Gait Abnormalities and Falls

52. Dementia
• How could the development of dementia interfere with
Jenny’s ability to monitor and treat her diabetes?
• What other aspects of Jenny’s life could be affected by
dementia?
• What are some of the barriers to diagnosis and
treatment of dementia in the elderly?
• How can the different members of the interdisciplinary
team help Jenny and her family in addressing her
dementia and maintaining independence and function for
as long as possible?
• What are some of the key issues that need to be
addressed as she faces this progressively debilitating
and life limiting illness?
• If Jenny does not have dementia, what could she do to
try to prevent it?

53. Dementia will reach epidemic
proportions by 2040
• Alzheimer's Disease accounts for the vast
majority of dementias in the US
• Among people >65, the prevalence of AD
is 6-8%
• Among people >85, the prevalence is 30%
• 4 million people in the US currently suffer
from AD
• By 2040, AD patients will number 14
million

54. Alzheimer’s Disease

55. Costs of Dementia
• Decreased quality of life for patient and family
– Loss of independence in ADLs and IADLs
– Need for supervision, outside caregivers
• Financial burdens on family and society
– Lost wages and direct costs for caregivers
– $100 billion spent annually in US on care
• Difficulties obtaining appropriate medical care
– Inability to give accurate history
– Inability to understand and follow directions and
medical regimens

56. “A A A, O x 3” is not very
helpful
• Dementia, in its early stages, is often
missed by medical professionals and
families
• Up to 50% of moderate dementias are
missed by physicians
• Patients can remain oriented to person,
place and time long after they have
developed serious impairments in other
areas of cognitive function

57. Screening for dementia can avert many
future problems in diagnosis treatment and
management
• Have a high index of suspicion
– Forgetfulness, getting lost, inability to follow
medical regimen, poor personal hygiene
• Use validated screening tools
– MMSE, animal naming test, clock drawing test
• Look for reversible causes of dementia
– B12 def, sensory def., depression, thyroid
disease
• Obtain history from other sources

58. Clock Drawing Test

60. Dementia Prevention

61. Dementia Prevention

62. Dementia Prevention

63. Dementia Prevention

65. Conclusion
• Aging presents a unique set of challenges both to
individuals and to the health care professionals who care
for them.
• The range in presentation is tremendous: there 90 year
olds who are still working and living independently in the
community while there are 70 year olds who require
institutional care.
• Early signs of serious problems are easy to miss on
routine examination
• Addressing geriatric issues and syndromes can help the
elderly maintain function and independence
• Even patients without apparent deficits may have little
functional reserve so that an acute illness or insult can
lead to disability and dependence far more frequently
than among younger individuals

66. Conclusion, continued
• Older people comprise ever increasing portions
of the general and patient populations and are
the largest users of health care resources
• Geriatric care is best provided by an
interdisciplinary team
• The pool of geriatric specialists in all disciplines
is insufficient to meet current needs and is not
expected to increase significantly despite
increasing demands over the next quarter
century
• All health care professionals, thus, need to learn
the basic principles of geriatrics and acquire
core clinical skills in the care of the older patient