Transcript No Slide Title

Aging Q3
3
Quality
Education
Aging
Quality of Life
Quality
Care
Characteristics of the 21st Century
Health Care System
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Safe
Effective
Patient-centered
Timely
Equitable
Efficient
Aging Q3
Quality Education
Quality education is focused on
learners attaining specific evidencebased knowledge and skills about
health care for older adults, and
establishing a positive attitude toward
aging and health care for the elderly.
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Q
Aging
Quality Care
Quality care is focused on
translating knowledge, skills and
attitudinal changes into practice,
using effective quality
improvement implementation
strategies.
Aging Q3
Quality of Life
Quality of life seeks to demonstrate
improved care outcomes, such as
maximized cognitive and functional
status, reduced prevalence of aging
associated syndromes, and
compassionate end of life care.
Table 2. MUSC Internal Medicine Resident self-reported confidence with managing selected ACOVE conditions/issues in Frail
elderly.*
ACOVE issue
PGY 1
PGY 2
PGY 3
Overall
Continuity of Care
2.5
3.5
3.4
3.2
Dementia
2.0
3.3
3.2
2.9
Depression
3.4
3.9
3.5
3.6
Diabetes mellitus
3.8
4.4
4.7
4.4
End of Life Care
3.0
3.9
4.2
3.8
Falls and mobility
2.7
2.6
3.4
2.9
Hospital care
3.7
3.9
4.5
4.1
Hearing impairment
2.2
2.0
2.2
2.2
Heart failure
3.8
4.2
4.5
4.3
Hypertension
3.8
4.4
4.8
4.4
Ischemic heart disease
3.7
4.4
4.6
4.3
Malnutrition
3.2
3.3
3.5
3.3
Osteoarthritis
3.7
3.7
3.8
3.7
Osteoporosis
3.4
3.5
3.6
3.5
Pain management
3.1
3.9
4.0
3.8
Pharmacologic mgmt.
3.1
3.7
3.9
3.7
Pneumonia / influenza
3.5
4.4
4.4
4.2
Pressure ulcers
2.8
3.1
3.3
3.1
Screening/ prevention
2.5
3.5
3.8
3.5
Stroke/a-fib
2.7
4.0
4.0
3.7
Urinary incontinence
2.5
2.9
2.8
2.8
Vision impairment
2.1
2.5
2.3
2.3
Mean by PGY year
3.0
3.5
3.7
3.5
* Average for italicized conditions is at or below overall mean (1=not confident, 5=very confident, n=39, PGY=post-graduate year). Bold indicates
Assessing care of Vulnerable
Elders (ACOVE)
• Focus on quality of care in elders
• Loss of physiologic reserves make
elderly more susceptible to adverse
effects of lower quality of care
• Elderly may be more susceptible to
side-effects/complications of guidelinebased care
Aging Q3: ACOVE areas
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End of life care
Falls and mobility
Hospital care
Hearing impairment
Malnutrition
Osteoporosis
Pain management
Pressure ulcers
Continuity of care
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Dementia
Delirium
Depression
Pharmacologic
mgmt
• Screening /
prevention
• Urinary
incontinence
• Vision impairment
Aging Q3 process
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Faculty will focus on content
Traditional didactics
Detailing
Nurse assessment communicated to
MDs
• Data fields in Practice Partner
• Evaluation:
• Survey monkey questionnaires
• Patient surveys
“To see or not to see….”
Vision and Aging
Vision and Aging
• Vision related changes occur through
life like similar to other physiologic
systems
• Vision loss is not normal aging
• Vision loss dramatically impacts QOL
• Vision loss reduces safety
• MVAs, accidents, falls
• Vision loss leads to social isolation
Causes of Worldwide Blindness
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Cataract
17 million
Trachoma
6.0 million
Glaucoma
3.0 million
Xerophthalmia
0.5 million
Onchocerciasis
0.5 million
AMD
1.0 million
Diabetic retinopathy
0.25 million
Leprosy
0.25 million
Others
2.5 million
• 85% of blindness is in Africa and Asia
• 85% of cases are potentially treatable or preventable
• Prevalence:
• 0.125-0.25% in Western world
• 0.2-1.5% (av 0.75%) in Asia
• 0.3-3.1% (av 1.2%) in Africa
Allen Foster in Clinical Ophthalmology - Duane, ed. (1991)
What is the definition of blindness?
• 20/10 - 20/25: Normal
• 20/30 - 20/60: Near-normal
• 20/70 - 20/160 : Moderate vision impairment - eligible
for education assistance in US
• 20/200 - 20/400: Severe vision impairment - legal
blindness in US (visual field < 20 degrees)
• 20/500 - 20/1000: profound vision impairment - WHO
and several European countries definition of
blindness (visual field < 10 degrees), CF < 3m
• < 20/1000: Near-total visual impairment: used by
some developing countries as definition of blindness
(visual field < 5 degrees), HM, LP
• NLP: Total visual impairment
Vision and Aging
• Changes with normal Aging
• Vision loss and Aging
• Prevalence
• Functional Impact and complications
• Pathologic causes of low vision
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Aging-related Macular Degeneration
Cataracts
Glaucoma
Diabetic retinopathy
Eyelid anatomy: Entropion and
Ectropion
Entropion—turning
inward of the lid
Ectropion - sagging and
eversion of the lower lid
Visual Changes with Aging:
Pupil
• Pupil Decreases
in Size
• Slower Light and
Dark Adaptation
Clinical Considerations
• Caution
• Rapid Changes in Lighting
• Low Light / Night Driving
Visual Changes With Aging :
Lens
• Yellowing of the
Lens
• Increased:
• Scatter
• Fluorescence
• Loss of Flexibility /
Accommodation
Blue and Yellow less
distinguishable
Increased Scatter
Increased Reflections
Presbyopia
Cataract
Central Cataract
Monet: Bridge at Giverny 1899
Adapted from Morley,et al
Monet: Bridge at Giverny 1900
Adapted from Morley,et al
Monet: Bridge at Giverny 1923
Adapted from Morley,et al
Monet: Bridge at Giverny 1923
Adapted from Morley,et al
1923
1899
Adapted from Morley,et al
Adapted from Morley,et al
Cataract Prevention and
Treatment
• Avoid Ultraviolet
Light
• Sun Exposure
• Sunglasses
• Surgery With
Lens Implant
Impact of cataract surgery with lens implantation on vision and
physical function in elderly patients
W. B. Applegate, S. T. Miller, J. T. Elam, J. M. Freeman, T. O. Wood and
T. C. Gettlefinger
We conducted a prospective study of 293 elderly patients undergoing
cataract surgery with intraocular lens implantation to determine the
impact of the surgery on vision and on subjective and objective
measures of patient function. Visual acuity in the surgical eye improved
from a mean of 20/100 before surgery to 20/40 four months after
surgery; improvement was maintained at one year. Positive changes
occurred in some subjective measures of patient function, such as
reported activities of daily living and patient report of vision-dependent
activities, but these changes were modest. The most marked changes
in patient function occurred in objective measures of function. Mental
status had improved not quite significantly at four months but
significantly at one year. Timed manual performance improved
dramatically and significantly at four months and one year. Cataract
surgery was associated with improved vision and improved objective
function in most patients by four months after surgery, and these
improvements were maintained at one year.
Retinal Changes
Young Adult
Older Adult
Macular
Degeneration
Leading Cause of Blindness in the United
Leading causes of blindness
in Western societies
Age-related macular
degeneration
• (aka: AMD, ARM, SMD)
• Dry versus Wet
• Atrophic versus Exudative
(CNVM)
• Most common cause of
blindness
• Majority of cases are “dry”
form (>80%), however
88% of those registered
as legally blind (in
Germany) from AMD had
exudative disease.
Macular Degeneration
• Oxidative
Damage to the
Retinal
Pigmented
Epithelium
Macular Degeneration:
What Helps?
• Green Leafy
Vegetables
• Antioxidant
Supplements
• Cholesterol
Lowering Agents?
Figure 1 (a)
Macula Lutea and Ocular Structures with Age-Related
Macular Degeneration (AMD)
JAMA, May 24/31, 2006 – Vol. 295, No 20
Jorge G. Arroyo, MD, MPH
Figure 1 (b)
Macula Lutea and Ocular Structures with Age-Related
Macular Degeneration (AMD)
JAMA, May 24/31, 2006 – Vol. 295, No 20
Jorge G. Arroyo, MD, MPH
Figure 1 (c1)
Macula Lutea and Ocular Structures with Age-Related
Macular Degeneration (AMD)
JAMA, May 24/31, 2006 – Vol. 295, No 20
Jorge G. Arroyo, MD, MPH
Figure 1 (c2)
Macula Lutea and Ocular Structures with Age-Related
Macular Degeneration (AMD)
JAMA, May 24/31, 2006 – Vol. 295, No 20
Jorge G. Arroyo, MD, MPH
Intravitreous Injection
n
Steinbrook, Robert, The Price of Sight – Ranibizumab, Bevacizumab, and the Treatment of Macular
Degenderation, The New England Journal of Medicine. Vol. 355 Number 14. October 5, 2006. pp 1409-1414.
87 female admitted with a hip fracture,
after tripping over her blind, deaf dog.
Glaucoma
• Second Leading Cause of Blindness in
the US
• “Silent”
• Increased Intraocular pressure (IOP)
• Screen every 2 years after Age 50
• Treatment
• Topical Medications
• Surgery
• Oral agents
Glaucoma: Increased
Cupping of the Optic Disc
Normal
Abnormal
Circulation of the Aqueous Humor. This anterior segment of the eye shows the circulation of the
aqueous humor from the ciliary body through the pupil into the anterior chamber. The aqueous humor
then passes through the trabecular meshwork into Schlemm's canal and travels from there into the
episcleral venous system. A smaller amount of aqueous humor leaves the eye through the face of the
ciliary body, just below the trabecular meshwork.
Optic Disks and Corresponding Visual Fields in a Patient with Primary Open-Angle
Glaucoma and a MYOC Mutation.
The Optic-Nerve Head and Proposed Events Leading to Retinal
Ganglion-Cell Death in Glaucoma.
Glaucoma: Tunnel Vision
79 year old man in ED with
nausea, vomiting and eye pain
• Exam – left eye
• reduced vision, conjunctival injection, mild
corneal edema
• Fixed, mid-dilated pupil
• Diagnosis?
Closed-angle glaucoma
• Mechanical obstruction of outflow
• Common among Asians
• Rapid increase in intra-ocular pressure
• Eye pain, nausea, halos around lights
• Exam reduced vision, conjunctival hyperemia,
corneal edema
• Fixed, mid-dilated pupil
• Increased intraocular pressure
• Narrow anterior chamber
• Treatment – topical pilocarpine or timolol, IV
acetozolomide
Diabetic Retinopathy
cotton wool spots
venous loop
Diabetic Retinopathy
Exudates
New vessels at the disk
Diabetic Retinopathy
preretinal
haemorrhage
tractional retinal
97 year old woman seen in UIM
for weakness for 2 weeks
• mostly when getting up at night - concerned pass out
• Diarrhea for 2 days
• Daytime symptoms of weakness become
less noticeable,
• No SOB, PND, mild leg swelling, palpitations
PMH
• 1969 MI
• 1996 Dx Glaucoma
• 2007 fractured left arm
97 year old woman seen in UIM
for weakness
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hydrochlorothiazide 25 mg daily
lisinopril 10 mg daily
diltiazem XT 240 mg
Methyldopa 500 mg q.i.d.,
aspirin 81 mg daily
lorazepam 1 mg p.o. t.i.d.
Travoprost eyedrops daily
Cosopt eyedrops twice a day
97 year old woman seen in UIM
for weakness
• BP 146/63 lying
157/76 sitting
152/63 standing
• Pulse 42
• EKG sinus bradycardia
• Admitted
97 year old woman seen in UIM
for weakness
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hydrochlorothiazide 25 mg daily
lisinopril 10 mg daily
diltiazem XT 240 mg
Methyldopa 500 mg q.i.d.,
aspirin 81 mg daily
lorazepam 1 mg p.o. t.i.d.
Travoprost eyedrops daily
Cosopt eyedrops twice a day
Other Considerations
• Increased susceptibility to
physiologic effects of
ophthalmic medications
• Medication Effects on vision
• Blurred Vision
• Changes in Color
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