Transcript GERIATRIC OVERVIEW - Lock Haven University of Pennsylvania

GERIATRIC OVERVIEW
Changes in Physiology
and
Psychosocial Functioning
Ronald H. Byerly, BA, AS, PA-C
General Internal Medicine
Director, Advanced Practice Council
Geisinger Health System
Danville, PA
TODAY’S GERIATRIC
POPULATION
Who are they?
- Our parents, grandparents, aunts and
uncles.
- Our teachers, mentors and role models.
- Our patients.
TODAY’S GERIATRIC
POPULATION
Who are they?
“They came of age during the Great
Depression and the Second World War
They went on to build modern America–
men and women whose everyday lives of
duty, honor, achievement, and courage
gave us the world we have today.”
Tom Brokaw
The Greatest Generation
OVERVIEW
The Geriatric Vacuum
Physiology of Aging
Systemic signs and symptoms
Psycho-social Ramifications
GERIATRIC VACUUM
 WHY IS THIS IMPORTANT?
- First of the “Baby Boomers” turned 60 in
2006. (Boomers were those born from 1946-1964)
- In 2003, 12% of US Population was 65 +
- In 2030, 20% of US Population will be 65 +
US Census Bureau, 2005
GERIATRIC VACUUM
Expected Population Growth
2000 – 2050
Entire US Population: 49%
US Population Age 65+: 147%
US Census Bureau, 2006
GERIATRIC VACUUM
GERIATRIC VACUUM
2009 US Life Expectancy- 78.6 Years
GERIATRIC VACUUM
Impending Shortage of Graduate Physicians?
- Miscalculation of future work force needs from the
1980’s and early 1990’s has led to a currently stagnant
growth rate in the profession.
- By 2015, the physician shortfall is expected to be about
63,000
- The number of physicians choosing primary care
careers has fallen sharply since 1990.
GERIATRIC VACUUM
Narrowing the Focus
- From 2000 to 2010 US Population 85+ increased by
50%.
- From 1998 to 2003, 3rd year Internal Medicine
Residents choosing primary care careers dropped from
54% to 17%.
Michael S. Barr, MD, MBA, FACP
VP, Practice and Advocacy Improvement
American College of Physicians
GERIATRIC VACUUM
Closer to Home
Number of Med/Surg residents trained in
PA who stay in PA to practice
-1994: 50.5%
- 2004: 7.8%
Pennsylvania Medical Society
State of Medicine in Pennsylvania: 2005
GERIATRIC VACUUM
Our senior population continues to show
improvements in their overall health.
32 million Americans (young and old) may be
gaining health insurance
The elderly have increasingly delayed onset of
chronic diseases and tend to live more
successfully with those disorders for a longer
period of time.
GERIATRIC VACUUM
The sheer numbers of seniors with age,
and non-age related health problems will
maximally stress our ability to provide
appropriate care for them.
This will require not only increased
numbers of clinicians, but a change in the
system of care delivery.
ADVANCED PRACTICE
CLINICIANS
There WILL be a prominent role for PA’s,
APRN’s and other non-physician
clinicians.
Physician leaders and politicians are, and
have been, discussing this issue
seriously and with greater frequency over
the past few years.
PHYSIOLOGY OF AGING
There are definable, chronological changes
in both anatomy and physiology which
define the process of aging in the human
body.
There is a difference between these
changes and disease states which we
commonly associate with the elderly.
PHYSIOLOGY OF AGING
Differentiating Normal Aging
From Pathology
- There are symptoms and findings which
are purely age-related.
- Many of our older patients don’t
understand this concept…….an
opportunity for artful reassurance!
PHYSIOLOGY OF AGING
Differentiating Aging From Pathology
The onset of some disorders are age-related
because:
1) They are dependent upon age-related changes
in anatomy and physiology.
2) The longer we live, the greater the chance of
developing disorders related to heredity,
environmental exposures, and unhealthy lifestyle
choices.
3) Age-related Genetic Susceptibility?
PHYSIOLOGY OF AGING
 In general, the most common age related
changes are those related to impaired
response to external stimuli.
 As age progresses, physiologic reserve
diminishes.
PHYSIOLOGY OF AGING
 Generally healthy elderly persons with
elevated BP, higher overnight cortisol
and catecholamine secretion, and
activation of other stress responses were
more likely to have declines in cognitive
or physical function at 3 year follow-up.
M. McDonald, MD and D. Swagerty, MD
University of Kansas, School of Medicine
KUMC
PHYSIOLOGY OF AGING
 Older persons may employ some of their
physiologic reserves to maintain baseline
homeostasis.
 This would be one explanation as to why
there is less physiologic reserve available
to respond to external stressors.
PHYSIOLOGY OF AGING
Response to Infection
- Thermoregulation is impaired. Up to 25% of
septic elderly are afebrile.
- Antibody response to infection and vaccination
is impaired.
- Changes in the thymus reduce the production
of numbers of those lymphocytes ready to
respond to new challenges (naïve
lymphocytes).
PHYSIOLOGY OF AGING
Systemic Review
Cardiology
 Impact of aging at rest is nominal.
 Age-related change in stroke volume to
perform a given workload is minimal.
BUT
 Recovery from exertion is prolonged, in part,
because heart rate response is decreased.
 This is due to impairment of sympathetic and
catecholamine mediated responses.
PHYSIOLOGY OF AGING
Systemic Review
Cardiology
 Mulifactorial increase in both systolic and
diastolic blood pressure, including:
1) Diminished elasticity of arterial
vasculature.
2) Diminished ability to maximally dilute
urine.
PHYSIOLOGY OF AGING
Systemic Review
Cardiology
 B-adrenergic mediated vasodilatation is
significantly impaired in arteries, but less
so in veins.
 Renin-Angiotensin system is downregulated.
 These factors result in an increased risk
for orthostatic hypotension, which is more
prevalent in patients with hypertension.
PHYSIOLOGY OF AGING
Systemic Review
Cardiology
 Left Ventricular Hypertrophy
 Valvular Calcium Deposition
 Increased P-R Interval
 Increased Frequency of Ectopy
PHYSIOLOGY OF AGING
Systemic Review
Pulmonary
 Pulmonary function peaks at age 30.
 This peak determines timing and risk of
future age-related compromise.
 Total Lung Capacity does not change,
but Residual Volume increases.
PHYSIOLOGY of AGING
Systemic Review
Pulmonary
Nonsmoking Men After Age 30:
1) Forced Vital Capacity decreases ~0.2L
per decade.
2) Forced Expiratory Volume1 decreases
by~0.25L per decade.
Nonsmoking Women After Age 30:
1) Changes are slightly smaller and more
gradual.
PHYSIOLOGY of AGING
Systemic Review
Pulmonary
 Mucociliary Clearance Slows
 Increasing Dependence on Abdominal
Musculature for Inspiration
 Full Lung Expansion Occurs Only in the
Standing Position
PHYSIOLOGY of AGING
Systemic Review
Pulmonary
 Decreased responses to hypoxia and
hypercapnia, in the absence of other
diseases, are generally due to
deconditioning and improve with exercise
training.
PHYSIOLOGY OF AGING
Systemic Review
GI Tract
 Swallowing becomes less coordinated,
increasing the risk of aspiration.
 Lactase levels decline, increasing the risk
of developing lactose intolerance.
 Decrease in the number of esophageal
ganglion cells diminishes coordination of
peristalsis.
PHYSIOLOGY OF AGING
Systemic Review
GI Tract
 Colonic transit time is increased.
 Colonic contraction becomes less
coordinated.
 Increase in the number of opioid
receptors, increasing the risk of drug
induced constipation.
PHYSIOLOGY OF AGING
Systemic Review
GI Tract
 The number of Vit D receptors in the gut
decreases, reducing the efficiency of
calcium absorption.
 Increased risk of cholesterol gallstones
due to changes in bile composition.
 Gradual decline in synthesis of Vit K
dependent clotting factors.
PHYSIOLOGY OF AGING
Systemic Review
Musculoskeletal
Between the ages of 30 and 80:
- Muscle mass decreases 30% - 40%.
- Grip strength decreases by 60%.
- Lower extremity strength decreases at a
more rapid rate.
PHYSIOLOGY OF AGING
Systemic Review
Musculoskeletal
 Loss of muscle tone leading to:
- Reduced ability to breath deeply
- Problems with bowel and bladder continence.
- Increased fall risk
 Again, regular physical exercise reduces the
extent of some of these problems
PHYSIOLOGY OF AGING
Systemic Review
Musculoskeletal
 In men and women, beginning around
age 35, changes in calcium absorption
and utilization cause bones to become
less dense.
 In women, this process accelerates after
menopause.
 Osteoporosis is a major and costly public
health concern.
PHYSIOLOGY OF AGING
Systemic Review
Musculoskeletal
 1/3 of women 65+ incur at least one
vertebral fracture.
 About 300,000 Americans are
hospitalized annually for hip fracture.
PHYSIOLOGY OF AGING
Systemic Review
Musculoskeletal
Hip Fracture
- Mortality Rate as high as 20% within 1
year of injury.
Leibson et al, 2002
PHYSIOLOGY OF AGING
Systemic Review
Eyes
 Vision:
- Periorbital tissues become more flaccid.
- Tear production decreases.
- Changes in lens and iris lead to presbyopia.
- Number of retinal neurons decreases.
- ARMD (Age Related Macular Degeneration)
PHYSIOLOGY OF AGING
Systemic Review
Ears
 Hearing:
- Auditory canal atrophies and cerumen
becomes drier and more tenacious.
- Atrophic and calcific changes of internal
structures reduces both high and low
frequency hearing.
PHYSIOLOGY OF AGING
Systemic Review
CNS
 Despite significant age-related decrease
in size and efficiency of energy use in the
brain, reduction of intellectual function is
minimal.
 Decreased performance on basic
intelligence tests are more likely due to
non-cognitive factors.
PHYSIOLOGY OF AGING
Systemic Review
CNS
Non-cognitive Factors
- Fewer years of education.
- Impairment of motor function and
sensory deficits.
- Less experience taking intelligence
tests.
- These people are, for the most part,
NOT computer literate. Computer-based
testing leaves them at a disadvantage.
PHYSIOLOGY OF AGING
Systemic Review
CNS
Memory
- Learning new information takes longer.
- Information retrieval is impaired.
- Older adults require more cues in order
to retrieve learned information, especially
information which is similar to that which
was previously learned.
PHYSIOLOGY OF AGING
Systemic Review
CNS
 Cognitive processes are very responsive
to the person’s physical and
psychological state.
 Add to this the effect of medication(s) on
neuronal function and potential reduction
in energy for cognitive function.
PHYSIOLOGY OF AGING
Systemic Review
CNS
 Most cognitive functions have been
shown to improve with “exercise.”
- Increased social interaction
- Activities requiring logistical planning
- Reading
- And again, physical exercise
PHYSIOLOGY OF AGING
Systemic Review
CNS
Personality
- Multiple studies, including The Baltimore
Longitudinal Study, have found selected
personality traits to remain remarkably
stable.
- Other traits do undergo change over
time:
PHYSIOLOGY OF AGING
Systemic Review
CNS
1) Increased degree of introspection
2) Become less impulsive
3) Decreased need to conform
3) Men tend to become more nurturing,
expressive and affiliation-seeking
4) Women tend to become more
achievement-oriented
PSYCHO-SOCIAL
FUNCTION
Activities of Daily Living
- Bathing (sponge, bath or shower)
- Dressing
- Toilet use
- Transferring (in and out of bed or chair)
- Continence
- Eating
PSYCHO-SOCIAL
FUNCTION
 Each activity is assessed on level of
independence:
- Performs independently
- Performs with assistance
- Unable to perform
PSYCHO-SOCIAL
FUNCTION
Other activities which require assessment
- DRIVING: “There is only thing more
worrisome for a middle aged adult than
their concern for an elderly parent
driving……..their teenager who just got
her driver’s permit!”
Ron Byerly, PA-C
July 17, 2006
PSYCHO-SOCIAL
FUNCTION
- To the older adult, driving represents
freedom and independence.
- It is also a means by which socialization
and healthy activity can take place.
PSYCHO-SOCIAL
FUNCTION
As clinicians, we have a legal and ethical
responsibility to assess a patient’s physical and
mental capability for driving, if we have reason
to believe they are a danger to themselves or
others.
The Physician’s Guide to Assessing and
Counseling Older Drivers
http://www.amaassn.org/ama/pub/category/10791.html
PSYCHO-SOCIAL
FUNCTION
 Many healthy seniors do well, even into
late ages if they have the opportunity to
remain in familiar surroundings and have
regular contact with people they know
and trust.
 Functional deterioration tends to be more
prevalent and rapid when removed from
their home.
FINALLY
It is impossible to discuss psycho-social
function without mentioning the “3 D’s.”
 Delirium
 Dementia
 Depression
Although they are not normal aspects of
aging, they are common and create great
difficulty in patient management.
DELERIUM
 A state of mental agitation (sometimes
violent). It is characterized by acute
onset, a fluctuating course, and
alterations in consciousness and
attention. May be accompanied by
hallucinations and involuntary
movements. Patients with pre-existing
dementia are at increased risk.
DEMENTIA
 Non-vascular: A syndrome of constant,
gradual decline in global cognitive
function with insidious onset. In its
earlier stages, consciousness and
attention are preserved.
 Vascular: Sudden or insidious onset of
cognitive decline which may remain
relatively constant if vascular insult can
be controlled.
DEPRESSION
 A condition of sadness, dejection and/or
withdrawal which ranges in intensity and
is either prompted by life circumstance or
mediated by abnormalities in function of
certain neurotransmitters. It may be
acute or sub-acute in origin and if severe,
may mimic advanced dementia. If
accompanied by psychosis, it may mimic
delirium.
PATIENT INTERACTIONS
- “Are you trying to tell me I’m getting
old?”
(Artful response: “Not really, I think it’s a
combination of gravity and turning
calendar pages”)
- “Don’t get old!”
(Artful response: “I’m not sure I really
like the alternative.”)
End Of Life Issues
The Major Decision Point
Prolongation of the process of living
VS.
Prolongation of the process of dying
CASE STUDY #1
Mrs. B is a 91 Y/O widow who lived in her own
home with 2-5 hours of paid assistance a day,
5 days a week. She has mild but progressive
dementia. She no longer drives.
PM/SH- Breast Ca 1970
- Colon Ca 1985
- Dehydration w/hospital witnessed
Torsade de Points and successful
cardioversion 1996
CASE STUDY #1
As her dementia progressed, her family and
caregivers have found doors unlocked, pots
and pans w/scorched bottoms, and a decline in
hygiene. Although oriented in all spheres, she
seems to make decisions poorly and has
trouble with word finding. Her son was
scheduled to visit, so she began making
arrangements by moving a heavy coffee table
and trying to pull out the sofa bed.
CASE STUDY #1
In the process she fell, striking the table
and suffering closed comminuted
fractures of 5 ribs and a hemothorax.
She pressed her medic alert necklace
button and was subsequently admitted to
the local hospital. She is designated as a
modified code, no CPR, no
cardioversion. Trial of intubation, prn.
Fluids, nutrition, and medication are ok.
CASE STUDY #1
 What should her initial management
include?
 What is the most common complication
at this point?
 Would she likely survive this
complication?
CASE STUDY #1
For 3 days, Mrs. B is somnolent and noncommunicative with depression of resp rate
and depth, borderline hypotension, and chest
tube is draining minimal bloody fluid. Renal
functions are preserved w/IVF.
This lady IS going to make it out of the hospital
to rehab and then home! How do we attempt
to prevent complications and make this
happen?
The Beer’s List
 A list of potentially harmful medications
for the elderly patient
 AND, a list of logical alternatives
www.fmda.org/beers.pdf
More Geriatric Stuff
 What is the most common cardiac
arrhythmia after age 65?
 What medications do we use to treat it
and prophylax against its potential
sequellae?
More Geriatric Stuff
 Under what circumstances should we
NOT use this prophylactic medication?
 What is the most commonly used
medication that has the most frequent
risk of adverse interaction with other
drugs?
SENILITY PRAYER
...God grant me...
The senility to forget the people I
never liked, The good fortune to run
into the ones that I do, And the
eyesight to tell the difference.