Transcript Dr. Leipzig`s Talk - NY/NJ MLA Chapter

The Librarian as Gerontologist
Rosanne M Leipzig MD PhD
Professor and Vice Chair
Departments of Geriatrics and Medicine
Mount Sinai School of Medicine
Aging: The Numbers
There were 3 million Americans
over age 65 in 1900
• What’s the estimated number for 2030?
***
A.
B.
C.
D.
10 million
30 million
50 million
70 million
Medical Librarians Are Also Aging
Medical Library Association. Hay Group/MLA 2005 salary survey
[Web document]. 2005 [cited 10/12/2007].
Projected Population Distribution
What percent of those 65+ are
high school graduates?
A.
B.
C.
*** D.
10%
30%
50%
70%
Education level of older
population
80%
70%
60%
All
Whites
API
AA
Hispanics
50%
40%
30%
20%
10%
0%
HSG
Coll Grad
Percentage of all persons over 65
living in nursing homes?
*** A. 5%
B. 10%
C. 15%
D. 20%
Nursing Home Population By
Age: 2000
%
20
18
16
14
12
10
8
6
4
2
0
>65
65-74
75-84
85+
>65
65-74
75-84
85+
Percentage of all persons over 65
living with their spouses?
A.
B.
*** C.
D.
20%
35%
50%
65%
Living Arrangements of Persons 65+
80
70
60
50
Women
Men
40
30
20
10
0
Living with Spouse
Living Alone
Other
Social Activities
Leisure-time Physical Activity 65+
2004-5
% engaged in REGULAR ACTIVITY
30
25
20
Male
Female
15
10
5
0
50-64
65-74
75-84
85+
CDC http://209.217.72.34/aging/TableViewer/tableView.aspx?ReportId=383
Reporting Good to Excellent Health
Disability in Aging:
The Good News in the U.S.
• age 65-74: 89% report no disabilities
• age 85+: 40% report no disabilities
• In 1999, there were 1.4 million fewer disabled
persons than there would have been if health status
had not improved since 1982.
The Librarian As Gerontologist:
What Do You Need To Know
• How does aging affect one’s health and wellbeing?
• What might physicians and other health care
professionals be asking you about aging?
• What might the public be asking about aging?
AAMC/John A. Hartford Foundation
Consensus Conference on Geriatric
Competencies: July, 2007
• Rationale:
– Almost every graduate of every medical school will be
providing care to older adults
– Faculty who received little exposure and training in the
care for the elderly are uncomfortable teaching
geriatrics to students- don’t know where to start
– Lists of geriatric curriculum topics exist, but are
extensive and imprecise
AAMC/John A. Hartford Foundation
Consensus Conference on Geriatric
Competencies: July, 2007
• Goal: Consensus on minimum standards for
graduating medical students
• Input provided by many non-geriatric educators
• Results
– 8 content domains identified
– 26 minimum geriatric competencies identified within these
domains
Competency Domains
•
•
•
•
•
•
•
•
Atypical Presentation of Disease
Medication Management
Cognitive and Behavioral Disorders
Falls, Balance, Gait Disorders
Self-Care Capacity
Health Care Planning and Promotion
Palliative Care
Hospital Care for Elders
Atypical Presentation of Disease
Acute MI: 30 Day Mortality
Adjusted ORs
%
35
2.00
30
1.69
25
1.49
20
15
1.21
Ref
10
5
0
65-69
70-74
75-79
80-84
>85
Adapted from Mehta RH et al. J Am Coll Cardiol 2001;38:736-41
Presentation of MI:
Chest Pain
80
70
60
50
40
30
20
10
0
<70
70-74
75-79
80-84
Adapted from Bayer et al JAGS 1986;34:263-266
>85
Painless MI in Patients>70 yrs:
Presenting Symptoms
Dyspne
a
Syncope
Stroke
Confusion
Weakness
Giddiness
Vomiting
Sweating
Palpitations
0
10
Bayer et al. JAGS 1986;34:263-266
20
30
40
50
Atypical Presentation of Disease
• Generate a differential diagnosis based on
recognition of the unique presentations of
common conditions in older adults,
including
–
–
–
–
–
Acute coronary syndrome
Dehydration
Urinary tract infection
Acute abdomen
Pneumonia.
Compensatory Response to
Orthostatic Hypotension
1. Compensate for hypovolemia:
– Thirst response
– ADH secretion
– Increase urine concentration
2. Increase heart rate
Compensatory Response to
Orthostatic Hypotension in Elders
1. Compensate for hypovolemia:
– Thirst response
– ADH secretion
– Increase urine concentration
2. Increase heart rate
Atypical Presentation of Disease
• Identify at least 3 physiologic changes of
aging for each organ system and their
impact on the patient, including their
contribution to homeostenosis (the agerelated narrowing of homeostatic reserve
mechanisms).
Medication Management
Medication Management:
Drugs to Watch Out For
• Identify medications, including
–
–
–
–
–
–
Anticholinergic
Psychoactive
Anticoagulant
Analgesic
Hypoglycemic
Cardiovascular drugs
that should be avoided or used with caution in older adults and
explain the potential problems associated with each.
Medication Management
• Explain impact of age-related changes on drug
selection and dose based on knowledge of agerelated changes in:
– renal and hepatic function
– body composition,
– and Central Nervous System sensitivity.
Why you become a
cheaper drunk as you age
• As you get older,
– Higher blood alcohol concentrations
– Worse for women than men
– Less tolerance for quantities previously enjoyed
• Brain more sensitive
• Balance worse even without the alcohol
Common Diseases 65+
2004-5
Male Female
HTN
Arthritis
Heart Dis
Ca
DM
Ulcer
Sinusitis
Stroke
%
0
10
20
30
40
CDC http://209.217.72.34/aging/TableViewer/tableView.aspx
50
60
Medication Management
• Document a patient’s complete medication list,
including:
– prescribed,
– herbal and
– over-the-counter medications,
and for each medication provide the dose, frequency,
indication, benefit, side effects, and an assessment
of adherence.
Anti-Aging Medicine
Growth Hormone Levels
Decline with Age
Growth Hormone
• Review of 18 studies (31 publications)
• 220 participants; Mean age 69
• Positive Results
– Fat Mass decreased 2.1 kg
– Lean Mass increased 2.1 kg
• No change: cholesterol, BMD, other lipids
Growth Hormone: Down Side
• Increased
–
–
–
–
–
–
Soft tissue swelling
Joint pain
Carpal tunnel syndrome
Breast swelling
New onset diabetes
Impaired fasting glucose
Cognitive and Behavioral
Disorders
Severe Memory Impairment
Severe Depressive Symptoms
Cognitive and Behavioral Disorders
• Define and distinguish among the clinical
presentations of delirium, dementia, and depression
• Perform and interpret a cognitive assessment in
older patients for whom there are concerns
regarding memory or function .
• Formulate a differential diagnosis and implement
initial evaluation in a patient who exhibits cognitive
impairment.
Cognitive and Behavioral Disorders
• Urgently initiate a diagnostic work-up to determine
the root cause (etiology) of delirium in an older
patient.
• Develop an evaluation and non-pharmacologic
management plan for agitated demented or
delirious patients.
Falls, Balance, Gait Disorders
I Fall To Pieces $200
% of healthy elders in the community that
fall annually
A.
B.
*** C.
D.
5%
15%
30%
45%
Falls, Balance, Gait Disorders
• Ask all patients > 65 y.o., or their
caregivers, about falls in the last year, watch
the patient rise from a chair and walk (or
transfer), then record and interpret the
findings.
Significant Risk Factors
for Falls in Elders
•
•
•
•
•
•
•
•
•
Medications
Cognitive impairment
Lower extremity disabilities
Balance and gait abnormalities
Poor vision and/or hearing
Medical Disorders
Previous Falls
Level of activity
Upper extremity weakness
Multiple Falls vs.
Number of Risk Factors
Percent with Two or More Falls in One Year
80
69
70
60
50
39
40
30
20
16
10
10
0
0-1
2
3
4+
Number of Risk Factors*
* White, previous falls, arthritis, parkinsonism, difficulty rising, poor tandem gait.
Nevitt JAMA, 1989. (n=325)
Falls, Balance, Gait Disorders
• In a patient who has fallen, construct a
differential diagnosis and evaluation plan
that addresses the multiple etiologies
identified by history, physical examination
and functional assessment.
Self-Care Capacity
Functional Status Impairment
40%
35%
30%
25%
65-74
>85
20%
15%
10%
5%
0%
Eating
Shopping
Food Prep
Performance Impairment >70 yos
Community-dwellers
30%
25%
20%
15%
Men
Women
10%
5%
0%
Walk 1/4 Climb 10
mi
Stairs
Stoop
Reach
Up
Any 1/9
On feet for 2 hrs; sit for 2 hrs; Reach out to shake hands;
Use fingers to grasp or handle; Lift or carry 10#s
Self-Care Capacity
• Assess and describe baseline and current
functional abilities
– instrumental activities of daily living
– activities of daily living
– special senses
in an older patient by collecting historical data
from multiple sources and performing a
confirmatory physical examination.
Functional Status:
Activities of Daily Living
• ADLs
–
–
–
–
–
Dressing
Eating
Ambulation
Transfer
Hygiene
• Bathing
• Toileting
• Instrumental ADLS
– Telephone use
– Getting to places beyond
walking distance
– Grocery shopping
– Preparing meals
– Housework/handyman work
– Taking medications
– Managing money
Mobility Disability
Women
Men
1) Unable to walk up and down the stairs to the 2nd floor without help or
2) Unable to walk half a mile without help
Self-Care Capacity
• Develop a preliminary management plan for patients
presenting with functional deficits, including adaptive
interventions and involvement of interdisciplinary
team members from appropriate disciplines, such as
social work, nursing, rehabilitation, nutrition, and
pharmacy.
Self-Care Capacity
• Identify and assess safety risks in the home
environment, and make recommendations to mitigate
these.
Health Care Planning and
Promotion
Life Expectancy 2003
Years
100
80.1
74.8
80
60
Birth
40
20
0
6
Male
65
19.8
16.8
7.2
Female
85
CDC http://209.217.72.34/aging/TableViewer/tableView.aspx
Health Care Planning and Promotion
• Accurately identify clinical situations where
–
–
–
–
life expectancy
functional status
patient preference or
goals of care
should override standard recommendations for
screening tests or for treatment in older adults.
Hospital Care for Elders
Adults Over 65 years Old
60%
49%
50%
38%
40%
30%
20%
13%
10%
0%
Population
Hospital Admissions
Hospital Days
Outcomes of Acute Care for
Older Adults
• 31% lose >1 basic ADL at baseline c/w preadmission (see card)
– 2/5 of these remained impaired 3 months later
• 40% have IADL decline at 3 months
Hospital Care for Elders
• Identify potential hazards of hospitalization
for all older adult patients including:
–
–
–
–
–
–
–
–
Immobility
Delirium
Medication side effects
Malnutrition
Pressure ulcers
Procedures
Peri and post operative periods
Hospital acquired infections
and identify potential prevention strategies.
Hospital Care for Elders
• Explain the risks, indications, alternatives, and
contraindications for indwelling (Foley) catheter
use in the older adult patient.
• Explain the risks, indications, alternatives, and
contraindications for physical and
pharmacological restraint use.
• Conduct a surveillance examination of areas of the
skin at high risk for pressure ulcers and describe
existing ulcers.
Acute vs Chronic Disease
• Acute
– Short duration
– Severe Symptomatology
– Singular etiology
• Infection
• Injury
• ‘No matter how you pinch
and squeeze……”
– Goal of care is cure
• Return to pre-acute illness
functional status
• Chronic
– Longer duration (>3-6 months)
– Not always symptomatic
• Symptoms can exacerbate and remit
– Can have multiple etiologies
• Diabetes and ASCVD
• Frailty
– Goal of care is symptom control and
maximizing function
• Incurable, but ‘manageable’
• Unlikely to return to pre-acute illness
functional status
• Require ongoing interactions between
patients and healthcare team
Hazards of Hospitalization
• Chronic disease and function decompensate
• Longer hospitalization
• Can’t return home without help or subacute
admission
Which are reasonable discharge
destinations for a patient?
Hospital
Home
Home with
Services
Acute
Rehab
Rehab
Nursing Home
Sub-Acute
Rehab
Hospital Care for Elders
• Communicate the key components of a safe
discharge plan (e.g., accurate medication
list, plan for follow-up), including
comparing/contrasting potential sites for
discharge.
Managing Chronic Illness
•
•
•
•
Adapting to change
Mastery and sense of control
Social support network
Meaning of life and illness
RWJ Chronic Care Model
http://www.improvingchroniccare.org/change/model/components.html
Chronic Care Model
• Health System
– That promotes safe, high quality care
• Delivery System
– Assures effective, efficient clinical care and self-management support
• Clinical Information Systems
– Organize patient and population data to facilitate efficient and effective
care
• Community resources
– Mobilize community resources to meet needs of patients
• Self-Management Support
– Empower and prepare patients to manage their health and health care
• Decision Support
– Clinical care that is consistent with scientific evidence and patient
preferences
http://www.improvingchroniccare.org/change/model/components.html
The Librarian As Gerontologist:
What You Need To Know
• How does aging affect one’s health and well
being ?
• What might physicians and other health care
professionals be asking you about aging?
• What might the public be asking about aging?
The Librarian as Gerontologist
What You Need to Know
• High-quality sources of info on:
– Demographics of aging
– Age-related changes in function
– CAM
– Geriatric Drug Dosing
– Drug Interactions
– Community Resources
– Patient self-management
– Caregiver support
Doris Lessing
“The great secret that all old people share is that you really haven't
changed in seventy or eighty years. Your body changes, but you don't
change at all. And that, of course, causes great confusion.”
What is Old Age?
“To Me, Old Age is always 15 years older than I am”
Bernard M. Baruch
Oliver Wendell Holmes, Jr.