Transcript aging america updated fall segu 2013

Aging America:
Clinical Management of
the Elderly Patient
Pat Segu, OD FAAO
Clinical Associate Professor
Definitions
• Gerontology
– a branch of knowledge involving the study of
aging and problems associated with the aged
• Geriatrics
– a specialized part of gerontology; it covers the
mental and physical health aspects and problems
of elderly individuals
Definitions
• Aging – to show signs of growing old;
succession of states of a system along a time
line
• Ageism – bias or prejudice against elderly
people based on belief that older people are
incapacitated or incompetent simply b/c they
are old
• Senescence – condition of growing old
Definition
• Elderly Population
– Young Old
65 – 74
– Middle Old
75 – 84
– Old - Old
> 85 yrs
• Each Age group require different aspects of
our attention
Definition
• Older Patient
– Well Elderly
– Moderate Impaired Elderly
– Severely Impaired Elderly
Well Elderly
•
•
•
•
•
Independent
Chronic Health Problems
NOT Functionally Impaired
Susceptible to age-related diseases (i.e. Cataracts)
Patient Education
– Importance of Annual Eye Exam
– Education Regarding Disease
Moderate Impaired Elderly
• Compared to Well-Elderly-may have same or
more chronic health conditions
• Need help with Daily Living Activities
– Cooking
– Personal Care
– Shopping
• Assistive Devices – Walkers / Wheelchair
• Multiple Meds
– Impt Complete List of Medication
– Possible SE interfere with Visual System
Severely Impaired Elderly
• Many Disabling Conditions
• Multiple RX & OTC Meds
• “Confusion”
• Homebound or Long-term care facility
– Nursing Home
What is your Aging IQ?
• The older you get, the less you sleep. True or
False
• FALSE
– Quality of sleep declines but NOT the total sleep
time
– Elderly take more naps throughout the day
– Overall get the same amount of sleep except that
the sleep is fragmented
What is your Aging IQ?
• Families Don’t Bother with Their Older
Relatives. True or False
• FALSE
– Most Elderly live close to their children and many
live with their spouses
– Approx. 5 % nationwide live in nursing homes
– Cultures Differences
What is your Aging IQ?
• Does IQ Change with age? Yes or No
• NO
– No serious decline in intelligence with age
– Wisdom increase with age
– Rate/Speed of learning decreases with age
• Absorbing new information at an older age maybe
more difficult
– Calculated IQ test may be lower because of
emphasis on speed
What is your Aging IQ?
• Everyone becomes confused or forgetful if
they live long enough. True or False
• FALSE
– Alzheimer’s can cause confusion and forgetfulness
– Many Treatable problems may also elicit these
symptoms
• Poor Nutrition
• Adverse Drug Reaction
• Depression
What is your Aging IQ?
• Falls and injuries are most common among
people over 65 years of age True or False
– TRUE
– Important for Regular Hearing and Vision Tests
– Good Safety Habits to prevent accidents
– Adverse Drug Reaction can affect balance and
coordination
Characteristics of Aging
Common Physical Changes
• Decreased
–
–
–
–
Hearing
Vision
Taste
Smell
• Increase reaction time for complex tasks
• Decrease ability to multi-task
• Disease and injury is more difficult to recover from as
we age
Clinical Impact Elderly Patients
•
•
•
•
•
Cardiovascular diseases
Cancer
Cerebrovascular disease
DM
Rheumatic disorders
•
•
•
•
•
Smoking
Poor nutrition
Alcohol abuse
Lack of exercise
Mental Health
– Depression
– Dementia
Clinical Impact Elderly Patients
• Auditory considerations
– Loss of high frequency pitch
– Presbycusis
• Progressive Hearing Loss occurring bilaterally
• Affects 30% of 65-74 yrs
• 50% of >75yrs and older
– Tinnitis
• affects 30% of people over 65
– Vertigo
Psychological considerations
•
•
•
•
•
•
• Death of a spouse
Retirement
• Children leaving
Declining health
home
Decreased mobility*
• Reduction in social
Income decline
role
Sensory decline
•
Institutionalization
Decreased response time
• Elder abuse
Prescribing Considerations
• Physiological changes metabolism
– decreased liver and kidney function
– decreased muscle mass/increased body fat
– decrease GI absorption & serum protein
• Toxicity (systemic medications)
• Poly-pharmacy
– Side effects
– Contraindications with other meds
Family Support
• Expressive
– Advice
– Affection
– Love
• Instrumental
– Financial
– Transportation
– Household Tasks
• Informal or unpaid care estimated to account for
95% of all care given to older adults
Family Support
• Social Change
– Relocation
• Family Size
– Smaller
– More women in the workforce
– Grandparents help with looking after grandkids
• Increased longevity of older results
Demographics of
Aging in America
“Graying of America”
www.aoa.gov (Administration on Aging)
Elderly Populations
“Graying of America” (65+)
• Increase in Elderly Population (>65yrs)
– Decrease infant mortality
– Preventive health care measures
– Advanced life saving technology
– Improved Clinical Medicine
• In the U.S., approximately 1 person out of
every 8 is an older American
• 2002: 35.6 Million (increase of 10.2% from 1992)
“Graying of America”
Future Growth
• 2011-2029 the “coming of age” of baby
boomers will yield a sudden sharp increase
• By the year 2030, the older population will
more than double to 71.5 million
• Age group of >85 is increasing the most
quickly
• 3.1 % of US Labor Force
“Graying of America”
Future Growth
“Graying of America”
Future Growth
Figure 1: Number of Persons 65+,
1900 - 2030 (numbers in millions)
80
70
60
50
40
30
20
10
0
71.5
54.6
25.7
31.2
35
40.2
16.7
3.1
4.9
9
1900 1920 1940 1960 1980 1990 2000 2010 2020 2030
Year (as of July 1)
Life Expectancy
• Life Expectancy 1900
• Life Expectancy 2001
47.9yrs
77.2 yrs
– F (78-79 yrs) vs. M (71-72yrs)
• Centenarians in the U.S.
– In the year 1990: 37,306
– In the year 2002: 50,364
• Represents in increase of 35%.
Living Arrangements (2001-02)
• Majority of Elderly live in the community
– 5% of adults live in institutional setting
• 80% Homeowners vs. 20% Renters
• Older Men More Likely to be Married
• ½ of the Older Female live alone
• Less likely to Relocate
Living Arrangements
Women
Men
10%
19%
40%
41%
living with spouse
living alone
Other
18%
72%
living with spouse
living alone
Other
Marital Status
• Men more likely to be married vs. Female
• ½ of Older Females widows (2002)
• 10% Older population divorced or separated
Figure 2: Marital Status of Persons 65+ - 2002
80%
73%
70%
60%
50%
41%
46%
Women
Men
40%
30%
14%
20%
10%
10% 9%
4% 4%
0%
Married
Widowed
Divorced or Single (never
Separated/
married)
Spouse
Absent
Geographic Distribution (2002)
• Top 5 States
– California
3.7 million
– Florida
2.9 million
– New York
2.5 million
– Texas
2.2 million
– Pennsylvania 1.9 million
• Most Older American lived in metropolitan
areas (77%)
Education Among Elderly
(2002)
• Education Level is Increasing
• Between 1970 and 2002, the percentage completed
High school increased from 28% to 70%
–
–
–
–
74% Caucasians
68% Asians
51% AA
35% Hispanics
• 17% Bachelor Degree or more
Economic Status (2002)
• Sources
– Social Security
91%
– Income from Assets
58%
– Public & Private Pensions 40%
– Earnings
22%
• Poverty rate: 10.4%
• Elderly group are actually wealthier
• Net Worth increases until Age 74
– Median Net Worth (2000) was $108,000 vs.
$55,000 for total population
Economic Status (2002)
Family Households 65+ Householder
0.0%
Under $10,000
5.0%
10.0%
15.0%
20.0%
25.0%
4.5%
7.1%
$10,000 - $14,999
20.9%
$15,000 - $24,999
19.6%
$25,000 - $34,999
18.4%
$35,000 - $49,999
$50,000 - $74,999
$75,000 and over
15.3%
14.3%
Economic Status (2002)
Poverty
• About 10% of all elders have incomes < the
poverty line
• Older Women > Older Men
• AA > Hispanics > Caucasians
• Older Hispanic women living alone HIGHEST
Poverty Rates (47%)
Health and Health Care
• Majority of Elderly are Healthy
• Greater Disability with >80+
• Relationship Disability & Health Status
• Most Older Adults have 1 Chronic Condition
• Probable Multiple Chronic Disease
Chronic Health Conditions
Sensory Impairments and Oral Health
Use of Time
Use of Time
Vision Care and the Elderly
• Vision Care Needs will INCREASE
• Correction of Refractive Error & Presbyopia
• Problems
–
–
–
–
–
–
Dry Eyes
Cataracts
Floaters
Age-related macular degeneration
Retinopathy
Glaucoma
• Medicare Billing
• Increase need for LV services
Evaluation
• Vision Care Setting
– Private Office
– Private Residence
– Hospital
– Nursing Home
Evaluation
• Visual and Non-visual Needs
• BVA in Office = Home Environment
• Familiar with Home Environment
• Functional Demand
• Services Available
Optometric Evaluation
• Gross Observations
–
–
–
–
–
Hearing Impairment
“Confusion”
Fatigue
Asymmetry / Note Lid Margins
Mobility
• Careful Case History
–
–
–
–
–
–
–
CC
Ocular
Medical
Meds / Allergies
Social
Mental
Functional
DIFFICULTY IN TAKING A CASE HISTOR
•
•
•
•
•
•
Reduced VA
Impaired Hearing
Cognitive Ability
Slower Response
Under Report Visual Symptoms
Time Consuming
Functional Abilities
• Effect on Everyday Function
– Ex. Patient w/ Arthritis Unable to Open Bottle
• Ask Patient Able To Perform Activities
– Shopping
– Cooking
– Self-Medication
– Reading Mail
– Writing Bills
Visual Acuity
• Enhanced using LV charts with increase
contrast
• Contrast sensitivity testing good to explain
non-specific complaints
• Multiple Glasses – test with more freq worn
• Pinhole VA to ______________
Rule out Media Opacity
• Problems with GLARE
• Amsler Grid
Normal Ocular Aging Changes
• Decreased vergence ability (speed & amplitude)
– Diplopia
– Break down of a high phoria
• Stereopsis might be reduced after age 50
• Impaired smooth pursuits
• Slower eye movements
Refractive error
• Hyperopic shift vs. myopic shift
• Astigmatism
– Shift from WTR to ATR
• Optical aberrations
– Increased diffraction (smaller pupil)
• Age induced miosis
• R/O Trauma / Inflammation / Surgery
– Increased light scatter
Presbyopia
• Age norms
– 45 yrs
+1.50
– 50 yrs
+2.00
– 55 yrs
+2.50
– >55 yrs +2.50 (if working dist is 40cm)
• Calculated amplitude
– minimum = 15.0 – 0.25 (age)
– average = 18.5 – 0.3 (age)
– maximum = 25.0 – 0.4 (age)
Aphakic Correction
• High plus lenses
– 25% Magnification
– Objects appear larger and closer
– Pin-cushion distortion
– Ring scotoma
– “Jack-in-the-box”
– Increase vergence demand
Practice Strategies
• Concentrate on Geriatric Population 15-20
minutes from Practice
• Community Service Activities
– Public education
– Vision screening
– Network health care providers
• Employing staff member >55 yrs
Practice Strategies
•
•
•
•
•
•
•
•
•
Adjust exam time
Do not use reflective or glossy paper for materials
Avoid blue, violet, or green colored paper
Good Contrast of furniture, walls, carpets etc
Proper lightening
Handicap accessible
Door handle that pulls
Reception counter waist level
Office should not be cluttered
REMEMBER
• Handle One Complaint @ a time
• Case History Never Ends
• Educate Your Patient
• Refer
– Mental problems
– Physical problems
Normal Age
Related Vision &
Ocular Changes
Adnexa
Orbital Aging Changes
• Orbital fat shrinks
• Lids become flaccid
– Entropion
– Ectropion
• Dry Skin
• Orbital fat prolapses into upper nasal lid
• Decreased levator function
Adnexa
• Dermatologic
– Decreased
• Elasticity
• Muscular tone
– Wrinkling
• Increased chance of infection
– Dermatochalasis
• Decreased Cilia
Adnexa
• EOMs
– Fibrosis/sclerosis leads to relative restriction,
especially superiorly
• Aperture
– Lateral canthus drifts inward
• shortens lateral dimension
– Reduced levator function
• shortens vertical dimension
– Sagging Skin
• shortens vertical dimension
Loss of Elasticity “Snap-Back Test”
Failure of the lid
to snap back into
position
eyelearn.med.utoronto.ca/. ../04Ectropion.htm
Ectropion
• Horizontal Lid Laxity
– Snap Back Test
• Pull center part of LL >10 mm
• Failure to snap back into position
• Medial Canthus Tendon Laxity
– Pull LL laterally & evaluate position of puncta
• Normal – 1-2 mm displacement of puncta
• Mild – Position of puncta @ limbus
• Severe – Position of puncta @ pupil
• Lateral Canthus Tendon Laxity
– Ability to pull LL medially > 2mm
Uneven Eyelid Margins
• Normal aging change
• Check to see that a mass isn’t causing this
(Sebaceous carcinoma)
• Recurrent chalazia need to be biopsied
Adnexa
• Tear Film
– Important in Maintaining Corneal Integrity
• Lubrication
• Disinfection
• Removal of Debris
– Decreased Stability and Production
– Aqueous deficiency most common problem with the elderly
– Reduction in Blink Rate (blinks/minutes)
• 3-4 vs. 15-20
– Complaints of Dry Eye Symptoms
– Sjogren’s syndrome, post-menopausal females, medications
– Management Tear Supplementation & Ectropion Repair
Conjunctiva
• Saggy, loose, “redundant”
• Vasculature
– Increase in size and number
• Subconjunctival hemorrhage
– Increased incidence
– Caution w/patients taking blood thinners
• Coumadin
• Plavix
• Clarity
– Decreased; yellowing due to hyaline changes and
fat deposits
Sclera
• Clarity
– More transparent and yellow
• Due to dehydration and lipid deposits
• Increase in Rigidity
• Senile Scleral Plaque
Senile Scleral Plaque
Senile Scleral Plaque
• Local area of excessive scleral thinning
• Occurs at the area of the insertions of the
rectus muscles (MR & LR)
• Thin clear area, may be dark if it is very thin
and you are seeing the choroid through it
• Benign