Geriatrics 101:
How are older patients different from all other
patients and why does it matter?
Elizabeth Clark, MD, FACP
Associate Director/Clinical, VISN 3 GRECC
Bronx VA Medical Center
Associate Professor of Geriatrics
Mount Sinai School of Medicine
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
syndrome 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
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
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
Physiologic Changes Associated
with Aging
• Examples of changes (including diseases) that
are increasingly common, though not inevitable,
as people age
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Hearing loss
Macular degeneration
Hypertension
Heart disease
Cancer
Parkinson’s disease
Dementia
Social Problems More Common
with Aging
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•
•
•
Loss of income
Loss of close family
Loss of community
Social isolation
Geriatric Syndromes
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•
•
•
•
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•
•
•
•
Sensory Impairment (Visual and Hearing)
Gait Impairment
Falls
Incontinence
Dementia
Depression
Delirium
Polypharmacy
Sleep Problems
Pressure Ulcers
Functional Reserve
• 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
Functional Reserve
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
The Challenges of an Aging Population
2000 U.S. Census Data
Number of persons (% of population)
USA
Total
< 65
>64
65-74
75-84
273,643,274
240,529,940
33,113,334
18,108,981
11,708,844
(100)
NY State
18,395,995
(100)
NY City
7,825,848
(100)
NY
County
Bronx
County
1,477,358
(87.9)
16,058,189
2,337,806
(6.6)
1,253,232
3,295,509
(4.3)
(1.2)
834,532
250,042
(87.3)
(12.7)
(6.8)
(4.5)
(1.4)
6,913,082
912,766
493,874
319,936
99,956
(11.6)
(6.2)
(4.1)
(1.3)
182,644
92,857
65,301
24,486
(12.4)
(6.3)
(4.4)
(1.7)
(88.4)
1,294,714
(100)
(87.6)
1,327,690
1,093,593
(100)
(12.1)
>85
(89.9)
134,097
(10.1)
VISN 3 Primary Care Patients
Age Distribution of
Unique SSNs seen in FY2007
160000
No. of unique SSNs
140000
120000
100000
80000
<65
>64
Total
60000
40000
20000
0
BX
NJ
HV
NY
BK
Clinical Site
NP Total GPC
VISN 3 Primary Care Patients
Age Distribution of
Unique SSNs seen in FY2007
160000
No. of unique SSNs
140000
120000
100000
<65
65-74
75-84
>84
Total
80000
60000
40000
20000
0
BX
NJ
HV
NY
BK
Clinical Site
NP
Total GPC
VISN 3 FY2007
Discharges
Med./Surg. Discharges
20000
18000
16000
14000
12000
10000
8000
6000
4000
2000
0
>64
<65
Total
BK
BX
CP
EO
Facility
NY
NP
Total
VISN 3 FY2007
Discharges
Med./Surg. Discharges
20000
18000
16000
14000
12000
10000
8000
6000
4000
2000
0
>64
65-74
75-84
>84
Total
BK
BX
CP
EO
Facility
NY
NP
Total
Geriatric Interdisciplinary Team
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Medicine
Nursing
Social Work
Psychiatry
Psychology
Case Management
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Physical Therapy
Occupational Therapy
Speech Pathology
Pharmacology
Chaplaincy
Recreation Therapy
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
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 on the Upper West Side,
the other lives in California but calls frequently.
Sensory Impairment - Vision
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?
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
Cataracts
Glaucoma
Macular Degeneration
Diabetic Retinopthy
Low Vision Aids
Low Vision Aids
Gait Abnormalities and Falls
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?
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
Gait Abnormalities and Falls
• Falls
– 30-40% of community dwelling seniors fall each year
– Falls often result in decreased independence
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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
Gait Abnormalities and Falls
Gait Abnormalities and Falls
Gait Abnormalities and Falls
Gait Abnormalities and Falls
Gait Abnormalities and Falls
Dementia
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?
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
Alzheimer’s Disease
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
“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
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
Clock Drawing Test
Dementia Prevention
Dementia Prevention
Dementia Prevention
Dementia Prevention
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
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