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Physical Disorders Associated with Aging
Bruce Leff, MD
Associate Professor of Medicine
Division of Geriatric Medicine,
Dept Health Policy & Management
Physical Disorders of Older Persons
• Chronic conditions
• Medical issues related to chronic conditions
• Policy implications
Chronic Condition
• Long term disease
• Injury with long sequelae
• Onset -before birth to late life
• Defining aspects:
– Duration - permanent feature for remainder of life
– Perhaps controllable, not curable
Number of People with Chronic
Conditions
180
160
140
120
# Americans w
100
Chronic
Condition
80
(millions)
60
118
125
133
141
149
157
164
171
40
20
0
1995
2000
2005
Wu et al. Rand Corp, 2000
2010
2015
2020
2025
2030
Most Common Chronic Conditions
Hypertension
Arthritis
Respiratory Dz
Cholesterol Disorders
Chronic Mental Conditions
Heart Disease
Eye Disorders
Asthma
Diabetes
0%
5%
10%
15%
20%
25%
30%
% Noninstitutionalized Adults with Condition
Medicare Expenditure Panel Survey, 2001
Age and Prevalence of
Chronic Conditions
100%
87%
% w Chronic Condition
90%
80%
92%
73%
67%
70%
67%
60%
50%
40%
>= 1 Chronic
Condition
40%
40%
> = 2 Chronic
Condition
30%
20%
15%
10%
0%
Age20-44 Age 45-64
Age 65+
Age 80+
Medicare Expen
Panel Survey, 2001
% with Activity Limitation
Activity Limitation and # Chronic
Conditions
80%
67%
70%
60%
52%
50%
42%
40%
28%
30%
15%
20%
10%
4%
0%
0
1
2
3
# Chronic Illnesses
Medicare Expend Panel Survey, 1998
4
5+
% of Services Used by People w
Chronic Conditions
Health Care Utilization
Home Health
Visits
98%
91%
Prescriptions
Physician
Visits
76%
81%
Inpatient Stays
0%
20%
40%
Medicare Expen Panel Survey, 2001
60%
80%
100%
120%
Health Care Spending and Number of
Chronic Conditions
$14,000
$12,000
$11,500
$10,000
$8,900
$8,000
$6,000
$5,600
$4,000
$3,400
$2,000
$1,900
$800
$0
0
1
2
3
# Chronic Conditions
Medical Expenditures Panel Survey, 1998
4
5+
Chronic Conditions and Expenditures
to the Medicare Program
Number of Chronic
Conditions
0
Percent of
Beneficiaries 65+
18
Percent Medicare
Expenditures
1
1
19
4
2
21
11
3
18
18
4
12
21
5
6
7
3
18
13
7+
2
22%
14
66%
Chronic Conditions and Per Capita
Medicare Expenditures
Number of Chronic
Conditions
Mean Medicare Expenditures
Per Beneficiary
0
$211
1
$1,015
2
$1,870
3
$3,204
4
$5,246
5
$8,159
6
$11,948
7+
$23,825
% with Inpatient Hospital Stay
Chronic Conditions and Hospital Use
35%
31%
30%
23%
25%
20%
17%
15%
12%
10%
5%
7%
4%
0%
0
1
2
3
# Chronic Conditions
Medicare Expen Panel Survey, 2001
4
5+
ACSC per 1000 Beneficiaries
Hospitalizations for ACSC Conditions
400
362
350
300
296
267
250
216
200
169
150
119
100
74
50
0
8
0
0
1
40
20
2
3
4
5
6
# Chronic Conditions
7
8
9
10+
Ave Annual # Prescriptions
Chronic Conditions and Rx Meds
60
52.7
50
40
33.9
25.4
30
20
10
15.4
7.3
1.5
0
0
1
2
3
# Chronic Conditions
Medicare Expend Panel Survey, 2001
4
5+
Ave Annual Visits Per Person
Chronic Conditions, MD and Home
Health Visits
14
12.312.5
12
9.4
10
7.9
8
Home
Health
Visits
6.5
5.7
6
4.4
3.5
4
2
0
Physician
Visits
1.6
2.8
0.9
0.1
0
1
2
3
# Chronic Conditions
Medicare Expen Panel Survey, 2001
4
5+
Functional Status & Chronic Conditions
Ave Annual # Visits Per Person
14
13
12
10.8
9.6
10
7
5.4
6
2
9
7.8
8
4
9.8
3.3
No
Limitations
5.1
With
Limitations
3.2
1.6
0
0
1
2
3
4
# Chronic Conditions
5+
Medicare Expen Panel
Survey, 2001
Medical Care of Chronic
Conditions
What are the policy implications?
How does Medicare or the health
care system deal with this issue of
chronic conditions?
Medicare Bill Signed into Law - 1965
Public Domain
“Round Pegs and Square Holes:
Medicare and Chronic Care”
Courtesy J. Wolff
April 2002 NASI report
authored by Bruce Vladeck
Barriers to Quality Chronic Care in
the Medicare Program
•
•
Orientation toward acute care
Lack of incentives to provide state-of-the art
chronic care.
– No impetus to coordinate care
•
•
•
No IT infrastructure
Inadequate training of health professionals
Quality not paid for
How Do You Care for
These People?
What does quality care for these
people look like?
Are evidence-based disease
guidelines the answer?
Quality of Life and Patient Preferences Addressed in Guidelines:
Guidelines
Quality
of
life
Short term
quality of
life vs.
long-term
prevention
Incorporation of
Patient Prefs
into goals of
therapy
Time needed to
benefit/treat
Diabetes
No
No
Yes
Yes
Hypertension
No
No
No
No
Osteoarthritis
Yes
No
No
No
Osteoporosis
No
No
Yes
No
COPD
Yes
No
No
No
Atrial Fib
Yes
No
Yes
No
CHF
Yes
No
Yes: end-of-life
No
Angina
Yes
No
Yes
No
Lipids
No
No
No
No
No:
4/9
9/9
4/9
8/9
Boyd, JAMA 2005;294(6):716-24.
Time
Medications
Non-pharmacologic
Therapy
All Day
Periodic
7 AM
Ipratropium MDI
Alendronate 70mg weekly
Check feet
Sit upright 30 min.
Check blood sugar
Joint protection
Pneumonia vaccine, Yearly
influenza vaccine
Eat Breakfast
HCTZ 12.5 mg Lisinopril
40mg Glyburide 10 mg
ECASA 81 mg
Metformin 850mg
Naproxen 250mg
Omeprazole 20mg
MVI
Calcium + Vit D 500mg
2.4gm Na, 90mm K,
Adequate Mg, ↓
cholesterol & saturated
fat, medical nutrition
therapy for diabetes,
DASH
Exercise (nonweight bearing if
foot disease,
weight bearing for
osteoporosis)
Muscle
strengthening
exercises,
Aerobic Exercise
ROM exercises
Eat Lunch
Ipratropium MDI
Calcium+ Vit D 500 mg
Diet as above
Avoid
environmental
exposures that
might exacerbate
COPD
8 AM
12
PM
5 PM
Eat Dinner
7 PM
Ipratropium MDI
Metformin 850mg
Naproxen 250mg
Calcium 500mg
Lovastatin 40mg
11
PM
Ipratropium MDI
Diet as above
Total Monthly
Medication
Costs: $ 408
Energy
conservation
Wear appropriate
footwear
Albuterol MDI prn
Limit Alcohol
All provider visits:Evaluate
Self-monitoring blood
glucose, foot exam and BP
check:
Quarterly HbA1c, biannual
LFTs
Yearly creatinine,
electrolytes,
microalbuminuria,
cholesterol
Referrals: Pulmonary
rehabilitation
Physical Therapy
DEXA scan every 2 years
Yearly eye exam
Patient Education: Highrisk foot conditions, foot
care, foot wear
Osteoarthritis
COPD medication and
delivery system training
Diabetes Mellitus
Potential Interactions Resulting from Adherence to Multiple Guidelines
Hypertension Diabetes
Osteoarthritis
Osteoporosis
COPD
Her
meds
HCTZ
ACE inhibitor
NSAID
Proton Pump
inhibitor
Vit D, Calcium,
Bisphosphonates
Albuterol
Ipratropium
MedDisease
interactions
Diabetes:
1) Diuretics ↑
glucose &
lipids
MedMed
interactions
Diabetes Meds:
HCTZ may
↓effectiveness
of glyburide.
HTN Meds:
HCTZ + ACE
may ↓ BP.
MedFood
interactions
Sulfonylurea, Metformin,
ASA, HMG CoA reductase
HTN: 1) NSAIDS +
COX 2 ↑ BP
2) NSAIDS +HTN ↑
renal risk, 3) COX-2 s
and HTN/CAD/ CHF/
CKD interaction?
Osteoarthritis Meds:
1) NSAIDS + ASA ↑ risk of
bleeding
Diabetes Medications:
2) Glyburide and ASA : ↑
Hypoglycemia
3) Aspirin may ↓
effectiveness of lisinopril.
1) Glyburide + ETOH: low
sugar, flushing, ↑RR, ↑HR
2) Aspirin + ETOH: ↑ risk
of GI bleed
3) Metformin+ ETOH:
Extreme weakness, ↑RR
4) Atorvastatin + GF Juice:
Muscle weakness, pain
5) Metformin + Food:
Decreases amount absorbed
Diabetes M eds:
1) NSAIDS+A SA ↑
bleeding risk
HTN Meds:
2) NSAIDS ↓ diuretic
efficacy 3) Rofecoxib
may ↓ efficacy of
HCTZ & lisinopril
Diabetes Meds: 1)
Calcium may ↓ efficacy
of ASA
2) ASA + Alendronate
may lead to GI upset.
Osteoporosis Meds:
3) Calcium may ↓ serum
alendronate
4) Calcium + Oxalic acid
(spinach, rhubarb), Phytic
(bran & whole cereals)
may ↓ Calcium
5) Alendronate + calcium:
2 hours apart from food
with calcium and on
empty stomach
6) Avoid OJ on
alendronate
Presentation of Disease Patterns
%
ART
CHD
CLRT
DM
CVA
28
X
-
-
-
-
25
-
-
-
-
-
7
X
-
X
-
-
Blue = 2 diseases
Brown = 3 diseases
Red = 4 diseases
Prevalence of Disease Patterns, Women Age ≥65
% (95%CI)
ART
CHD
CLRT
DM
CVA
27.9 (25.2-30.6)
X
-
-
-
-
25.4 (22.8-27.9)
-
-
-
-
-
7.3 (5.8-8.8)
X
-
X
-
-
5.4 (4.4-6.3)
X
-
-
X
-
4.3 (3.0-5.6)
X
X
-
-
-
3.7 (2.8-4.6)
-
-
X
-
-
3.0 (2.1-3.9)
-
X
-
-
-
3.0 (2.2-3.8)
-
-
-
X
-
2.3 (1.4-3.2)
X
X
-
X
-
2.3 (1.5-3.1)
X
-
-
-
X
1.9 (1.2-2.6)
X
X
X
-
-
1.9 (1.0-2.8)
X
-
X
X
-
1.3 (0.8-1.8)
-
-
-
-
X
0.98 (0.32-1.7)
X
X
X
X
-
0.82 (0.39-1.3)
X
X
X
-
X
0.75 (0.17-1.3)
-
X
X
-
-
0.70 (0.21-1.2)
X
-
X
-
X
0.69 (0.24-1.2)
-
X
-
X
-
0.63 (0.19-1.1)
X
X
-
X
X
0.62 (0.31-0.92)
X
X
-
-
X
0.50 (0.15-0.86)
X
-
-
X
X
0.50 (0.16-0.84)
-
-
X
X
-
Blue = 2 diseases
Brown = 3 diseases
Red = 4 diseases
Prevalence of Disease Patterns, Women Age ≥65
% (95%CI)
ART
CHD
CLRT
DM
CVA
27.9 (25.2-30.6)
X
-
-
-
-
25.4 (22.8-27.9)
-
-
-
-
-
7.3 (5.8-8.8)
X
-
X
-
-
5.4 (4.4-6.3)
X
-
-
X
-
4.3 (3.0-5.6)
X
X
-
-
-
3.7 (2.8-4.6)
-
-
X
-
-
3.0 (2.1-3.9)
-
X
-
-
-
3.0 (2.2-3.8)
-
-
-
X
-
2.3 (1.4-3.2)
X
X
-
X
-
2.3 (1.5-3.1)
X
-
-
-
X
1.9 (1.2-2.6)
X
X
X
-
-
1.9 (1.0-2.8)
X
-
X
X
-
1.3 (0.8-1.8)
-
-
-
-
X
0.98 (0.32-1.7)
X
X
X
X
-
0.82 (0.39-1.3)
X
X
X
-
X
0.75 (0.17-1.3)
-
X
X
-
-
0.70 (0.21-1.2)
X
-
X
-
X
0.69 (0.24-1.2)
-
X
-
X
-
0.63 (0.19-1.1)
X
X
-
X
X
0.62 (0.31-0.92)
X
X
-
-
X
0.50 (0.15-0.86)
X
-
-
X
X
0.50 (0.16-0.84)
-
-
X
X
-
Blue = 2 diseases
Brown = 3 diseases
Red = 4 diseases
17.0
6.1
Disease Pattern
Results
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
0
.1
.2
ART CHD CLRT DM CVA
.3
.4
.5
.6
.7
Adjusted Probability of Hospitalization
probability
*adjusted for age and gender
95%CI
.8
.9
1
What is High Quality Chronic Care?
•
•
•
•
•
Accessible
Continuous/Longitudinal
Multidisciplinary
Coordinated and seamless
Encourages “activated” patient (self
management skills and education)
• Engages patients and their families
Source: EH Wagner, “Organizing Care for Patients with Chronic Illness” The Milbank Quarterly 74(4) 1994 and
The Chronic Care Model
Approaches to Chronic Care
Disease
Management
Case
Management
Individuals with a
specific disease
High risk
individuals
High reliance
Low to medium
reliance
Can be physically
distant
Typically local
Provider Integration
Low
Low
Economies of scale
Higher
Lower
Target Population
Use of evidence-based
guidelines/protocols
Geographical proximity of
contractors & patients
Adapted from Chen, “Best Practices in Coordinated Care”, Mathematica Policy Research, 2000.
Courtesy of Jennifer Wolff, PhD
“…there is insufficient evidence to conclude that
disease management programs can generally
reduce overall health spending ... The few
studies that report cost savings do so for
controlled settings and generally fail to account
for all health care costs, including the cost of the
intervention. Furthermore, if disease
management programs were applied to broader
populations … the programs could even raise
costs…”
- Cover Letter of 10/2004 CBO Report: “An Analysis of the
Literature on Disease Management Programs”
Courtesy of Jennifer Wolff, PhD