! See Slides:
12,13,14,15,17,18,22,29,35,36,52,53!
What Every
Ophthalmologist
Needs to Know about
Geriatrics
AGS
Andrew G. Lee, MD
Chair of Ophthalmology
The Methodist Hospital, Houston, TX
Professor of Ophthalmology,
Neurology, and Neurosurgery
Weill Cornell Medical College
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
OBJECTIVES
• Discuss scope of the problem (demographic
shift disproportionately affects
ophthalmology)
• Describe comorbidities in elderly
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Depression
Dementia
Hearing loss
Fall risk and prevention
Elder abuse
• Screening tips for elderly eye patients
Slide 2
GERIATRICS AS A MODEL FOR THE
ACGME COMPETENCIES IN
OPHTHALMOLOGY
• Unique needs of geriatric patients in medical
knowledge & patient care domains
• Professionalism (avoiding ageism)
• Communication skills (teaming with caregivers
and primary care, dealing with hearing loss and
dementia)
• Practice-based learning (age-specific evidence)
• Systems-based practice (nursing home,
comorbidities, fall prevention)
Slide 3
COMPETENCIES
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Patient care
Medical knowledge
Professionalism
Communication and interpersonal skills
Practice-based learning
Systems-based practice
Slide 4
THE COMPETENCIES ALIGN WITH
EVOLUTION OF DOCTOR-PATIENT
RELATIONSHIP
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Doctor-patient
Doctor-patient
Patient-doctor
Patient-doctor
Person-doctor
Person-person
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Practice-based learning
Medical knowledge
Patient care
Systems-based learning
Communication
Professionalism
Slide 5
CASE-BASED LEARNING
• Case vignettes to emphasize key points
• Platform for discussion of competencies
• Ophthalmologists do not have to be
geriatricians but need to recognize specific
geriatric syndromes
Slide 6
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Slide 10
GERIATRIC PATIENTS ARE
NOT JUST OLDER ADULTS
• Different responses to disease & treatment
• Different systems-based issues (transportation,
mobility, comorbidities)
• Different communication needs (hearing loss,
dementia, depression, nursing home)
• Different effects on functional outcome
Slide 11
CASE VIGNETTE
• A 75-year-old man is brought in by his family for
“poor vision”
• Only says very slow “yes” or “no” to questions
• Blunted affect & seems withdrawn
• 3 ophthalmologists said “he’s just getting older”
• Geographic atrophy retinal pigment epithelium
• Barely able to give visual acuity of 20/70 OU,
constricted visual field OU, slow responses
Slide 12
COMPETENCY ISSUES
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Medical knowledge
Patient care
Communication skills
Professionalism
Practice-based learning
Systems-based practice
???
Slide 13
Slide 14
SCREENING FOR DEPRESSION
• Geriatric Depression Scale (15 items)
• “Do you feel sad or depressed often?”
Slide 15
IMPORTANT RISK FACTORS
FOR SUICIDE IN
DEPRESSED ELDERLY PATIENTS
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Greater severity of depression
Symptoms of psychosis
Alcoholism
Abuse of sedatives
Recent loss or bereavement
Recent development of disability
White male
Age over 80
Apfeldorf et al. Principles of Geriatric Medicine and Gerontology.
5th ed. New York: McGraw-Hill, Inc; 2003: 1443-1458.
Slide 16
DEPRESSION & VISION LOSS
IN THE ELDERLY
• Elderly patients with depression may present with
vision loss (or other somatic symptoms)
• Depression is a common comorbidity with vision loss
(vision loss can cause depression)
• Depression is under-recognized in the elderly
• Depression in elderly may lead to suicide
• Screening by ophthalmologists might help to identify
patients at risk
• Depression is NOT a normal part of aging
Slide 17
OUTCOME
• Patient responded yes to screening depression
question (“Do you feel sad or depressed often?”)
• Referred to primary care service
• Underwent counseling & pharmacotherapy for
depression
• Returned to ophthalmologist “a different man”
• 20/20 OU! Full Goldmann visual field OU
Slide 18
CASE VIGNETTE
• 65-year-old woman with age-related macular
degeneration
• Lives in nursing home and doesn’t hear very
well
• During exam, she seems very hard of hearing
• Technician has to shout to get any response
• ARMD at 20/200 level OU
• She is told “nothing more can be done”
Slide 19
COMPETENCY ISSUES
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Medical knowledge
Patient care
Communication skills
Professionalism
Practice-based learning
Systems-based practice
???
Slide 20
HEARING LOSS
• Hearing loss = common comorbidity with
vision loss in elderly
• Combination deficits worse than either alone
• Hearing loss makes it more difficult to test
visual acuity
• Hearing loss makes it difficult to obtain the
history (tempting to give up)
• Many forms of hearing loss are amenable to
treatment
Slide 21
OUTCOME
• Hearing assessment with hearing aids
• Amazingly, her affect & mood improved
• She became more engaged & active
• She wrote a wonderful thank-you note to her
ophthalmologist for referring her for hearing
aids
Slide 22
CASE VIGNETTE
• A 66-year-old college professor is brought in
by his wife
• Chief complaint: “He cant see” (patient is
asymptomatic)
• 20/20 OU
• Normal eye exam
• 10 pairs of glasses over last 4 months
Slide 23
COMPETENCY ISSUES
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Medical knowledge
Patient care
Communication skills
Professionalism
Practice-based learning
Systems-based practice
???
Slide 24
WHAT CAN’T HE SEE?
• Doesn’t see road signs (wife won’t drive with
him anymore)
• Loses place in lecture (he is tenured) &
students complain that he rambles in class
• Used to write the checks & do the bills but gets
confused and writes “date” in “amount” line
• Gets lost easily on way to class
• No one wants to tell him because he holds a
named professorship & is chair of his
department
Slide 25
CLOCK DRAW FOR DEMENTIA
Instructions to patient:
• Draw a clock
• Put in time in numbers (1 through 12 o’clock)
• Draw hands at 11:10 AM
Slide 26
WHEN TO DO CLOCK DRAW TEST
• Brought in by spouse
• “Can’t read” despite many new glasses & 20/20
OU
• Homonymous hemianopsia with negative
neuroimaging
• Loss of executive function & memory (visual
variant of Alzheimer’s disease)
Slide 27
DEMENTIA & VISION LOSS
• Vision loss may worsen dementia symptoms
(analogous to “sundowning”)
• Vision loss may be presenting sign of
Alzheimer dementia (visual variant)
• Dementia = common comorbidity with vision
loss in elderly
• Clock draw = easy & fast screening test
• Treatment may slow progression of dementia
(earlier recognition is better)
Slide 28
CASE VIGNETTE
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70 y/o woman with Fuchs’ corneal dystrophy
20/80 OU
Stable
Glaucoma on 3-drop therapy
Stable IOP
Glaucomatous cups 0.9 OU
Stable
Glaucomatous field loss OU
Stable
S/P PKP OU clear grafts OU
Stable
S/P CE/IOL OU
Stable
Frequent falls (2x in 3 months) Not stable!
Slide 29
VISUAL RISK FACTORS FOR FALLS
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Decreased visual acuity
Glare
Altered depth perception
Decreased night vision
Loss of peripheral visual field
Slide 30
I HATE FALLING
• I―Inflammation of joints
(or joint deformity)
• H―Hypotension
(orthostatic blood
pressure changes)
• A―Auditory and visual
abnormalities
• T―Tremor (Parkinson's
disease or other causes
of tremor)
• E―Equilibrium (balance)
• F—Foot problems
• A―Arrhythmia, heart
block or valvular disease
• L―Leg-length
discrepancy
• L―Lack of conditioning
(generalized weakness)
• I—Illness
• N―Nutrition (weight loss)
• G―Gait disturbance
Sloan JP. Mobility failure. In: Protocols in primary care geriatrics.
New York: Springer, 1997:33-8.
Slide 31
FALLS ARE BAD IN ELDERLY
• Falls = leading cause of injury deaths &
disabilities among persons aged >65 years
• US: 1 in 3 older adults falls each year
• 1997: 9,000 (aged >65 years) died from falls
• 20%-30%: moderate to severe injuries that
reduce mobility & independence
• Hospitalized for falls 5x more than for other
causes
• Women: 3x more likely than men to be
hospitalized for a fall-related injury
Slide 32
FALLS & FRACTURES
• 19881996: hip fx increased from 230,000 to
340,000
• Hip fracture hospitalization rates are
substantially higher for white women
• Cost of hip fracture: $16,300$18,700
• 1991: hip fractures = $2.9 billion for Medicare
• Could reach $82 billion$240 billion by 2040
Slide 33
FALL RATE PER 100,000 PEOPLE
MMWR 2006
Slide 34
TAKE-HOME MESSAGES
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Vision loss increases risk for falling
Ask about falls
Fall prevention is superior to fall treatment
Fall  fracture  hospitalization  loss of
mobility & independence  nursing home or
death
• Fall checklist for all vision-impaired elders
• Stable eye exam ≠ stable patient (Unstable
patient at risk for falls)
Slide 35
CASE VIGNETTE
• 75-year-old woman with Alzheimer’s disease
• She is brought in by her pastor (but son has
power of attorney) for “falling” & hitting her eye
• She has ecchymoses OD, a hyphema, and a
retinal detachment OD
• She appears disheveled & unkempt
• Pastor is concerned about her health
• The patient tells you she is afraid to go home
Slide 36
COMPETENCY ISSUES
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•
•
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•
•
Medical knowledge
Patient care
Communication skills
Professionalism
Practice-based learning
Systems-based practice
???
Slide 37
CASE VIGNETTE
• When you call the son regarding your
concerns, he tells you to “mind your own
business”
• Son tells you that he is in charge of his
mother and how he treats her is his own
business
• The pastor feels that she might be neglected
or the victim of abuse, & he believes the son
might be taking her Social Security check
Slide 38
ELDER ABUSE (UMBRELLA TERM)
• Physical abuse: inflict or threat to inflict harm
• Sexual abuse: non-consensual sexual
contact
• Emotional or psychological abuse: verbal or
nonverbal
• Exploitation: financial or material
• Neglect: refusal or failure to provide food,
shelter, health care, or protection
• Abandonment: desertion of a vulnerable elder
Slide 39
http://www.ruralhealth.utas.edu.au/padv-package/module2-5.html
Slide 40
http://www.ruralhealth.utas.edu.au/padv-package/module2-5.html
Slide 41
REPORTING ELDER ABUSE
• Legislatures in all 50 states have passed
some form of elder abuse prevention laws
• All states have set up reporting systems
• Adult protective services (APS) investigates
reports of suspected elder abuse
Slide 42
ELDER ABUSE:
A GROWING PROBLEM
• 19.7% increase in reports from 2000–2004
• 15.6% increase in substantiated cases from
2000–2004
• Two in 5 victims (42.8%) are >80 years
Slide 43
TAKE-HOME MESSAGES
• Beware elder abuse
• As in child abuse, suspect if story doesn’t
match
• Adult Protective Services = equivalent of
Child Protective Services
• Physical abuse is not the only type of abuse
• Neglect is a form of abuse
Slide 44
SUMMARY (1 of 2)
• Demographic shift disproportionately affects
ophthalmology
• Geriatric patients are not just older adults
• ACGME competencies (model for
implementation)
• Recognize, triage, & refer comorbidities in the
elderly
 Depression
 Dementia
 Hearing loss
Slide 45
SUMMARY (2 of 2)
• Screening tips for elderly ophthalmology
patients
 Whether they look depressed or not, ask about
depression
 If you have to shout, they need a hearing
assessment
 Clock draw test for dementia
 If they have fallen or are at risk of falling, provide
fall checklist
 Think about elder abuse (especially if story
doesn’t add up)
Slide 46
THANK YOU FOR YOUR TIME!
Visit us at:
www.americangeriatrics.org
Facebook.com/AmericanGeriatricsSociety
Twitter.com/AmerGeriatrics
linkedin.com/company/american-geriatricssociety
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