Approach to the Care of the
Elderly
Implications for Oral Health
Albuquerque Area IHS Dental Officers
June 4, 2013
Bruce Finke, MD
Nashville Area Elder Health Consultatn
Our Agenda
• Principles of high quality geriatric care and iImplications
for the oral health care of the elderly
• Some things to look out for
• Recognizing Dementia – why, how, and what next
• Organization of care to provide effective care for the
elderly.
• Open discussion
The Goal of Elder Care…
• Maintain health
• Maintain function
• Maintain ability to play a vital role in the
life of community and culture
Prevent or delay disability, frailty, and
displacement from home and
community
What Distinguishes Elder Care?
• A focus on Function
– Functional assessment in the elderly =
developmental assessment in pediatrics
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Greater family involvement
Multiple co-morbidities
Geriatric syndromes
Increased adverse effects to medications
Increased heterogeneity of goals
Four Pillars of Elder Health
• Function
• Wellness and Prevention
• Relationships
• Management of Acute and Chronic
Conditions
Function
Help the elder to do the things they want
and need to do.
The patient’s view
Function
=
Health
(Quality of Life)
Function
Assess Function
• Activities of Daily Living (ADLs)
– Bathing, Dressing, Toileting, Feeding, Continence
• Instrumental Activities of Daily Living (IADLS)
– Finances, Cooking, Shopping, Housework/Chores, Medications,
Transportation
Address Function
• Elder’s goals drive the process
• function = eating, drinking, talking, and smiling
Wellness and Prevention
Health Promotion and Disease Prevention
Offer what we know helps elders maintain
health and wellness.
With the individual elder and their family,
identify the right tests or interventions in
the context of the elder’s age, health, and
preferences for care.
Wellness and Prevention
Health Promoting Behaviors
Early detection of hidden risks
Immunizations to prevent illness
Medications that reduce risk of illness or injury
Interventions to reduce the risk of injury
Wellness and Prevention
Health promoting behaviors
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Exercise
Diet
Tobacco Cessation
[Self-Management Support: Assessment,
Goal Setting, Problem Solving]
Wellness and Prevention
Early detection of hidden risks to health and wellness.
•Diabetes
•Oral Health
•HTN
•Eye Disease / Visual impairment
•Breast Cancer
•Hearing Loss
•Colorectal Cancer
•Alcohol Misuse
•Cervical Cancer
•Non-ceremonial Tobacco
•Abdominal Aortic Aneurysm
•Pain
•Osteoporosis
•Weight (weight loss / obesity)
•Depression
Elder Mistreatment
Alcohol Misuse
a) On average, how many days per week do you
drink alcohol?
b) On a typical day when you drink, how many
drinks do you have?
c) What’s the maximum number of drinks you
have had on a given occasion in the last month?
• Use in the family?
At-risk drinking is defined as:
PER WEEK
Men
> 14 Drink
Women
> 7 Drinks
Age > 65 > 7 Drinks
EXAM RESULT
Normal or Negative
Abnormal
Refused
PER OCCASION
> 4 Drinks
> 3 Drinks
> 1 Drink
DEFINITION
No evidence of risky alcohol use.
Potential risky alcohol use.
Declined screening
Wellness and Prevention
Immunizations to prevent illness
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Pneumovax
Influenza
Tetanus – Tdap at least once
Zoster
A bit about Zoster Vaccine
• Zoster incidence increases with age
– 5-6/1000at age 60
– 10-11/1000 at age 80
• Higher if impaired cell-mediated immunity (DM,
CKD, transplant, or frequent steroid use)
• 10-15% with post-herpetic neuralgia, increases
with age.
• Most efficacious in 60-69 age range (better take)
• Covered by Medicare D
Wellness and Prevention
Medications that reduce risk of illness
or injury.
•
Calcium for those with inadequate intake
(1200mg / day) - maybe not…..
•
Vitamin D for those at risk for Vitamin D
deficiency (800 miu/day)
•
Aspirin for prevention of cardiovascular disease
in those at increased risk
–
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risk of cardiac event >3% over 5 years
data is strongest between age 40 and 75
Estimates of Benefits and Harms of Asprin Therapy
Given for 5 Years to 1,000 Individuals with Various Levels of
Baseline Risk for Coronary Heart Disease*
Baseline risk for coronary heart disease over 5 years: 1%
Total mortality: No effect
CHD events**: 1-4 avoided
Hemorrhagic strokes***: 0-2 caused
Major gastrointestinal bleeding events****: 2-4 caused
Baseline risk for coronary heart disease over 5 years: 3%
Total mortality: No effect
CHD events**: 4-12 avoided
Hemorrhagic strokes***: 0-2 caused
Major gastrointestinal bleeding events****: 2-4 caused
Baseline risk for coronary heart disease over 5 years: 5%
Total mortality: No effect
CHD events**: 6-20 avoided
Hemorrhagic strokes***: 0-2 caused
Major gastrointestinal bleeding events****: 2-4 caused
Wellness and Prevention
Interventions to reduce the risk of injury
•
•
Medication Review
Fall Risk Assessment and strategies to
reduce fall risk
– AGS Fall Prevention Guidelines
– USPSTF Recommendations
» Exercise
» Vitamin D
» Multifactorial Fall Risk Assessment – not for
everyone at increased risk
Relationships
Understanding the relationships that support
the elder, that the elder supports, and that
the elder needs to remain healthy and
well.
Relationships
Spiritual
Family
Community
Healthcare
Relationships
Spiritual
•
How can we best support the elder’s beliefs and
practices
Family
•
Supportive relationships
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Who is available to the elder? What are their training needs?
Who does the elder support?
Healthcare proxy and preferences for care
Community
•
What resources are they taking advantage of in the
community?
•
What resources might benefit them?
Advance Directives…..
• Health care proxy
– Who speaks for you if you can’t speak for
yourself?
• Preferences for care
– If something sudden happens and we can’t
ask what a person wants, we usually do
everything to keep them with us. Would that
be right for you?
Relationships
Healthcare
•
Continuity with a primary care provider / care
team.
–
Does the care team / provider understand their values
and preferences for care to the degree that they are
able and want to express them?
•
Continuity with oral health provider / hygeinist
•
Coordination of care with specialists or other
primary care providers (VA?)
•
Coordination of care with other venues (hospitals,
SNFs, elder day health programs, and home)
•
Intensive Coordination of care across transitions
Management of Acute and Chronic
Conditions
The plan of care that is right for the
individual elder in the context of the
• Patient’s goals
• Condition being treated
• Age and life expectancy
• Function
Management of Acute and Chronic
Conditions
Common Conditions
• Geriatric Syndromes
– Incontinence
– Dementia
– Falls
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Diabetes
Hypertension
Arthritis
Congestive Heart Failure
Ischemic Heart Disease
Chronic Kidney Disease
Atrial Fibrillation
Depression
Palliative Care
Common Pathways
•
Blood Pressure
•
Blood Sugar
•
Kidney Function
•
Function
•
Affect
Look out!
• Acute illness or unstable chronic condition
– Elevated blood pressure, blood sugar
– Tachycardia or irregular pulse
– Worsening renal function – rising creatinine
• Red Flags
– Weight loss
– Change in function
• Fall in the last year?
• Evidence of elder neglect or exploitation
• Evidence of cognitive impairment
Look out!
• Pain Medications
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Confusion
Falls
Constipation
Diversion and risk of exploitation
Avoid codeine (risks outweigh benefits)
Scheduled Tylenol as first line
NSAIDS cautiously and at low doses
Low dose (1/2 tab) percocet / vicodan sparingly
Recognition of Dementia
• Major causes – with distinctive patterns and
etiology but many overlapping features
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Alzheimer’s disease
Vascular dementia
Lewy Body dementia (LBD)
Frontotemporal dementia (FTD)
Alcohol-related and TBI-related dementia
ADRD = Alzheimers’ Disease and Related Dementias
Recognition of Dementia - Why?
• Avoid crisis related to dementia
• Understand limitations of selfmanagement of illness and adherence to
treatment
• Better decision-making around therapeutic
options related to life-expectancy
• Support planning by person with dementia
and their family
Recognition of Dementia – How?
Dementia Warning Signs (VHA)
Is your patient…
•Inattentive to appearance or unkempt, inappropriately dressed for
weather or disheveled?
•A “poor-historian” or forgetful?
Does your patient...
• Fail to keep appointments, or appear on the wrong day or wrong time
for an appointment?
•Have unexplained weight-loss, “failure-to-thrive” or vague-symptoms
e.g., dizziness, weakness?
•Repeatedly and apparently unintentionally fail to follow directions e.g.,
not following through with medication changes?
•Defer to a caregiver or family member to answer questions?
Recognition of Dementia – What Next?
Referral to primary care: “Please evaluate cognition – the
following warning signs noted ………
In primary care:
•There may already be an explanatory diagnosis
•If not, the work-up should include:
– Focused history from patient and caregiver and review of
Systems.
– Focused physical exam, including cognition
– Standard laboratory testing
– Possible referral for imaging, specialty labs or consultation – only
in complex cases or situations with high clinical uncertainty.
Organization of Care
• Integration into primary care
– Oral health review of symptoms in primary care, with guidelines
for referral
– Alignment with Primary Care Team panels
• Strategies to increase access
– Links to existing appointments
– Warm hand-offs
– Alternate site care – e.g. Senior Center, Tribal Building, home
(truly home-bound elders)
– Mobile clinics
• Who aren’t you seeing?
One more thought…
How about education and training for
caregivers for persons with dementia?
The Goal…
• Maintain health
• Maintain function
• Maintain ability to play a vital role in the
life of community and culture
Prevent or delay disability, frailty, and
displacement from home and
community
Bruce Finke, MD
413-584-0790
615-727-2044
bruce.finke@ihs.gov