Gerry Gleich M. D.
Geriatrics Interclerkship
April 26, 2013

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13% of the U.S. population is currently over
65
By 2030 it is expected there will be 68 million
Americans older than 65 or 20% of the population

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In 1900 life expectancy was 47.3 years
By 1950 life expectancy was up to 68.2 years
2010 life expectancy was 78.7 years

 Older women outnumber older men at 23.0 million older women to 17.5 million older men.
 Current life expectancy for women is 81.1 years for men it is 76.2 years

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At age 65 life expectancy is about 19 more years
At age 75 life expectancy is about 12 more years
At age 85 life expectancy is about 7 more years

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The geriatric population is becoming more ethnically diverse in the U.S.
Currently the non-hispanic white are 73.6 % of the elderly but expected to decline to
60.5% by the year 2030
Increases in the Hispanic-American and
Asian-American populations are expected

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In the community 75% of men over 65 are likely to be married and living with their spouse
41% of women over 65 are married and living with their spouse
47% of women over 65 are widows
13% of men over 65 are widowers

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Likelihood of living alone increases with aging
Options for living
 Independent with or without assistance
 Retirement communities
 Group settings
 Foster care
 Assisted living
 Long-term care

Patient needs Resources
ADLs
IADLs
Physical
Emotional
Spiritual
Spouse/Family
Friends
Community
Church
Financial

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Own home or apartment
Congregate or senior housing may have: help with some household upkeep congregate meals activities
 staff specific home health services available through outside agencies
Naturally Occurring Retirement Communities (NORC)

 “A type of living arrangement in which personal care services such as meals, housekeeping, transportation, and assistance with ADLs are available as needed to people who still live on their own in a residential facility”
▪ Center for Medicare and Medicaid Services

2007
975,000 residents
38,000 facilities (25-120 units)
2009
$3022/mo ave cost for pvt unit
($10K-$50K/yr range)
Assisted Living Facilities of America
National Center for Assisted Living

Most Assisted Living Facilities will provide:
 Health care management and monitoring
 Help with activities of daily living such as bathing, dressing, and eating
 Housekeeping and laundry
 Medication reminders and/or help with medications
 Recreational and social activities
 Security
 Transportation
 Emergency call system in each unit

 Half the price of a nursing home, but what services are you getting?
 Liability is hurting development of the industry
 Much less regulation than nursing homes right now
 Aging in place is a big issue

2010
15,622 facilities (MA 429)
1.66 million beds (MA 48,484)
1.4 million residents
Av LOS 875 days
Av cost $198/day
(Alaska $687, MA $329)
%≥65 yo in NH?
www.longtermcare.gov
www.statehealthfacts.org

 Abuse in 1960s, 1970s led to
 Reforms in 1980s (OBRA ’87) led to
 Government regulation

 How is it changing?
 Can we make it a more positive alternative?
 Resident-centered care

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Expanding access to insurance
Reducing administrative costs
Payment reform
Incentivize Electronic Health Records
Incentivize prevention and primary care
Accountable Care Organizations
Bundled payments
Payment for quality of care

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Improvements in Prescription Drug benefits
Premium increases for more wealthy seniors
Preventive services covered

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Respond to Changing Demographics and
Economics
Improve quality of life and care
Minimize morbidity
Maximize function

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Normal age-related changes vs. pathologic
Biopsychosocial model of care
Patient-centered Goal-Oriented Care

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Age is not an accurate predictor of condition or function
Co-morbidities are common
Presentation of illness is altered (nonspecific)
Homeostatic control is less efficient

Less functional reserve. A Chain is only as strong as its weakest link

Medical
Cognitive
Polypharmacy
Nutrition Functional Decline Social support
Incontinence
Environmental
Special senses

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The single best predictor of institutionalization is impaired functional status
Self-reported function is an accurate predictor of health risks and costs
23% of older adults report some functional limitation in either ADLs or IADLs much higher percentage for the oldest segments

Functional Status at Age 70
Life Expectancy
(in years)
Annual Health
Care Costs
Independent
IADL Deficit Only
14.3
12.4
$4,600
$8,500
1 + ADL Deficit
Lubitz. NEJM 2003; 349:1048-55
11.6
$14,000

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Bathing
Dressing
Transferring
Toileting
Grooming
Feeding
Mobility

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Telephone
Meal preparation
Managing finances
Taking medications
Doing laundry
Doing housework
Shopping
Managing transportation

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Common presenting complaints should make alarms sound in your head to think comprehensively.
These presenting complaints are likely to have multifactorial causes including the effects of agerelated changes and chronic disease mediated changes

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 Frailty and failure to thrive
Dizziness
Syncope
Osteoporosis
Falls
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Malnutrition
Urinary incontinence
Pressure ulcers
Dementia
Delirium
Polypharmacy
More on some of these syndromes…

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Visual impairment
Hearing impairment

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Incidence is about 20% of those older than 65 and 50% of those older than 75
90% success with surgery (vision improved to at least 20/40)
Surgery is safe taking less than 30 minutes: breakdown of old lens, and new lens implant
About 15% of patients need addition laser capsulotomy after lens implant

 Central vision is affected

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Affects 10% of adults over age 65 and 25% over age 75
Can contribute to social isolation, anger, depression, family arguments

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Cerumen drier and thicker
Tympanic membrane thicker
Ossicular joints degenerate
Cochlear changes
 loss of hair cells
 stiffening of basilar membrane
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 neuronal loss
Decreased central auditory processing

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Ask the listener preferred way to communicate with them
Obtain listener’s attention before speaking
Eliminate background noise
Make sure the listener can see your lips
Speak slowly and clearly avoid shouting
Speak to the better ear
Change phrasing if listener doesn’t seem to understand
Spell, use gestures or write down words
Ask the listener to repeat what they heard

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Complications of falls are the leading cause of death from injury in adults over age 65
33% of adults over age 65 report falling within the past year
Most result in minor soft tissue injuries
10-15% result in fractures
5% result in more serious soft tissue injury or head trauma
Cost is considerable – ED visits, admission surgery etc.

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Age related changes
Disease related effects
Medication effects
Environmental

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Visual decline
Vestibular loss of hair cells, ganglion cells
Postural control declines
Muscle mass declines
Baroreceptor and autonomic nervous system efficiency decline

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Acute systemic illness
Parkinson’s
CVA
Osteoarthritis
Neuropathy
Visual impairments

 Psychotropic Medications
 Benzodiazepines
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 SSRIs
 Antipsychotics
Cardiac – orthostatic hypotension
Hypoglycemic agents
Anticholinergics

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Minimize medications
Prescribe exercise strength training
Treat visual impairments
Manage postural hypotension
Supplement Vitamin D 800IU/day
Manage foot and footwear issues
Assistive devices and supervision as needed
Modify home environment

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Affects 6-8% over age 65 and 30% over age 85
As baby boomers age this will be more and more common
Risk factors: Age, Family History, Down’s Syndrome,
Head trauma, Fewer years of education, CV risk factors
Patients with mild cognitive impairment progress to
Alzheimer’s at a rate of 12% per year

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Alzheimer’s Disease –Gradual Progression 8-10 years, memory, language, visuospatial, and later apraxia
Vascular Dementia –Step-wise progression related to small vessel disease
Lewy Body Dementia- Gradual progression with
Parkinson’s symptoms and hallucinations
Frontotemporal Dementia-may be more rapid and presenting with disinhibition

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Maximize function
Assess goals and advance directives early
Assess caregiver resources, understanding, and stress

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 Assess contribution of other medical conditions, environment and medications to overall picture
Could delirium or depression be present
Metabolic profile
Selective use of imaging
 Onset at a young age <65
 Sudden onset
 Focal neurologic findings
 Normal Pressure Hydrocephalus suspicion
 Recent fall or head trauma

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Support function
Physical activity
Family and caregiver education and support
Environmental modification
Attention to safety
Advance directives
Medications
 May slow decline
 Can manage behavioral symptoms

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Affects 15-30% of adults over age 65
Affects 60-70% of long term care residents
Can lead to cellulitis, ulcerations, social isolation, falls, institutionalization
Improvements can be made with an organized approach

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Urge
 Detrusor hyperactivity
Stress
 Pelvic floor relaxation and increased intra-abdominal pressure
Mixed
Incomplete emptying
 Dilated bladder with impaired contractility may also have detrusor hyperactivity with impaired contractility

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Multifactorial
Assess comorbidities, functional status and medication effects
U/A for hematuria and pyuria
No routine culture. Positive culture may reflect asymptomatic bacteriuria
Consider post void residual
 PVR >300 should lead to assessment of renal function and urology referral within 2 months
 PVR 200-300 evaluate renal function within 3 months
 PVR <200 maximize overall medical status

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Behavioral
 Incontinence supplies
Surgical
Pharmacologic
Catheters

 Extremely common in community dwelling older adults
 Difficulty falling asleep 40%
 Nighttime awakening 30%
 Early morning awakening 20%
 Daytime sleepiness 20%
 At least one half of community dwelling older adults use OTC or prescription sleep medications

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Total sleep time decreases
Time to fall asleep (latency) increase or no change
Sleep efficiency decreases
Daytime napping increases
Percent REM sleep decreases
Wake after sleep onset increases

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 30-60% associated with psychiatric disorders
(depression, anxiety)
Pain
GE Reflux
Nocturia
Periodic Limb Movements
Sleep related breathing disorders
Dementia
Medication effects

 Sleep hygiene measures
 Regular times for sleep
 Bed for sleep only
 Exercise daily
 Relax before bed
 Limit food intake, stimulants, alcohol before bed
 Dark quiet environment, comfortable temperature for sleep
 Exposure to bright light during the day

 Behavioral techniques to emphasize sleep hygiene
 Relaxation techniques
 Cognitive interventions
 Bright light therapy to correct circadian rhythm disturbance

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Try non-pharmacologic measures
Avoid benzodiazepines
 Associated with falls
 Rebound insomnia
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Sedation into the daytime
 Tolerance and withdrawal syndrome
Short acting nonbenzodiazepine-benzodiazepine receptor agonists NBRA’s
(zaleplon, zolpidem, eszopiclone)
Rapid onset take right before bed
 No rebound
 Only use 2-3 nights per week
Sedating antidepressants (mirtazapine, trazodone) for patients with depression
OTC Sleep Agents
 Avoid antihistamines - anticholinergic effects
 Melatonin – may be helpful
 Valerian no good evidence of efficacy
 Kava – risk of hepatotoxicity

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The elderly account for 33% of drug costs in the U.S.
The average elderly person is on 4.5 prescription drugs and 3.5 OTC drugs at any given time
The risk of an adverse drug reaction is proportional to the number of drugs a person is taking
“Any new symptom should be considered a drug side effect until proven otherwise”

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Reconcile medications at each visit
Stop unnecessary medications
Weigh risk vs. benefit for any new med
Consider the big picture - functional status
Monitor for adverse effects
Avoid the prescribing cascade

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Goals change as overall level of function and health changes
Knowledge of natural history of diseases is important in helping to prognosticate
Knowledge of functional status is even more important
Keep the big picture in focus
It can be a moving target so remain flexible
Do no harm and you can do a lot of good