INTRODUCTION TO GERIATRIC MEDICINE

1. INTRODUCTION TO GERIATRIC MEDICINE Third Year Medical Students 2004 Ronald Schonwetter, MD Lori Roscoe, PhD

2. ORIENTATION Attitude survey/Life Expectancy Calculator Organization of Week by Topics Successful Aging, Quality of Life, Acute/Chronic Disease, End of Life Care Clinical Exercises (clinics/LTC) Small Group Discussions Friday Case Assignments/Group Exercise Assignments (one H/P, Case exercise) Grading/Exam Syllabus/Book/Assessment Guide

3. GOALS Of CURRICULUM Appreciate the differences among and between elderly patients and the challenges this presents to the practitioner Understand the multidimensional approach to the practice of geriatric medicine Become familiar with comprehensive geriatric assessment Understand some of the common geriatric problems Appreciate how successful some elderly age

4. DEMOGRAPHICS 1900 � Life expectancy 47 years in US 4% over the age of 65 Mid 1990�s � Life expectancy 65 years in US 12.6% over the age of 65 By 2020 - % over the age of 65 By 2040 - % over the age of 65

5. DEMOGRAPHICS 1900 � Life expectancy 47 years in US 4% over the age of 65 Mid 1990�s � Life expectancy 65 years in US 12.6% over the age of 65 By 2020 � 17% over the age of 65 By 2040 � 22% over the age of 65 1/3 women live to 85; 15% men live to 85 Causes of death: heart, cancer, stroke, lung

6. DEMOGRAPHICS More than 70% of people now live to 65 (3 times that of 1900) Life expectancy at age 65 is now >17 years Population of US increased 3 fold in the 20th century; 11 fold for those over 65 1900 � 19% of those who died over age 65 2000 � 75% of those who die over age 65 Death rates changed from childhood and middle age

7. CENTENARIANS 1900 � rare 2000 � 60,000 2050- >1,000,000

8. CENTENARIANS

9. DEMOGRAPHICS 85% over age 65 have one chronic illness 60% over age 65 have 2 or more chronic illnesses 17% age 65-74 functional limitations 29% age 75-84 functional limitations

10. FLORIDA DEMOGRAPHICS 1995 � 19% over age 65 2025 � 26% over age 65 Four surrounding counties with mean age over 55 years Tampa Bay area has over half the skilled nursing units in the state and the two largest hospice organizations in US

11. THE MYTHS OF AGING Sick, demented, frail, weak, disabled, powerless, sexless, passive, alone, unhappy Holding back society Scientific reality or not?

12. MYTH # 1TO BE OLD IS TO BE SICK Are the new seniors very sick/old or healthier? Past: Infectious illnesses Mid century: Arthritis, HTN, heart disease Now: Decrease prevalence arthritis, HTN, stroke, lung disease Compression of morbidity; less institutionalized 1994: 39% over 65 health very good or excellent with 29% fair or poor

13. MYTH #2YOU CAN�T TEACH AN OLD DOG NEW TRICKS Fear of developing Alzheimer�s disease Even those with short term memory problems have been shown to improve recall Deficits can be overcome with proper training (lists, etc.)

14. MYTH #3 THE HORSE IS OUT OF THE BARN Risky behaviors � no point in changing Not too late for no smoking, exercise and diet

15. MYTH #4THE SECRET TO SUCCESSFUL AGING IS TO CHOOSE YOUR PARENTS WISELY Is the role of genetics overstated? Increased longevity of offspring of those who died at much earlier ages

16. MYTH #5THE LIGHTS MAY BE ON BUT THE VOLTAGE IS LOW Inadequate physical/mental/sexual abilities Sexual activity decreases in old age

17. MYTH #6THE ELDERLY DON�T PULL THEIR OWN WEIGHT One third of elderly continue to work One third of elderly volunteer Others provide informal caregiving Many more are willing and able to work

18. SUCCESSFUL AGING* Low probability of disease and disease related disability High cognitive and functional capacity Active engagement with LIFE *Rowe and Kahn, Gerontologist, 1997

19. HEALTH WHO: More than absence of disease WHO: Presence of physical, mental and social well being; perceived in the context of each individual�s experiences, beliefs, and expectations. Can 2 individuals with same objective measures of health status have different perceptions of health related quality of life?

20. GERIATRIC MEDICINE Functionally oriented biopsychosocial model fostering comprehensive, multidimensional approach to health assessment Context of patient�s beliefs and values Must elicit values of patients to determine benefits and burdens of interventions

21. ELEMENTS OF ASSESSMENTS Biomedical: acute/chronic diseases, physical function, ADLs, IADLs Psychological: Intellect. function, personality, mood, sensorium, psych history/symptoms Social: Family structure/involvement, friends, co-workers, neighbors, church, community, work history, financial resources, health insurance, living arrangements, life-style Values: Personal, cultural, ethnic, religious, spiritual

22. PRINCIPLES OF GERIATRIC ASSESSMENT Goal Promote wellness, independence Focus Function, performance Scope Physical, cognitive, psychol, social Approach Multidisciplinary Efficiency Perform rapid screens to identify target areas Success Maintaining/improving quality of life

23. PHYSICIAN ROLE To work collaboratively with older patients to identify goals of care to guide diagnostic and therapeutic interventions

24. STEPS TO ESTABLISH GOALS OF HEALTH CARE FOR ELDERLY Use biopsychosocial-values model to develop functionally oriented comprehensive health assessment Develop all feasible options for care with benefits/burdens/risks and projected outcomes. Acknowledge uncertainty where present Relieve suffering Communicate effectively to patients and significant others; become patient advocate

25. PHYSICIAN ROLE �The physician who enters the patient�s universe and understands the patient�s perceptions, assumptions, values and beliefs is a tremendous advantage.� Peabody, 1927 Care of the Patient, JAMA �It is therapeutic for the patient to feel that the physician cares enough about the individual to understand his life, particularly the meaning and purpose of his present existence.� Frankl 1959 (Man�s Search for Meaning)

26. COMPONENTS OF ASSESSMENT IN THE ELDERLY Knowledge of normal aging and syndromes Utilize comprehensive geriatric assessment Recognize functional impairments Always relieve suffering Effective communication skills Elicit patient values Become patient advocate

27. GOALS Of CURRICULUM Appreciate the differences among elderly patients and the challenges this presents to the practitioner Understand the multidimensional approach to the practice of geriatric medicine Become familiar with comprehensive geriatric assessment and establishing acceptable goals of care Understand some of the common geriatric problems Appreciate how successful some elderly age