Approach to the Care of the Elderly

1. 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

2. 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

3. 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

4. What Distinguishes Elder Care? • A focus on Function • Functional assessment in the elderly = developmental assessment in pediatrics • Greater family involvement • Multiple co-morbidities • Geriatric syndromes • Increased adverse effects to medications • Increased heterogeneity of goals

6. Four Pillars of Elder Health • Function • Wellness and Prevention • Relationships • Management of Acute and Chronic Conditions

7. Function Help the elder to do the things they want and need to do. The patient’s view Health (Quality of Life) Function =

8. 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

9. Wellness and PreventionHealth 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.

10. 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

11. Wellness and Prevention Health promoting behaviors • Exercise • Diet • Tobacco Cessation [Self-Management Support: Assessment, Goal Setting, Problem Solving]

12. Wellness and Prevention Early detection of hidden risks to health and wellness. • Diabetes • HTN • Breast Cancer • Colorectal Cancer • Cervical Cancer • Abdominal Aortic Aneurysm • Osteoporosis • Depression • Oral Health • Eye Disease / Visual impairment • Hearing Loss • Alcohol Misuse • Non-ceremonial Tobacco • Pain • Weight (weight loss / obesity) Elder Mistreatment

13. 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?

14. At-risk drinking is defined as: PER WEEK PER OCCASION Men > 14 Drink > 4 Drinks Women > 7 Drinks > 3 Drinks Age > 65 > 7 Drinks > 1 Drink EXAM RESULT DEFINITION Normal or Negative No evidence of risky alcohol use. Abnormal Potential risky alcohol use. Refused Declined screening

15. Wellness and Prevention Immunizations to prevent illness • Pneumovax • Influenza • Tetanus – Tdap at least once • Zoster

16. 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

17. 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 • risk of cardiac event >3% over 5 years • data is strongest between age 40 and 75

18. Estimates of Benefits and Harms of Asprin TherapyGiven for 5 Years to 1,000 Individuals with Various Levels ofBaseline Risk for Coronary Heart Disease*

19. 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

20. Relationships Understanding the relationships that support the elder, that the elder supports, and that the elder needs to remain healthy and well.

21. Relationships Spiritual Family Community Healthcare

22. Relationships Spiritual • How can we best support the elder’s beliefs and practices Family • Supportive relationships • 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?

23. 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?

24. 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

25. 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

26. Common Pathways Blood Pressure Blood Sugar Kidney Function Function Affect Common Conditions Geriatric Syndromes Incontinence Dementia Falls Diabetes Hypertension Arthritis Congestive Heart Failure Ischemic Heart Disease Chronic Kidney Disease Atrial Fibrillation Depression Palliative Care Management of Acute and Chronic Conditions

27. 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

28. Look out! • Pain Medications • 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

29. Recognition of Dementia • Major causes – with distinctive patterns and etiology but many overlapping features • Alzheimer’s disease • Vascular dementia • Lewy Body dementia (LBD) • Frontotemporal dementia (FTD) • Alcohol-related and TBI-related dementia ADRD = Alzheimers’ Disease and Related Dementias

30. Recognition of Dementia - Why? • Avoid crisis related to dementia • Understand limitations of self-management 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

31. 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?

32. 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.

34. 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?

35. One more thought… How about education and training for caregivers for persons with dementia?

36. 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

37. Bruce Finke, MD 413-584-0790 615-727-2044 bruce.finke@ihs.gov