1. A Senior Moment Time Passes By

2. And one man in his time plays many parts, His acts being seven ages. At first the infant, Mewling and puking in the nurse’s arms. And then the whining school-boy, with his satchel, And shining morning face, creeping like snail Unwillingly to school. And then the lover, Sighing like furnace, with a woeful ballad Made to his mistress’ eyebrow. Then a soldier, Full of strange oaths, and bearded like the bard, Jealous in honor, sudden and quick in quarrel, Seeking the bubble reputation Even in the cannon’s mouth. And then the justice, In fair round belly with good capon lin’d, With eyes severe, and beard of formal cut, Full of wise saws and modern instances; And so he plays his part. The sixth age shifts Into the lean and slipper’d pantaloon, With spectacles on nose and pouch on side, His youthful hose well sav’d, a world too wide For his shrunk shank; and his big manly voice, Turning again toward childish treble, pipes And whistles in his sound. Last scene of all, That ends this strange eventful history, Is second childishness and mere oblivion, Sans teeth, sans eyes, sans taste, sans everything

3. The Aging of America Every eight seconds another baby boomer turns 50, and by mid-century there will be more Americans over 55 than under 18 for the first time in history.

4. Prevalence > 65 2030: 20% >80/y/o in US 2000 9,300,000 2030 19,500,000 Average life expectancy 2004: 76-80 2050: 86-90 The Aging of America

5. 2000 2,300,000 2050 7,200,000 Costs of nursing home care and home health 1990 $66,000,000,000 2001 $232,000,000,000 Seniors with functional limitations

7. Major cause of physical decline • 70% of functional decline related to behavior • Lack of health promotion and disease prevention activities

8. Co-morbidity is the rule

9. Geriatric Assessment Specialty model • Comprehensive • Multidisciplinary • Time-intensive • Already identified as at risk

10. Geriatric Assessment • Primary care model • Caring for functional and healthy elderly • Comprehensive health screening • Continuity • Gather data over time

11. Primary Care Focus • Maximizing function • Critical question • “How does this problem/symptom impact your daily life?”

12. USPTF Focus in Geriatrics • Geriatric areas of special concern (over 65) • Sensory perception: vision, hearing • Accident prevention • Immunizations • Sexuality

13. [ Any Advice for these seniors?

14. Injury Prevention • Universal issues • Bike helmets • Safety belts • Smoke detectors • Hot water heater at 120 degrees F

15. Annual incidence 65-80: 25% rate of accidental falls >80: 50% 10% of the falls fracture Annual cost >$20,200,000,000 2020: $32,000,000,000 Senior Specific: Falls

16. Posture control Gait Visual perception Altered sensory input Strength and coordination Osteoporosis Hypotension Risks for falls: Intrinsic

17. Medication Poor lighting Slippery floors Loose footing: carpets, slippery floors Lack of supportive railing for stairs, bathrooms Obtrusive furniture Extrinsic risks

18. Screening • Review of intrinsic and extrinsic risks • Focused exam • One leg balance: stand on one leg for 5 seconds without assistance • Get Up and Go: Get up from chair, walk 10 feet, return and sit plus timing > 16 seconds • Sensitive for fall risk • Positive test: more complete evaluation

19. Counseling • Smoke detectors • Guns and ammunition • Lighting of halls and stairwells • Remove hazards and barriers • Loose rugs • Cords • Toys • Driving safety

20. Intervention Address risk factors

21. Trumped • Mrs. C.T. Rack is sad because she has to stop her Wednesday evening bridge club. She can no longer drive due to the halo like glaring of the street lights. She is also having more difficulty reading her mystery novels?

22. Sensory Perception: Vision • Visual impairment worse than 20/40 • 65-74: 4% • 80-84: 16% • Best correction worse than 20/40 • 4.5%

23. Impact of visual loss • Risk factor for falls • Reduced quality of life • Severe bilateral visual loss • Association with all-cause mortality and cardiovascular related mortality in women

24. Common Vision Problems • Presbyopia • Glaucoma • Macular degeneration • Diabetic retinopathy • Cataracts

25. Glaucoma Risks • Age • Caucasian > 65 • Black patients > 40 • Diabetics • Patients with myopia • Ocular hypertension • Family history of glaucoma

26. Blindness by race • Glaucoma, posterior capsular opacification, diabetic retinopathy • More common cause of blindness in blacks • Macular degeneration • More common cause of blindness in whites

27. Screening • Family history of visual problems • Ask about role of visual impairment in ADLs. • Because of your eyesight, do you have trouble driving a car, watching television, reading or doing your daily tasks? • Snellen eye chart

28. Referral to eye specialist • 20/40 or worse (with lenses) • Patients who report that vision interferes with ADLs • High risks individuals for glaucoma • Comorbidities that increase risk

29. Eh! What did you say • 3rd most prevalent condition in elderly • 14-46% prevalence • 32% of impaired have hearing aid

30. Impact • Social isolation • Depression • Cognitive well-being

31. Causes of Hearing Loss • Presbycusis most common cause • Reduced ability to interpret speech • Cerumen impaction • Chronic otitis media

32. Ask Pure tone audiometry Whisper test Otoscope: canal obstruction, TM inspection Hearing Handicap Inventory for the Elderly-Screening version (HHIE-S Screening

33. Intervention • Removal of ear wax • Hearing aids • Avoid ototoxic drugs • Periodic screening • Remove Ear Wax

34. Amplification • Barriers to hearing aid • Psychological • Functional • Financial • The peace of quiet Gas Powered Hearing Aid

35. Stand 2–3 ft away Have the person's attention Have the person seated in front of a wall, which will help reflect sound Use lower-pitched voice Speak slowly and distinctly; don't shout Rephrase rather than repeat Pause at the end of phrases or ideas Communication

36. A Matter of Taste • Olefactory impairment • ¼ of adults between 53 and 97 • 2/3 between 80 and 97 • Interferes with taste and enjoyment of food • Loss of appetite and weight loss

37. Nutrition: Jack Sprat • Failure to thrive • Involuntary weight loss • Abnormal BMI (<22, >27) • Hypoalbuminemia (< 3.58 (<160) • Vitamin or mineral deficiency • Hypocholesterolemia

38. Nutrition: Ms. Sprat • Unhealthy diet • Coronary heart disease • Stroke • Type II Diabetes • Cancer • Obesity

39. Screening: USPTF • Evidence • Fair evidence for brief, low- to medium-intensity behavioral counseling produce small to medium changes • Good evidence for medium- to high-intensity counseling for medium to large changes in adults at increased risk for diet related chronic disease

40. Screening • How • Malnutrition risk • Have you lost 10 pounds in the past six months without trying? • Oral health • Nutritional Health Screen • DETERMINE

41. Nutrition • Disease • Eating poorly • Tooth loss, mouth pain • Economic hardship • Reduced social contact • Multiple medicines • Involuntary weight loss or gain • Need for assistance in self-care • Elderly (age >80)

42. Intervention • Oral hygiene: • Flossing and brushing • Regular dental visits • Nutrition • Dietary counseling • Address barriers

43. Physical Inactivity 60% of elderly Americans are physically inactive

44. Less than 20 or more minutes of moderate activity on 3 or more days per week Physical Activity: 2002

45. Reduced cardiovascular mortality and morbidity Maintain ability to live independently Improved bone health Reduce risk of falling Reduce risk of fracture Reduced BP Reduced risk of chronic disease Reduced cancer risk Benefits of Physical Activity

46. Benefits • Improve stamina • Reduce the symptoms of arthritis • Reduction of depression and anxiety

47. Screening • Inquire about physical activity • Height, weight • BMI

48. Recommend at least 30 minutes of activity most days of the week Identify community resources Evaluate for safety of exercise intensity Community Advocacy Strength training Intervention

49. A Shot in the Dark • Mr. Gardener is a 65 year old gentlemen with a passion for his roses. He is in your clinic today for a health maintenance visit. It is October. He has no chronic health problems. He hasn’t had a shot in over a decade. • What, if any immunizations would you provide today?

50. Immunizations for the Elderly • Influenza • Yearly starting at age 50 • Pneumococcus: PPV23 • Age 65 or older • Low risk: once • High risk or received prior to age 65 • Repeat after 5 year interval