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Emory Reynolds Program
PGY-1 Workshop
Created by:
Jonathan M. Flacker, M.D.
[email protected]
Objectives
• Warm-up
• Describe Traditional Medical Thinking
• Identify Important Principles of a Geriatric
Medicine Approach (BIG 10)
• Have fun
What’s Different?
• So, what’s different about taking care of
older patients?
• What’s different about Geriatrics?
Case Study(ies) in Geriatrics
• Describe the last senior patient you saw
• What are the key important points of this
patient’s care?
Key Medical Issues?
• Pick a Disease, Any Disease….
– Epidemiology
– Pathophysiology
– Approach
• Testing
• Medications
• Interventions
Prevention
Of
Iatrogenesis
Cognitive
Affective
Issues
Appropriate
Site
Collaborators
Medication
Age
Appropriate
Expectations
TREATMENT
SUCCESS!!
Testing
Identification
of Problem
Interventions
Ethically
Appropriate
Social
Situation
Quality of Life
Impact
of
Comorbidities
Gerontology Quiz
THE MOST "AGED" NATION (HIGHEST %
OVER AGE 65) IS_______________?
SWEDEN
Adapted From Sokolovsky's Comparative Gerontology Quiz;
by Jay Sokolovsky, Professor of Anthropology, University of South Florida
Gerontology Quiz
WHAT IS THE ONLY COUNTRY IN THE WORLD
(PERHAPS IN HISTORY) WHERE THERE ARE
MORE PEOPLE OVER 60 THAN UNDER 20?
ITALY
Adapted From Sokolovsky's Comparative Gerontology Quiz;
by Jay Sokolovsky, Professor of Anthropology, University of South Florida
Gerontology Quiz
NAME THE TWO COUNTRIES WHICH ARE
CURRENTLY AGING THE FASTEST:
JAPAN and CHINA
Gerontology Quiz
IN THIRD WORLD COUNTRIES, BETWEEN
NOW AND THE YEAR 2020 THE
POPULATIONS OVER AGE 60 WILL GROW
TWICE AS FAST AS THE PART OF THE
POPULATION BETWEEN 5 AND 15.
[True or False]
TRUE
Gerontology Quiz
THE SOCIETY WITH THE HIGHEST
LONGEVITY IS __________?
JAPAN
Adapted From Sokolovsky's Comparative Gerontology Quiz;
by Jay Sokolovsky. Professor of Anthropology, University of South Florida
Gerontology Quiz
THE MAJORITY OF THE WORLD'S AGED
POPULATION, OVER 65 YEARS OF AGE, LIVE IN
THE INDUSTRIALIZED NATIONS OF NORTH
AMERICA, EUROPE, JAPAN AND THE FORMER
SOVIET UNION. [True or False]
FALSE
Adapted From Sokolovsky's Comparative Gerontology Quiz;
by Jay Sokolovsky, Professor of Anthropology, University of South Florida
Gerontology Quiz
THE AVERAGE MARRIED COUPLE, IN THE
U.S. NOW HAS MORE PARENTS ALIVE THAN
CHILDREN IN THEIR FAMILY. [True or False]
TRUE
Adapted From Sokolovsky's Comparative Gerontology Quiz;
by Jay Sokolovsky, Professor of Anthropology, University of South Florida
Intro to the Basics in
Geriatrics 10 (“BIG” 10)
Developed by the Emory Reynolds Program
SO, WHAT DO YOU
THINK?
The BIG 10
1. Aging is not a disease
Peripheral Vascular Disease
Newman: J Am Geriatr Soc, Volume 48(9).September 2000.1157-1162
But, What Does Happen With
Aging?
Homeostenosis
The depletion in physiologic reserves
or diminished responsiveness to external
stimuli with aging
The Average Younger Person
RESERVE
REQUIRED LEVEL OF FUNCTION
RESERVE
Lungs
Brain
Muscles
Balance
Bladder
Older Person: Illness=Delirium
RESERVE
REQUIRED LEVEL OF FUNCTION
RESERVE
Lungs
Brain
Muscles
Balance
Bladder
SO, WHAT DO YOU
THINK?
The BIG 10
1. Aging is not a disease
2. Medical conditions in older
patients are commonly
chronic, multiple, and
multifactorial
Traditional Medical Syndrome
Specific Morbid Process
Multiple Phenomenologies
“Moon facies”
“Buffalo Hump”
Truncal obesity
Cortisol Excess
Proximal muscle weakness
Easy bruisability
Skin thinning
Flacker J. J Am Geriatr Soc 2003
Osteoporosis
The Geriatric Syndrome
Multiple Morbid Processes
Specific Phenomenology
Dementia
Dehydration
Severity of illness
Sensory impairment
Delirium Syndrome
Medication effects
Sleep disturbance
Older age
Flacker J. J Am Geriatr Soc 2003
Multifactorial Health Conditions
•
•
•
•
•
Falls
Depression
Dizziness
Delirium
Incontinence
SO, WHAT DO YOU
THINK?
The BIG 10
1. Aging is not a disease
2. Medical conditions in older
patients are commonly
chronic, multiple, and
multifactorial
3. Reversible and treatable
conditions are often
underdiagnosed and under
treated in older patients
Put In Order (Low to high)
A. % Hospitalized Elderly Patients That
Experience Delirium
B. % Elderly Patients After Surgical Repair Of
Hip Fracture Who Were Discharged With
Delirium
C. % Delirious Elderly Patients That Is Not
Recognized By Physicians And Nurses
D. % Elderly Patients Admitted To A Nursing
Home Suffering From Some Degree Of
Delirium
Put In Order
A. % Hospitalized Elderly Patients That
Experience Delirium (20%)
B. % Elderly Patients After Surgical Repair Of
Hip Fracture Who Were Discharged With
Delirium (29%)
C. % Delirious Elderly Patients Not Recognized
By Physicians And Nurses (54%)
D. % Elderly Patients Admitted To A Nursing
Home Suffering From Some Degree Of
Delirium (46%)
More To Put In Order (Low to high)
A. %Prevalence Rate Of Osteoporosis In USA
B. % Of Men Over 50 In The USA Who Will Have
An Osteoporosis Related Fracture During
Their Lifetime
C. % Prevalence Of Undiagnosed Osteoporosis
In Seniors In USA
D. % Of White Women Over 50 Who Have
Osteoporosis In The USA
More To Put In Order
A. % Prevalence Rate Of Osteoporosis In USA
(10%)
B. % Of Men Over 50 In The USA Who Will Have
An Osteoporosis Related Fracture During
Their Lifetime (25%)
C. % Prevalence Of Undiagnosed Osteoporosis
In Seniors In USA (6.6%)
D. % Of White Women Over 50 Who Have
Osteoporosis In The USA (15%)
Still More To Put In Order (Low to High)
A. % Prevalence Of Isolated Systolic Hypertension in
Women > 65 Years Old in USA
B. % Prevalence Of Isolated Systolic Hypertension in
Men > 65 Years Old in USA
C. % Reduction In Occurrence Of Congestive Heart
Failure As A Result Of HTN Treatment For 3-5 Years
D. % Reduction in Occurrence Of Strokes Among
Treated Older Patients With Blood Pressure
Reductions Of 12 to 14 mm Hg Systolic and 5 to 6
mm Hg Diastolic
Still More To Put In Order
A. % Prevalence Of Isolated Systolic Hypertension in
Women > 65 Years Old in USA (30%)
B. % Prevalence Of Isolated Systolic Hypertension in
Men > 65 Years Old in USA (20%)
C. % Reduction In Occurrence Of Congestive Heart
Failure As A Result Of HTN Treatment For 3-5 Years
(48%)
D. % Reduction in Occurrence Of Strokes Among
Treated Older Patients With Blood Pressure
Reductions Of 12 to 14 mm Hg Systolic and 5 to 6
mm Hg Diastolic (30%)
What Else?
SO, WHAT DO YOU
THINK?
The BIG 10
1. Aging is not a disease
2. Medical conditions in older
patients are commonly
chronic, multiple, and
multifactorial
3. Reversible and treatable
conditions are often
underdiagnosed and under
treated in older patients
4. Functional ability and
quality of life are critical
outcomes in the geriatric
population
ADL OR IADL?
EATING
ADL
ADL OR IADL?
HOUSEKEEPING
IADL
ADL OR IADL?
TELEVISION REMOTE
USE
OK, Neither
ADL OR IADL?
SHOPPING
IADL
ADL OR IADL?
DRESSING
ADL
ADL OR IADL?
BABYSITTING
OK, Neither
ADL OR IADL?
HYGEINE
ADL
ADL OR IADL?
ACCOUNTING
IADL
ADL OR IADL?
TRANSPORTATION
IADL
ADL OR IADL?
TOILETING
ADL
ADL OR IADL?
PET CARE
OK, Neither
ADL OR IADL?
FOOD PREPARATION
IADL
ADL OR IADL?
AMBULATING
ADL
FUNCTIONAL ASSESMENT
ADLs
•
•
•
•
•
Dressing
Eating
Ambulating
Toileting
Hygiene
IADLs
•
•
•
•
•
Shopping
Housekeeping
Accounting
Food Preparation
Transportation
SO, WHAT DO YOU
THINK?
The BIG 10
1. Aging is not a disease
2. Medical conditions in older
patients are commonly
chronic, multiple, and
multifactorial
3. Reversible and treatable
conditions are often
underdiagnosed and under
treated in older patients
4. Functional ability and
quality of life are critical
outcomes in the geriatric
population
5. Social history, social
support, and patient
preferences are essential
aspects of managing
geriatric patients
Living Arrangements
of Older Men
LIVING ARRANGEMENTS
ARE IMPORTANT!
Living Arrangements
of Older Women
Caregiver Burden
• Any examples?
Aging Quick Fact # 2
Question: What Ethnic Group Is Estimated
To Have The Largest Percent Population
Of Older Persons Living In Poverty?
Source: Administration on Aging. Achieving Cultural Competence:
A Guidebook for Providers of Services to Older Americans and Their Families.
www.aoa.gov
Aging Quick Fact # 3
WHITE
BLACK
AMERICAN
INDIAN
ASIAN OR
PACIFIC IS.
HISPANIC
What Are The Leading Causes of
1
Heart Disease Heart Disease Heart Disease Heart Disease Heart Disease
Death
for Persons
Age 65Cancer
and Over?
2
Cancer
Cancer
Cancer
Cancer
How
Do They
Differ
By Ethnicity?
3
Stroke
Stroke
Diabetes
Stroke
Stroke
4
COPD
Diabetes
Stroke
Pneumonia /
Influenza
COPD
5
Pneumonia /
Influenza
Pneumonia /
Influenza
COPD
COPD
Pneumonia /
Influenza
Source: Administration on Aging. Achieving Cultural Competence:
A Guidebook for Providers of Services to Older Americans and Their Families.
SO, WHAT DO YOU
THINK?
The BIG 10
1. Aging is not a disease
2. Medical conditions in older
patients are commonly
chronic, multiple, and
multifactorial
3. Reversible and treatable
conditions are often
underdiagnosed and under
treated in older patients
4. Functional ability and
quality of life are critical
outcomes in the geriatric
population
5. Social history, social
support, and patient
preferences are essential
aspects of managing
geriatric patients
10.Ethical issues and end-oflife care are critical aspects
of the practice of geriatrics
MOCK COURT:
Can She Make This Decision?
Group 1
• Explain why the Doctor was WRONG to
allow Mrs. Dubois to make this decision
Group 2
• Explain why the Doctor was RIGHT to
allow Mrs. Dubois to make this decision
Group 3
• Decide which arguments are compelling
and reasonable
GO
Competency
• Competence is presumed unless a court
has determined that an individual is
incompetent
• A judicial declaration of incompetence may
be global or limited (e.g., to financial
matters, personal care, or medical
decisions)
Decision-Making Capacity
• A clinical term that is task-specific
• In order to make valid treatment decisions, a
person must be able to:
– Recognize there is a decision to be made
– Understand
• The needed information
• The treatment options
• The likely consequences of each option (i.e. risks,
burdens, and benefits)
– Rationally manipulate the information to
come up with a decision consistent with his or
her values.
PRACTICE TOOL
Aid To Capacity Evaluation (ACE) Etchells et
al. Assessment of patient capacity to consent
to treatment. J Gen Intern Med.
1999;14(1):27-34
“ASK THE DOCTOR”
Question #1
• WHAT IS A HEALTH CARE PROXY?
– Under most state laws a competent person
can authorize another person, to make health
care decisions if the patient is unable to do so
– Done by completing the state-specific
standard health care proxy form
Question #2
• WHY DO I NEED A HEALTH CARE PROXY?
– Without a health care proxy a doctor may be
required to provide medical treatment that you
would have refused if you were able to do so
Question #3
• WHEN DOES IT TAKE EFFECT?
– The health care proxy becomes effective only
when the patient is unable to make decisions,
as determined by a physician
– Until then, the patient continues to be in
charge of making their own health care
decisions
– It can be revoked orally, and one always have
the right while competent to sign a new health
care proxy
Question #4
• HOW IS A HEALTH CARE PROXY DIFFERENT
THAN A POWER OF ATTORNEY?
– A power of attorney primarily authorizes the
person designated to make financial decisions
but it cannot be used to make health care
decisions
– A health care proxy must be completed for an
agent to make health care decisions when
one is not able
Question #5
• WHAT IS THE DIFFERENCE BETWEEN A
HEALTH CARE PROXY AND A LIVING WILL?
– A living will is a document signed in advance
in which one specifically sets forth decisions
about health care treatment
– Unlike the health care proxy, however, it does
not authorize one to appoint an agent to make
decisions that were not anticipated when you
completed the living will
Practice Tool
• Georgia Health Care Proxy Form
• Georgia Durable Power of Attorney for
Health Care
SO, WHAT DO YOU
THINK?
The BIG 10
1. Aging is not a disease
2. Medical conditions in older
patients are commonly
chronic, multiple, and
multifactorial
3. Reversible and treatable
conditions are often
underdiagnosed and under
treated in older patients
4. Functional ability and
quality of life are critical
outcomes in the geriatric
population
5. Social history, social
support, and patient
preferences are essential
aspects of managing
geriatric patients
9. Geriatric care is provided in
a variety of settings ranging
from the home to long-term
care institutions
10.Ethical issues and end-oflife care are critical aspects
of the practice of geriatrics
Personal Care Homes (PCHs)
• PCHs provide:
– Lodging
– Food
– Some Support Services
• Elderly or Mental or Physical Disabilities
– Unable to care for themselves
– Do not require 24 hour nursing services
– Need help with IADLs and ADLs
Assisted Living
• Designed for older people who cannot live on their own
• Specially constructed for care of seniors
• Generally apartment style with wheelchair access,
emergency call pull cords, etc.
• Typically, assistance with bathing and dressing, supervision
of medications, assistance with toileting, management of
bladder and bowel incontinency, and special diets
• Typically intermittent skilled nursing services such as
diabetic insulin injections or colostomy care can are handled
by outside licensed home health agencies
• Private Pay
Skilled Nursing Facility (SNF)
• SNF Rehab Provides:
– Transitional step between hospital stay, another level of
care, or home
– Rehabilitation program for those lacking endurance/need
for an acute rehabilitation program
– Plan of care focused on stabilizing patients following acute
illness or injury
• Payment => Medicare
– Only pays while receiving actual medical services for 100
days
– Only pay for the first 20 days for skilled care
– For days 21-100, for skilled care, Medicare will pay for all
allowable costs over $97 a day. The patient will have to pay
up to $97 a day.
Acute Rehabilitation Hospital
• Acute rehabilitation program is a highly
structured
• Intensive interdisciplinary program intended for
patients with significant functional impairments
• Must follow “75% rule” and “3 hour rule”
• Provides patients with a supportive, structured
and coordinated rehab program designed to
improve the ability to perform daily living tasks
• Medicare Payment based on RUGs
Where Else
• ?
SO, WHAT DO YOU
THINK?
The BIG 10
1. Aging is not a disease
2. Medical conditions in older
patients are commonly
chronic, multiple, and
multifactorial
3. Reversible and treatable
conditions are often
underdiagnosed and under
treated in older patients
4. Functional ability and
quality of life are critical
outcomes in the geriatric
population
5. Social history, social
support, and patient
preferences are essential
aspects of managing
geriatric patients
8. Iatrogenic illnesses are
common and many are
preventable
9. Geriatric care is provided in
a variety of settings ranging
from the home to long-term
care institutions
10.Ethical issues and end-oflife care are critical aspects
of the practice of geriatrics
Are Hospitals Good For Your
Health?
•
•
•
•
•
•
•
Deconditioning
Incontinence
Falls
Delirium
Malnutrition
Dehydration
Etcetera, Etcetera, Etcetera…..
Hazards of Hospitalization in Older Persons
Creditor, Ann Intern Med 1993;118:219-223
SO, WHAT DO YOU
THINK?
The BIG 10
1. Aging is not a disease
2. Medical conditions in older
patients are commonly
chronic, multiple, and
multifactorial
3. Reversible and treatable
conditions are often
underdiagnosed and under
treated in older patients
4. Functional ability and
quality of life are critical
outcomes in the geriatric
population
5. Social history, social
support, and patient
preferences are essential
aspects of managing
geriatric patients
7. Cognitive and affective
disorders are prevalent and
commonly undiagnosed at
early stages
8. Iatrogenic illnesses are
common and many are
preventable
9. Geriatric care is provided in
a variety of settings ranging
from the home to long-term
care institutions
10.Ethical issues and end-oflife care are critical aspects
of the practice of geriatrics
Q&A
• Do you screen for cognitive impairment?
How?
• Do you screen for depression? How?
The BIG 10
1. Aging is not a disease
2. Medical conditions in older
patients are commonly
chronic, multiple, and
multifactorial
3. Reversible and treatable
conditions are often
underdiagnosed and under
treated in older patients
4. Functional ability and
quality of life are critical
outcomes in the geriatric
population
5. Social history, social
support, and patient
preferences are essential
aspects of managing
geriatric patients
6. Geriatric care is
multidisciplinary
7. Cognitive and affective
disorders are prevalent and
commonly undiagnosed at
early stages
8. Iatrogenic illnesses are
common and many are
preventable
9. Geriatric care is provided in
a variety of settings ranging
from the home to long-term
care institutions
10.Ethical issues and end-oflife care are critical aspects
of the practice of geriatrics
SO, WHAT DO YOU
THINK?
Multidisciplinary “Survivor”
Hypothetical Scenario: The new CEO of a large
public hospital is forced to make significant budget
cuts. As the head of your department you must
explain the importance of you discipline to the
multidisciplinary care of patients
In the Health Care System
Multidisciplinary Survivor
• You have 5 minutes to present your case.
Don’t be surprised if the CEO asks some
tough questions
• At the end the department heads will each
complete a list in order of from who should
be cut the most to who should be cut the
least
• The area targeted for the least budget cuts
wins!
GO
The BIG 10
1. Aging is not a disease
2. Medical conditions in older
patients are commonly
chronic, multiple, and
multifactorial
3. Reversible and treatable
conditions are often
underdiagnosed and under
treated in older patients
4. Functional ability and
quality of life are critical
outcomes in the geriatric
population
5. Social history, social
support, and patient
preferences are essential
aspects of managing
geriatric patients
6. Geriatric care is
multidisciplinary
7. Cognitive and affective
disorders are prevalent and
commonly undiagnosed at
early stages
8. Iatrogenic illnesses are
common and many are
preventable
9. Geriatric care is provided in
a variety of settings ranging
from the home to long-term
care institutions
10.Ethical issues and end-oflife care are critical aspects
of the practice of geriatrics
Objectives
• Warm-up
• Describe Traditional Medical Thinking
• Identify Important Principles of a Geriatric
Medicine Approach (BIG 10)
• Have fun
• The videos used in this presentation were
developed by the University of Wisconsin
Reynolds Program for educational use
only.
• The remainder of the presentation was
developed by the Emory University
Reynolds Program. For more information
contact [email protected].