Download aging america updated fall segu 2013

Aging America:
Clinical
Management of the
Elderly Patient
Pat Segu, OD FAAO
Clinical Associate Professor
Definitions

Gerontology


a branch of knowledge involving the
study of aging and problems
associated with the aged
Geriatrics

a specialized part of gerontology; it
covers the mental and physical health
aspects and problems of elderly
individuals
Definitions

Aging – to show signs of growing old;
succession of states of a system along a
time line

Ageism – bias or prejudice against elderly
people based on belief that older people
are incapacitated or incompetent simply
b/c they are old

Senescence – condition of growing old
Definition


Elderly Population

Young Old
65 – 74

Middle Old
75 – 84

Old - Old
> 85 yrs
Each Age group require different
aspects of our attention
Definition

Older Patient
Well Elderly
 Moderate Impaired Elderly
 Severely Impaired Elderly

Well Elderly
Independent
 Chronic Health Problems
 NOT Functionally Impaired
 Susceptible to age-related diseases

(i.e. Cataracts)

Patient Education
Importance of Annual Eye Exam
 Education Regarding Disease

Moderate Impaired Elderly
Compared to Well-Elderly-may have same
or more chronic health conditions
 Need help with Daily Living Activities

Cooking
 Personal Care
 Shopping

Assistive Devices – Walkers / Wheelchair
 Multiple Meds

Impt Complete List of Medication
 Possible SE interfere with Visual System

Severely Impaired Elderly

Many Disabling Conditions

Multiple RX & OTC Meds

“Confusion”

Homebound or Long-term care facility

Nursing Home
What is your Aging IQ?
The older you get, the less you
sleep. True or False
 FALSE

Quality of sleep declines but NOT the
total sleep time
 Elderly take more naps throughout the
day
 Overall get the same amount of sleep
except that the sleep is fragmented

What is your Aging IQ?
Families Don’t Bother with Their
Older Relatives. True or False
 FALSE

Most Elderly live close to their children
and many live with their spouses
 Approx. 5 % nationwide live in nursing
homes
 Cultures Differences

What is your Aging IQ?
Does IQ Change with age? Yes or No
 NO

No serious decline in intelligence with age
 Wisdom increase with age
 Rate/Speed of learning decreases with age

 Absorbing
new information at an older age maybe
more difficult

Calculated IQ test may be lower because of
emphasis on speed
What is your Aging IQ?
Everyone becomes confused or
forgetful if they live long enough.
True or False
 FALSE

Alzheimer’s can cause confusion and
forgetfulness
 Many Treatable problems may also
elicit these symptoms

 Poor
Nutrition
 Adverse Drug Reaction
 Depression
What is your Aging IQ?

Falls and injuries are most common
among people over 65 years of age
True or False
TRUE
 Important for Regular Hearing and Vision
Tests
 Good Safety Habits to prevent accidents
 Adverse Drug Reaction can affect balance
and coordination

Characteristics of Aging
Common Physical Changes

Decreased




Hearing
Vision
Taste
Smell

Increase reaction time for complex tasks

Decrease ability to multi-task

Disease and injury is more difficult to
recover from as we age
Clinical Impact Elderly Patients





Cardiovascular diseases
Cancer
Cerebrovascular disease
DM
Rheumatic disorders





Smoking
Poor nutrition
Alcohol abuse
Lack of exercise
Mental Health


Depression
Dementia
Clinical Impact Elderly Patients

Auditory considerations

Loss of high frequency pitch

Presbycusis
 Progressive
Hearing Loss occurring bilaterally
 Affects 30% of 65-74 yrs
 50% of >75yrs and older

Tinnitis
 affects

Vertigo
30% of people over 65
Psychological
considerations







Retirement

Declining health
Decreased mobility*

Income decline
Sensory decline
Decreased response 

time
Death of a spouse
Children leaving
home
Reduction in social
role
Institutionalization
Elder abuse
Prescribing Considerations

Physiological changes metabolism



decreased liver and kidney function
decreased muscle mass/increased body fat
decrease GI absorption & serum protein

Toxicity (systemic medications)

Poly-pharmacy


Side effects
Contraindications with other meds
Family Support

Expressive




Instrumental




Advice
Affection
Love
Financial
Transportation
Household Tasks
Informal or unpaid care estimated to account
for 95% of all care given to older adults
Family Support

Social Change


Relocation
Family Size
Smaller
 More women in the workforce
 Grandparents help with looking after
grandkids


Increased longevity of older results
Demographics of
Aging in America
“Graying of
America”
www.aoa.gov (Administration on Aging)
Elderly Populations
“Graying of America” (65+)

Increase in Elderly Population (>65yrs)
Decrease infant mortality
 Preventive health care measures
 Advanced life saving technology
 Improved Clinical Medicine

In the U.S., approximately 1 person out of
every 8 is an older American
 2002: 35.6 Million (increase of 10.2% from 1992)

“Graying of America”
Future Growth
2011-2029 the “coming of age” of
baby boomers will yield a sudden
sharp increase
 By the year 2030, the older
population will more than double to
71.5 million
 Age group of >85 is increasing the
most quickly
 3.1 % of US Labor Force

“Graying of America”
Future Growth
“Graying of America”
Future Growth
Figure 1: Number of Persons 65+,
1900 - 2030 (numbers in millions)
80
70
60
50
40
30
20
10
0
71.5
54.6
25.7
31.2
35
40.2
16.7
3.1
4.9
9
1900 1920 1940 1960 1980 1990 2000 2010 2020 2030
Year (as of July 1)
Life Expectancy
Life Expectancy 1900 47.9yrs
 Life Expectancy 2001 77.2 yrs



F (78-79 yrs) vs. M (71-72yrs)
Centenarians in the U.S.
In the year 1990: 37,306
 In the year 2002: 50,364

 Represents
in increase of 35%.
Living Arrangements (2001-02)

Majority of Elderly live in the community

5% of adults live in institutional setting

80% Homeowners vs. 20% Renters

Older Men More Likely to be Married

½ of the Older Female live alone

Less likely to Relocate
Living Arrangements
Women
Men
10%
19%
40%
41%
living with spouse
living alone
Other
18%
72%
living with spouse
living alone
Other
Marital Status
Men more likely to be married vs. Female
 ½ of Older Females widows (2002)
 10% Older population divorced or
Figure 2: Marital Status of Persons 65+ - 2002
separated

80%
73%
70%
60%
50%
41%
46%
Women
Men
40%
30%
14%
20%
10%
10% 9%
4% 4%
0%
Married
Widowed
Divorced or Single (never
Separated/
married)
Spouse
Absent
Geographic Distribution (2002)

Top 5 States
California
 Florida
 New York
 Texas
 Pennsylvania


3.7
2.9
2.5
2.2
1.9
million
million
million
million
million
Most Older American lived in
metropolitan areas (77%)
Education Among Elderly
(2002)

Education Level is Increasing

Between 1970 and 2002, the percentage
completed High school increased from
28% to 70%





74%
68%
51%
35%
Caucasians
Asians
AA
Hispanics
17% Bachelor Degree or more
Economic Status (2002)

Sources
Social Security
 Income from Assets
 Public & Private Pensions
 Earnings

91%
58%
40%
22%
Poverty rate: 10.4%
 Elderly group are actually wealthier
 Net Worth increases until Age 74


Median Net Worth (2000) was $108,000 vs.
$55,000 for total population
Economic Status (2002)
Family Households 65+ Householder
0.0%
Under $10,000
5.0%
10.0%
15.0%
20.0%
25.0%
4.5%
7.1%
$10,000 - $14,999
20.9%
$15,000 - $24,999
19.6%
$25,000 - $34,999
18.4%
$35,000 - $49,999
$50,000 - $74,999
$75,000 and over
15.3%
14.3%
Economic Status (2002)
Poverty

About 10% of all elders have
incomes < the poverty line

Older Women > Older Men

AA > Hispanics > Caucasians

Older Hispanic women living alone
HIGHEST Poverty Rates (47%)
Health and Health Care

Majority of Elderly are Healthy

Greater Disability with >80+

Relationship Disability & Health Status

Most Older Adults have 1 Chronic Condition

Probable Multiple Chronic Disease
Chronic Health Conditions
Sensory Impairments and Oral Health
Use of Time
Use of Time
Vision Care and the Elderly
Vision Care and the Elderly



Vision Care Needs will INCREASE
Correction of Refractive Error & Presbyopia
Problems








Dry Eyes
Cataracts
Floaters
Age-related macular degeneration
Retinopathy
Glaucoma
Medicare Billing
Increase need for LV services
Evaluation

Vision Care Setting
Private Office
 Private Residence
 Hospital
 Nursing Home

Evaluation

Visual and Non-visual Needs

BVA in Office = Home Environment

Familiar with Home Environment

Functional Demand

Services Available
Optometric Evaluation

Gross Observations






Hearing Impairment
“Confusion”
Fatigue
Asymmetry / Note Lid Margins
Mobility
Careful Case History







CC
Ocular
Medical
Meds / Allergies
Social
Mental
Functional
DIFFICULTY IN TAKING A CASE
HISTORY
Reduced VA
 Impaired Hearing
 Cognitive Ability
 Slower Response
 Under Report Visual Symptoms
 Time Consuming

Functional Abilities

Effect on Everyday Function


Ex. Patient w/ Arthritis Unable to Open
Bottle
Ask Patient Able To Perform
Activities
Shopping
 Cooking
 Self-Medication
 Reading Mail
 Writing Bills

Visual Acuity
Enhanced using LV charts with
increase contrast
 Contrast sensitivity testing good to
explain non-specific complaints
 Multiple Glasses – test with more
freq worn
Rule out Media Opacity
 Pinhole VA to ______________
 Problems with GLARE
 Amsler Grid

Normal Ocular Aging
Changes

Decreased vergence ability (speed & amplitude)


Diplopia
Break down of a high phoria

Stereopsis might be reduced after age 50

Impaired smooth pursuits

Slower eye movements
Refractive error
Hyperopic shift vs. myopic shift
 Astigmatism



Shift from WTR to ATR
Optical aberrations

Increased diffraction (smaller pupil)
 Age
induced miosis
 R/O Trauma / Inflammation / Surgery

Increased light scatter
Presbyopia

Age norms
45 yrs
 50 yrs
 55 yrs
 >55 yrs


+1.50
+2.00
+2.50
+2.50 (if working dist is 40cm)
Calculated amplitude
minimum = 15.0 – 0.25 (age)
 average = 18.5 – 0.3 (age)
 maximum = 25.0 – 0.4 (age)

Aphakic Correction

High plus lenses
25% Magnification
 Objects appear larger and closer
 Pin-cushion distortion
 Ring scotoma
 “Jack-in-the-box”
 Increase vergence demand

Practice Strategies
Concentrate on Geriatric Population
15-20 minutes from Practice
 Community Service Activities

Public education
 Vision screening
 Network health care providers


Employing staff member >55 yrs
Practice Strategies









Adjust exam time
Do not use reflective or glossy paper for
materials
Avoid blue, violet, or green colored paper
Good Contrast of furniture, walls, carpets
etc
Proper lightening
Handicap accessible
Door handle that pulls
Reception counter waist level
Office should not be cluttered
REMEMBER

Handle One Complaint @ a time

Case History Never Ends

Educate Your Patient

Refer


Mental problems
Physical problems
Normal Age
Related Vision &
Ocular Changes
Adnexa
Orbital Aging Changes
Orbital fat shrinks
 Lids become flaccid

Entropion
 Ectropion

Dry Skin
 Orbital fat prolapses into upper
nasal lid
 Decreased levator function

Adnexa

Dermatologic

Decreased
 Elasticity
 Muscular

tone
Wrinkling
 Increased


chance of infection
Dermatochalasis
Decreased Cilia
Adnexa

EOMs


Fibrosis/sclerosis leads to relative restriction,
especially superiorly
Aperture

Lateral canthus drifts inward


Reduced levator function


shortens lateral dimension
shortens vertical dimension
Sagging Skin

shortens vertical dimension
Loss of Elasticity “Snap-Back
Test”
Failure of the lid
to snap back into
position
eyelearn.med.utoronto.ca/. ../04Ectropion.htm
Ectropion

Horizontal Lid Laxity

Snap Back Test



Medial Canthus Tendon Laxity

Pull LL laterally & evaluate position of puncta




Pull center part of LL >10 mm
Failure to snap back into position
Normal – 1-2 mm displacement of puncta
Mild – Position of puncta @ limbus
Severe – Position of puncta @ pupil
Lateral Canthus Tendon Laxity

Ability to pull LL medially > 2mm
Uneven Eyelid Margins
Normal aging change
 Check to see that a mass isn’t
causing this (Sebaceous carcinoma)
 Recurrent chalazia need to be
biopsied

Adnexa

Tear Film

Important in Maintaining Corneal Integrity






Decreased Stability and Production
Aqueous deficiency most common problem with the elderly
Reduction in Blink Rate (blinks/minutes)




Lubrication
Disinfection
Removal of Debris
3-4 vs. 15-20
Complaints of Dry Eye Symptoms
Sjogren’s syndrome, post-menopausal females,
medications
Management Tear Supplementation & Ectropion Repair
Conjunctiva


Saggy, loose, “redundant”
Vasculature


Increase in size and number
Subconjunctival hemorrhage


Increased incidence
Caution w/patients taking blood thinners



Coumadin
Plavix
Clarity

Decreased; yellowing due to hyaline changes
and fat deposits
Sclera

Clarity

More transparent and yellow
 Due
to dehydration and lipid deposits
Increase in Rigidity
 Senile Scleral Plaque

Senile Scleral Plaque
Senile Scleral Plaque
Local area of excessive scleral
thinning
 Occurs at the area of the insertions
of the rectus muscles (MR & LR)
 Thin clear area, may be dark if it is
very thin and you are seeing the
choroid through it
 Benign
