Introduction to Geriatric Medicine Carolyn Clevenger, DNP, GNP-BC Assistant Professor, NHW School of Nursing VA Geriatric Research, Education, & Clinical

Introduction to Geriatric Medicine

Carolyn Clevenger, DNP, GNP-BCAssistant Professor, NHW School of Nursing

VA Geriatric Research, Education, & Clinical Center

Jonathan Flacker, MD AGSFChief, Section of Geriatrics and Gerotology

Associate ProfessorEmory University School of Medicine

Industry Disclosures- CKC

I believe none of the following industry relationships are relevant to the current educational activity:

Consultancies (within last 3 years)- None Research funding- None Speakers’ bureaus, stocks, patents, family employment by

industry- None

2

Industry Disclosures- JMF

External Industry Relationships * Company Name(s) Role

Equity, stock, or options in biomedical industry companies or publishers**

JNJ Stock

Board of Directors or officer Nope

Royalties from Emory or from external entity

Nope

Industry funds to Emory for my research

Nope

Other Nope

3

Learning Objectives

Understand important demographic trends in aging Be able to explain the concept of functional status Learn a framework for understanding basic

principles affect either recovery from, or treatment during, acute illness in older patients

4

What is Geriatrics?

Geriatrics is the branch of medical science that focuses on health promotion and the treatment of disease and disability in later life.

The American Geriatrics Society5

What is a Geriatrician?

A Geriatrician is a physician who is specially trained to prevent and manage the unique and often multiple health problems of older adults.

The American Geriatrics Society 6

What is a GNP?

Gerontological Nurse Practitioners (GNPs) are advanced practice nurses with specialized education in the diagnosis, treatment and management of acute and chronic conditions often found among older adults and generally associated with aging.

Gerontological Advanced Practice Nurses Association 7

Age Distribution of US Population

http://www.nationmaster.com/country/us/Age_distribution 8

Aging in Georgia

9

The Emory University Reynolds Program

10

Basic Principles of Geriatrics

1. Aging is not a disease Disease happens to some, but aging

is not optional Aging does not generally cause

symptoms Successful aging is common

11

http://www.11alive.com/news/local/story.aspx?storyid=180571

12

Physiologic Reserve

Physiologi

c Reserve

Homeostasis

AGE -----------------------------------------------

Symptomatic Edge

13

Years Remaining When You Are Already “Old”

14


2. Medical conditions in geriatric patients are commonly chronic and multiple, and multi-factorial in origin Acute illnesses are superimposed on

existing chronic conditions Treatment of one condition can affect

another Geriatric conditions usually have multiple

contributing factors

15

Juanita 86 year-old female comes to

the clinic for refill for thyroid med

Gait speed is slow and appears out of breath

History of: Hypothyroidism, hypertension, osteoarthritis, atrial fibrillation

Potentially new: heart failure, angina, anemia, lung disease, spinal stenosis

16

Older Americans: Key Indicators of Well-Being 2012 (agingstats.gov)

Geriatric Conditions are Usually Chronic and Multiple

17

Geriatric Conditions are Often Multi-factorial

Multiple Morbidities Clinical Presentation

Delirium

Infection

Dehydration

Sensory impairment

Sleep disturbance

Medication effects

18

3. Reversible and treatable conditions are often under-diagnosed and under-treated in geriatric patients


19

Case

Ms J is in your clinic She is 80 years old and has hypertension and

stage II CKD You should of course ask her about?

20

http://www.pfizer.co.za/Themes/Content%20Themes/Pfizer_2012/Templates/general.aspx/?pageidref=1910

21

Examples of Common, Treatable Geriatric Syndromes That are Often Overlooked

Constipation Incontinence Fatigue Dizziness Sleep disorders Gait instability

22


4. Functional ability and quality of life are critical outcomes in the geriatric population

23

John 84 year-old male with

vascular disease including dementia, diabetes, veinous insufficiency, obesity

Hospitalized for cellulitis/sepsis

Could no longer walk independently after prolonged bedrest

Moved to assisted living Profoundly depressed

24

Measurement of Health Outcomes

Biological Clinician-Reported Patient-ReportedBlood tests Physical exam Symptoms

EKG/MRI Alertness/Orientation Well-being

Biopsies Diagnosis Functioning

Blood pressure Vitality

25

26

27


5. Social history, social circumstances, and available social support are essential aspects of managing geriatric patients

28

Case

Ms Malone is an 85 year old female admitted to the hospital from home for a pneumonia

Once he is better she should go __________

29

Living Arrangements of Older Men

Living Arrangements of Older Women

LIVING ARRANGEMENTS ARE IMPORTANT!

30

Hazards of Living at Home Alone

Isolation Poor nutrition Environmental hazards

and accidents Behavioral hazards

www.agingatlanta.com 404-463-3333 31


6. Geriatric care is commonly multidisciplinary

Multiple disciplines work together as an interprofessional team

32

MaryEllen 76-year old female with stroke;

great improvements in mobility, less so in cognition

Goals of care: to return to home to live independently

Structured family meeting on day 5 Patient and son MD and NP Physical and occupational therapy Social work and chaplain Psychologist

33

Team Members

Interdisciplinary Geriatric CareInterdisciplinary Geriatric Care

• Psychologists• Pharmacists• Housekeepers• Engineers• Pastoral care• IT support• Administration

•& Patient and Family

• Physicians• NPs, PAs• Nurses • Nurse’s Aides• Rehab therapists• Social workers• Dieticians

34

Principles of High-Functioning Teams

Clear roles and responsibilities Who does what? Who will take the lead in a given situation?

Shared mental model Same goal and general idea of how to achieve it

Mutual trust To back-up and monitor performance

Team orientation Believe that team based care is better than alone

Honest and clear communication Including negative feedback

35


7. Cognitive and affective disorders are highly prevalent and commonly undiagnosed at early stages

36

Case

Mr Tam is a 79 year old male brought to the clinic by his children who are concerned about weight loss

What must you consider?

37

Early cognitive impairment is commonly hidden and overlooked

Depression is commonly undiagnosed and under - treated

Behavioral symptoms such as agitation and aggression are very distressing and difficult to manage for family members

Cognitive and Affective Disorders

Cognitive and Affective Disorders

38

Depression is in the U.S.

39


8. Iatrogenic illness are common and many are preventable

Iatro = physicianGenesis = origin

Medications, diagnostic tests, and hospitalizations can be hazardous in older people

40

Betty Admitted to nursing home

from hospital following heart failure exacerbation

Unintentionally losing weight Treated with Marinol

(dronabinol) Side effect: munchies One bag of Cheetos later…

readmitted with HF exacerbation

41

Common Iatrogenic Illnesses in Geriatric Patients

Adverse drug reactions Delirium Falls and injuries Incontinence Immobility

Deconditioning Pressure ulcers Contractures

Risk Factors Normal age-related changes Atypical presentation of

disease High prevalence of chronic

disease and comorbidity Provider beliefs and attitudes Inadequate geriatric training

of healthcare providers

42


9. Geriatric care is provided in a variety of settings

43

Case - Sites of Geriatric CareCase - Sites of Geriatric CareCase - Sites of Geriatric CareCase - Sites of Geriatric Care

Home

Acute CareFacility

Outpatient/Facility

Long Term CareFacility

Assisted LivingFacility

Personal CareHome

Sub Acute Rehab

Home with home health

44


Geriatric care is provided in a variety of settings ranging from the home to long-term care institutions Criteria for levels of care Financing Care transitions and coordination

45

Sites Geriatric CareSites Geriatric Care

Acute Hospital Outpatient Clinics Nursing Home Assisted Living Facilities Home

Acute Hospital Outpatient Clinics Nursing Home Assisted Living Facilities Home

Care is not generally well coordinated

46


10. Ethical issues and end-of-life care are critical aspects of the practice of geriatrics

Not all people who live into extreme old age have to die in a hospital

47

May 73-year old with leukemia

Burdensome side effects from chemo, ready to stop treatments and go home from hospital

Son disagreed with plan “This meeting is not to reach

consensus, it is to hear what your mother wants”

48

Anticipatory Guidance

49

www.chcr.brown.edu/dying/factsondying.htm

Advance Directives

In Georgia, a large proportion of terminally ill older people in nursing homes do not have advance directives

50

Learning Objectives

Understand important demographic trends in aging Be able to explain the concept of functional status Learn a framework for understanding basic

principles affect either recovery from, or treatment during, acute illness in older patients

51

WHAT GOES UP, WHAT GOES DOWN:THE PHYSIOLOGY OF AGING

Manuel A. Eskildsen, MD, MPHFinancial Relationships w Industry Disclosures



None

Board of Directors or officer None


None


None

Other None

53

Objectives

Understand the physiologic changes that occur with aging.

Differentiate the normal aging process from disease.

54

Outline

Discuss changes across different organ systems Body compositions Cardiac Pulmonary Gastrointestinal Renal Endocrine Reproductive Nervous System Sensory Skin

Discuss your assigned cases

55

56

Aging is not a disease

57

What is normal aging, and what is disease? Normal aging

Is an expected part of getting older

However, it may be variable

A direct consequence of the physiologic aging process

Disease Represents a

pathological change in the tissues involved

Aging may make the system vulnerable– but not a direct consequence of aging

58

Examples of cellular changes

Activation or suppression of aging genes

Telomeres Damage by free radicals

to mitochondria

59

The Consequences of Aging

Lack of adaptability to stress

Decreasing reserves Makes it more likely to

see symptoms and disease in organ far from primary problem

Homeostenosis

60

Physiologic Changes

61

Body composition changes with aging

More Less

• At age 30, total body water is 60%• At age 75, total body water is 50%• Total body fat rises with age

62

Effects on Medications

Likely the most important to consider Lipophilic medications (e.g., diazepam)

Larger volume of distribution Stays in body longer

Hydrophilic medications (e.g., digoxin) Smaller volume of distribution Comparatively, may achieve higher plasma

concentrations

63

Cardiac Changes - Overview

Little difference at rest Structurally, muscle

thickness and heart weight increase

Functional changes: Decreased maximal heart

rate Increased dependence on

“atrial kick”

64

Cardiac Structural Changes

Thickened heart muscle Hardening and thickening of

arteries Both are involved in elevated

BP with aging

This thickened cardiac muscle may result in a normal S4 in an older person

65

Cardiac Functional Changes

Resting heart rate and cardiac output don’t change

However… Maximal heart rate decreases Maximal cardiac output decrease

Thickened left atrium Decreased atrial kick

More susceptible to complications like heart failure

66

Maximal heart rate

Male Maximal HR = 220 – age

Female Maximal HR = 220 – (0.6 x age)

67

Atrial Kick

In the younger heart, diastolic filling is easier. Thicker heart depends more on active filling due to

atrial kick Atrial fibrillation takes away that atrial kick

68

Pulmonary and Lungs - Overview Also, few changes evident

at rest Structurally, generally

tissues are stiffer Maximal reserve decreases

69

Pulmonary Structural Changes

Alveolar surface decreases overall

Lungs are stiffer Airway flow is

decreased Diaphragm is weaker Ciliary action less

effective

70

Pulmonary Function

Decreased vital capacity (amount of air that can be maximally inspired)

Increased residual volume (air trapping)

Ventilation/Perfusion (V/Q) mismatch

71

Arterial O2 changes with age

PaO2= 100 – (age/3)

Age 17 Age 87

72

PaO2= 71 mm HgPaO2= 94 mm Hg

Question An 85-year-old man has had increasingly severe shortness

of breath on exertion over the past 3 months. For the past 20 years, he has walked 30 minutes three times weekly at a fairly rapid pace without symptoms. He has no chest pain, wheezing, or cough. Blood pressure is 140/85 mm Hg. On examination, the lungs are clear and there is no evidence of wheezing. Radiographs of the chest and an electrocardiogram show normal findings. Which of the following additional findings would require further evaluation?

(A) Arterial PO2 of 80 mm Hg (B) Decreased cardiac output on ultrasonography (C) Decreased maximum heart rate on stress testing (D) Decreased vital capacity on pulmonary function testing (E) Presence of an S4 gallop

Gastrointestinal/Hepatic

74

Gastrointestinal Changes (Potential Disease Consequences) Decreased salivary

production (oral ulcers)

Gastric mucosal atrophy, impaired acid clearance (GERD)

Slower transit times (constipation)

Decreased calcium absorption (bone loss)

75

Constipation

Constipation is not normal aging, but aging predisposes to it

Slower transit time plus… Low fiber Poor mobility Effects of medications (narcotics)

Equals constipation

76

Hepatic Changes

Phase I metabolism (oxidation/reduction)

Cytochrome P450 system

Significant declines with aging

Careful with diazepam (valium)

Phase II reactions (conjugation)

Like glucuronidation Facilitates renal

excretion Less affected with

aging Example:

Lorazepam (ativan)

77

Renal Changes - Overview

Decrease in renal mass, especially cortical Overall decreases in function Electrolyte changes

78

Renal Changes

Decrease in size, especially at the expense of the cortex

Decrease in renovascular bed 30% of glomeruli lost by age 75

Decreased creatinine clearance --- serum creatinine is less of an important indicator

Decrease in concentrating capacity --- tendency toward dehydration

79

Renal Elimination Cockcroft-Gault Equation

CCr = (140-AGE) x (Wt in KG) (72 x Cr in mg/dl)

x 0.85 for women

Changes variable, but can be guesstimated:

80

Creatinine Clearance Comparison

Age 30130 lbsCreatinine= 1.5

Age 85120 lbsCreatinine= 1.5

CrCl = 51 CrCl = 2481

Implications of Aging Changes on Kidney Need to know whether drugs are excreted

renally And whether dose needs to be adjusted Example

The 80-year old woman in the example above has CrCl of 24 ml/min

She has a DVT and her MD decides to treat with enoxaparin. Ordinary dosing is 1 mg/kg BID

For CrCl < 30, dose is 1 mg/kg Qday Dose is 55 mg Qday

82

Endocrine Changes - Overview

Changes in Glucose Tolerance Decrease in GH, Testosterone, Estrogen Ovarian failure (menopause) already happened

in 50s

83

Glucose and Insulin

Clinically insignificant increases in fasting glucose after age 20 (1% per decade)

Decreased response of peripheral tissues to insulin

SEDENTARY LIFESTYLE contributes much more to poor glucose tolerance than age

84

Reproductive/Genitourinary

85

Female – GU and Breast

Best known change – menopause Permanent end to menstrual periods (around age

50) Vagina thinner, drier, less elastic

Intercourse may be more difficult Breasts less firm tend to sag

86

Male Changes

Fewer sperm and decreased sex drive over time Hormone changes are more gradual

Blood flow to penis tends to decrease Erections may not last as long; also less rigid Erectile dysfunction more common (but not part of

normal aging) Prostate enlarges

Older men may urinate with less force, take more time to initiate stream

87

Central Nervous System

Structure ↓ Brain Weight ↓ no. of nerve cells in brain ↓ cerebral blood flow (20%) ↑ neurofibrillary tangles and

scattered senile plaques

88

Central Nervous System - Function

Intellect Maintained until at least age 80 Slowing in central processing → Tasks take longer to

perform

Verbal skills Maintained until age 70 Gradually ↓ in vocabulary, ↑ semantic errors and

abnormal prosody

Mentation Difficulty learning, especially languages and

forgetfulness in non-critical areas – doesn’t impair recall of important memories or affect function

89

Dementia vs. Normal Aging

Dementia Difficulty naming

common words Forgetting names of

known places, family members

Example: putting sweater in microwave

Normal Aging Occasional word-

finding difficulty Difficulty learning

new languages Example: Forgetting

your keys

90

Peripheral Nervous System

↓ spinal motor neurons Nerve conduction slows ↓ vibratory sensation –

especially feet ↓ thermal sensitivity (warm-

cool) ↓ size of large myelinated

fibers91

Musculoskeletal - Bone

Decreased bone density

Increased bone loss Decreased Vitamin D

absorption, decreased bone formation

Implications: Loss of height

(women > men) Osteoporosis is not

normal aging

92

Musculoskeletal - Muscle

Muscle mass decreases by 30 – 40 % linear acceleration with age Fewer motor units (so decrease power) Produce less heat per KG

Decreased transfer ability Decreased stair climbing ability Decreased gait speed Activity makes a big difference!

93

Sensory Changes

Visual Auditory Smell Taste

94

Visual Changes

Hardening of lens Difficulty with accommodation Presbyopia

After age 40; part of normal aging

Yellowing of lens Eventually can lead to cataracts (not normal aging)

Impaired dark adaptation and contrast sensitivity Implications for night driving

95

http://www.healthandage.com/html/res/primer/eyes.htm

Thickens

Result: Loss of high >> low frequency hearing

Auditory Changes

96

Hearing – Clinical Implications

Clinical Question: Describe a Strategy for Communicating With Older Patients Who Have Hearing Loss?

Clinical Question: What easy physical exam component should you carry out before referring a patient to an ENT?

97

Taste & Smell Changes

# of taste buds and responses are unchanged

Olfaction ↓↓↓ significantly Detection thresholds increase 50% by age 80

Smell recognition decreases by 15% Decreased Smell leads to Decreased

taste May predispose to malnutrition

98

Skin

99

Skin Changes

Loss of subcutaneous fat Atrophy of sweat glands Impaired vasoconstictor/vasodilator response in

skin arterioles Decreased temperature discrimination Ineffective DNA repair

100

Skin Changes-Implications

Less fat over bony prominences (pressure ulcers)

Temp discrimination impairments; Less efficient shivering; less muscle activity Hypothermia

Higher temperature for sweating, less production Hyperthermia

Ineffective DNA repair Carcinogenesis

101

Summary

Changes in multiple organ systems are a part of normal aging

They may predisposed to disease but are not in of themselves pathologic

Have clinical implications which may necessitate adjustment of treatment

102

CHRONIC DISEASE MANAGEMENT

Ugochi Ohuabunwa MDDivision of General Medicine and GeriatricsEmory University School of [email protected]

External Industry Relationships * Company Name Role

Equity, stock, or options in biomedical industry companies or publishers

None

Board of Directors or officer None


None

Industry funds to Emory for my research None

Other None

Ugochi Ohuabunwa, M.D.Personal/Professional Financial Relationships with Industry

104

Learning Objectives

Discuss the definition and epidemiology of chronic diseases

Describe models of care in management of chronic diseases

Compare and contrast acute and chronic disease management modalities

Discuss effective inter-professional team collaborative practice in chronic disease management

Describe the steps of management of a patient with Heart Failure using the Chronic Care Model

105

You as a patient………….

What would you consider to be excellent medical care if you had a chronic medical condition?

How best would you like your disease managed?

How do you think the medical practice where you are cared for should be best organized to provide excellent patient care?

106

You as a physician………….

What would you consider to be excellent medical care provided to your patients?

How would you like your medical practice organized to facilitate provision of excellent patient care?

What measures can your practice put in place to ensure that your patients are doing well and have good outcomes?

107

Mr. Smith – History of Present Illness

A 78-year-old man admitted to Emory University Hospital with three days of nausea and vomiting, shortness of breath, cough, and leg swelling. He had a heart attack in January 2013. Since then, he has had worsening symptoms of heart failure, necessitating five hospital admissions over the last six months

108

Past Medical History

Coronary Artery Disease with Acute Heart Attack January 2013

Congestive Heart Failure High Blood Pressure High Cholesterol Diabetes Dementia

109

Medications on Admission

Furosemide 20mg once daily Clopidogrel 75mg once daily Aspirin 325mg once daily Simvastatin 20mg at night Metoprolol 25mg twice daily Lisinopril 20mg once daily Donepezil 10mg once daily Glipizide XL 10mg once daily

110

Social History

Widowed and lives alone in an independent living senior high rise

Has 2 living children both of whom live out of state

Has a niece who checks in on him 3 times a week

Does not drink alcohol, smoke or use recreational drugs

111

Functional History

Able to complete his activities of daily living Bathing Toileting Grooming

Has had increasing difficulty in performing some instrumental activities of daily living due to his increasing shortness of breath Cooking Cleaning

112

Questions

What do you think is going on with Mr. Smith?

Why the very frequent re-hospitalizations?

As Mr. Smith’s physician, how best can you manage his acute and chronic medical problems?

113

Definition

Chronic conditions are "any conditions that require ongoing adjustments by the affected person and interactions with the health care system." (Improving chronic illness care, 2008)

Examples Asthma Diabetes Heart disease Hypertension High Cholesterol

http://www.improvingchroniccare.org

114

http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

Epidemiology

133 million people - almost half of all Americans, live with a chronic condition

That number is projected to increase by more than one percent per year by 2030, resulting in an estimated chronically ill population of 171 million."

http://www.improvingchroniccare.org

115

Epidemiology

80% of persons over 65 have one or more chronic conditions

Chronic conditions contribute to ¾ of the healthcare budget

Need for development of innovative and impactful methods to deliver quality patient care

116

Epidemiologic Transition

Non-Communicable Disease

Infectious Disease

Epidemiologic Transition

Mo

rta

lity

Ra

tes

Omran, A. The Epidemiologic Transition: A theory of the epidemiology of a population change. Milbank Q. 1971:49:509-538. 117

PARADIGM SHIFT

ACUTE CARE CHRONIC CAREFocus: illness

Care: fragmented

Focus: prevention

Care: coordinated

Transition in Health Care

118

Current State of Primary Care Practice

Acute Disease Management Primary care practice largely designed

To provide ready access and care to patients with acute problems

Emphasis on triage and patient flow Short appointments Diagnosis and treatment of symptoms and signs Reliance on laboratory investigations and

prescriptions Brief, didactic patient education Patient-initiated follow-up

119


Care is not necessarily based on evidence, but experience and training

Seldom is there a team approach…care is mainly driven by the physician alone

Paternalistic and directive approach with little attention to patients’ behavioral needs

120


Limited access Insurer limitations Reluctance of primary care referral Fragmented access

Poor information systems Poor tracking

121

Is the Current System Working?

Patients and families struggling with chronic illness have different needs

These needs are unlikely to be met by an acute care organization and culture

They require planned, regular interactions with their caregivers

Need for focus on function and prevention of exacerbations and complications

122

Ideal Healthcare System

Evidence-based, planned care Systematic assessments Attention to treatment guidelines

Reorganization of practice (team approach) Includes ancillary professionals with the patient as the

most important member

Attention to patient needs (information) Counseling, education, information feedback Behaviorally sophisticated support for the patient's

role as self-manager

123

Ideal Healthcare System

Access to clinical expertise Patient and provider education, access to

specialists

Supportive information systems Patient registries Provider feedback on preventive service

utilization

124

Models of Care in Chronic Disease Management

Chronic Care Model Guided Care Model Innovative Care for Chronic Diseases Model

(World Health Organization) Stanford Self-Management Program Fennell Four Phase Model of chronic illness

125

Chronic Care Model (CCM)

CCM summarizes the basic elements for improving care in health systems on different levels The community The health system Self-management support Delivery system design Decision support Clinical information systems

126

127

Guided Care Model

In Guided Care, a specially-educated registered Guided Care Nurse, based in a primary care practice, works in partnership with 2-5 primary care physicians and other members of the health care team in providing 8 processes to 50-60 chronically ill patients.

128

Guided Care Processes

Assessing the patient and primary caregiver at home

Creating an evidence-based comprehensive "Care Guide" (care plan) for providers and a patient-friendly "Action Plan" for patients and caregivers

Promoting patient self-management Monitoring patient's conditions monthly

129

Guided Care Processes

Coordinating the efforts of all health care providers, healthcare facilities, rehab facilities, home care agencies, hospice programs, and social service agencies

Smoothing transitions between sites of care, focusing more intensively on transitions into and out of hospitals

Educating and supporting family caregivers Facilitating access to community resources

130

Back to Mr. Smith

How best can we manage his illnesses?

Which model of care would be best suited for him?

How will the model work?

131

A Review of His Chronic Medical Conditions

Coronary Artery Disease with Acute Heart Attack January 2013

Congestive Heart Failure High Blood Pressure High Cholesterol Diabetes Dementia

132

His Social History

Widowed and lives alone in an independent living senior high rise

Has 2 living children both of whom live out of state

Has a niece who checks in on him 3 times a week

Does not drink alcohol, smoke or use recreational drugs

133

His Functional History

Able to complete his activities of daily living Bathing Toileting Grooming

Has had increasing difficulty in performing some instrumental activities of daily living due to his increasing shortness of breath Cooking Cleaning

134

Mr. Smith

Based on this history, can you summarize the needs of Mr. Smith?

Which of these needs would you like to address as Mr. Smith’s physician?

How best can you organize your practice and harness resources to meet these needs?

135

Needs of Mr. Smith

Medical Needs Multiple medical diseases with frequent

exacerbations Need for optimal medication management Need to ensure that these diseases are well

controlled and are at goal Need to ensure that he is well informed and

compliant

136

Needs of Mr. Smith

Social Needs Lives alone, only checked on 3ce a week by niece Has dementia and may be unable to manage his

medications May also be forgetful of dietary needs and other

self management measures Functional Needs

Increasing difficulty with completing IADLs such as cooking

May be eating the wrong things

137

Mr. Smith

Which of these needs would you like to address as Mr. Smith’s physician? Medical needs? Social needs? Functional needs

As a Clinician, which of these needs are your responsibility to meet?

How best can you organize your practice and harness resources to meet these needs?

138

Applying the Chronic Care Model to the management of his chronic medical conditions

Mr. Smith

139

Chronic Care Model Components The community The health system Self-management support Delivery system design Decision support Clinical information systems

140

1. The Community

Linkages with community- based resources Exercise programs Senior centers Self-help groups Patient education classes Home care agencies

141

1. The Community

Which community resources would Mr. Smith benefit from?

Based on his Medical History

Based on his Social History

Based on his Functional History

142

2. Self-management Support

Involves collaboratively helping patients and their families acquire skills and confidence to manage their chronic illnesses through: Education on management of illnesses including -

diet, exercise, medication use, self measurement Provision of self-management tools e.g, blood

pressure cuffs, glucometers, bathroom scales Referrals to community resources Routinely assessing problems and accomplishment

of goals

143

2. Self-management support

How can we help Mr. Smith acquire skills and confidence to manage his chronic illnesses?

What should be the content of his education?

What self-management tools can we provide Mr. Smith?

144

4. Delivery System Design

Redesign of the medical practice, creating practice teams with a clear division of labor

Non physician personnel are trained to support Patient self-management Arrange for routine periodic tasks (e.g, laboratory

tests, eye examinations, and foot examinations) Ensure appropriate follow-up

Pre - planned visits are an important feature of practice redesign

145

4. Delivery System Design

Which members of the healthcare team should be involved in the care of Mr. Smith?

Define the role of each member of the

healthcare team and what services they should provide?

146

5. Decision Support

Use of evidence-based clinical practice guidelines for optimal chronic care

Guidelines integrated into daily practice through physician reminders

Guidelines reinforced by physician “champions” leading educational sessions for practice teams

Prompt access to specialists for expert evaluation

147

5. Decision Support

You are the physician champion of the clinic

How can you ensure that members of the practice team are well equipped to provide up to date evidence based care to Mr. Smith?

What systems can you create to ensure that Mr. Smith’s physician integrates evidence based practice guidelines into his routine management ?

How can we coordinate his care to ensure ease of specialist referral?

148

6. Clinical Information Systems

Presence of computerized information system Has 3 important roles:

As reminder systems that help primary care teams comply with practice guidelines

As feedback to physicians, showing how each is performing on chronic illness measures such as HbA1c and lipid levels

As registries for planning individual patient care and conducting population-based care

149

6. Clinical Information Systems

How can we incorporate the clinical information system into the management of Mr. Smith?

Based on Mr. Smith’s medical history, what chronic illness measures would best be used for providing feedback to Mr. Smith’s doctor about his care?

How best can we plan Mr. Smith’s care prior to and during each visit based on the information received from the computerized system?

150

Mr. Smith

Summarize your goals and care plan for the management of Mr. Smith’s chronic medical illnesses

151

Conclusions

Chronic Disease Management should not be problem-based, designed to handle only acute patient problems

Should be a system that is prevention based to avoid long-term complications

Should adopt a wholesome approach, taking into account the medical, psychosocial, functional and educational needs of a patient in order to harness available resources to meet these needs

152

Conclusions

Should involve a well prepared proactive practice team with appropriately defined roles, operating with the support of clinical information systems to provide evidence based care

Should collaboratively help patients and their families acquire skills and confidence to manage their chronic illnesses

A successful chronic disease management model would

result in a more informed activated patient and a prepared proactive practice team working together in a partnership to improve functions and clinical outcomes.

153

AGING WEEK 2013CAMILLE VAUGHAN, MD, MS

ASSISTANT PROFESSORDIVISION OF GENERAL MEDICINE & GERIATRICS

TUESDAY, NOVEMBER 12TH, 2013

Appetite for Life



None N/A

Board of Directors or officer None N/A


None N/A


Astellas Pharma, Inc Investigator Initiated Trial

Other Kimberly-Clark, Corp. Spouse is full-time employee

*Consulting, scientific advisory board, industry-sponsored CME, expert witness for company, FDA representative for company, publishing contract, etc.**Does not include stock in publicly-traded companies in retirement funds and other pooled investment accounts managed by others.

Camille Vaughan, MD, MSPersonal/Professional Financial Relationships with Industry within the past year

155

Learning Objectives

Factors impacting the nutritional status of older adults

Physiologic changes of aging which impact nutrient requirements

Nutrients – which ones are most important?

Health benefits and risks of weight loss in overweight and obese older adults

The role of medical nutrition therapy

Programs to enhance nutrition in community dwelling older adults

156

Role of Food/Nutrition in Aging

Physiologic well-beingQuality of Life

Social Cultural Psychological

Promotes health and functionalityMedical Nutrition Therapy (MNT)

Disease management Lessen chronic disease risk Slow progression Lessen disease symptoms

Position Paper, J Acad of Nutrition & Dietetics, 2012157

Role of Food/Nutrition in Aging

Nurses’ Health Study ~ 10,000 womenHealthy diet & Mediterranean Diet in mid-life

associated with healthy aging (15 yrs later)

158Samieri et al. Ann Int Med 2013

Factors influencing nutritional status

Nutritional Status

Aging Process

Physical/Functional Status• Physical limitations• Balance• Physical strength & endurance• Physical activity

Environment• Living situation• Economics• Cultural beliefs & traditions• Religious beliefs & traditions• Lifestyle• Access to food & food prep• Socialization

Medical/Health Status• Chronic/Acute illness• Medications• Sensory changes• Oral health

Cognition/Psychological• Change in mental status• Depression or emotional needs• Habitual food intake• Health/nutrition beliefs• Advertising

Adapted from Bernstein and Luggen, Nutrition for Older Adults, 2010, Jones & Bartlett Learning

159

Medical & Health Status Factors

Medical conditions – acute & chronic Diabetes, infection, head injury

Medications Common culprits

Dysgeusia: Lithium, ACE inhibitors, some antibiotics, cancer drugs, chlorhexadine mouthwash, thyroid medications, metformin

Xerostomia: Anticholinergics, diuretics Constipation: Anticholinergics, antiparkinsonian meds Altered absorption/metabolism: proton pump inhibitors, metformin

Diminished smell/taste with advancing ageOral health – less saliva

160

Physical & Functional Status

Less physical activity is commonDiminished ability to chew/swallowAbility to prepare food impacted by functional statusReduction in energy needs impacts ability to meet

nutrient requirements Eating ‘nutritionally dense’ foods even more important

161

Cognition/Psychological Impact

Impacts ability to prepare foodsFood choices may be impacted by habits (good/bad)DepressionLabeling/advertising readabilityNutrition beliefs

162

Environment

Living situation Independent Assisted living Safety

EconomicsCultural/Religious beliefs/traditionsAccess to food – food security

Availability of nutritionally adequate and safe food

Socialization

http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-of-food-security

163

Defining Food Insecurity

USDA defines based on questionnaire

The three least severe conditions that result in a household being classified as food insecure:

Worried whether food would run out before having money to buy more

Food purchased didn't last, and didn't have money to get more

Couldn't afford to eat balanced meals

164

Food Insecurity in Dekalb Cty

http://www.ers.usda.gov/data-products/food-environment-atlas/go-to-the-atlas.aspx 165

Food Insecurity

Risk factors for food insecurity among older adults Income below poverty line Population subgroups – ethnic minorities/rural Lower educational level Disabled Living with a grandchild Supplemental Nutrition Assistance Program (SNAP)

166

Nutrient Requirements

Physiologic changes of aging Total energy requirements decrease with aging

Primarily due to decreased physical activity Loss of skeletal muscle mass

Loss of 15% of fat free mass between age 30 and age 80 Increase in body fat and visceral fat Renal function

Diminished ability to concentrate urine Blunted thirst sensation

Most vitamin and mineral needs remain constant or increase despite need for lower caloric intake

167

Decline in Total Energy Expenditure with Aging

Roberts & Dallal. Public Health Nutr 2005 168

Nutrients Requirements

Reference standards developed by the IOMRecommended Dietary Allowance (RDA)

Started in 1941 Intake which is adequate for about 97-98% of healthy persons

Dietary Reference Intakes (DRI) Started in early 1990’s by FDA More comprehensive – subsets for different age

groups/men/women Include RDAs as well as other measures (like Adequate Intake

[AI] when RDA is not established)

169


Fluid (includes high moisture foods) DRI for men ≥ 19 yrs = 3.7 L/day (no change for > 70 yrs) DRI for women ≥ 19 yrs = 2.7 L/day (no change for > 70 yrs) General recommendations in the clinic:

6-8 eight oz glasses of fluid daily

Dehydration is a major problem in older adults Increases risk of constipation, impaction Increases risk of kidney injury in the event of an acute event like infection/fall

www.iom.edu 170


Fiber DRI for women ≥ 50 yrs = 21 g/day DRI for men ≥ 50 yrs = 30 g/day May be difficult to meet DRI without choosing fiber-rich foods Foods low in fiber

Usually have inferior nutrient composition Contribute to discretionary energy intake (increase risk of obesity)

In patients with poor appetite – high-fiber foods may lead to early satiety

Adequate fluid intake is essential with fiber recommendations

High fiber foods: pears, bran, whole grains, prunes, walnuts

www.iom.edu 171


Protein RDA women & men ≥ 19 yrs = 0.8 g/kg/day

56 g/day for men, 46 g/day for women May be difficult with limited resources, reduced appetite Role of protein in the prevention of sarcopenia - unclear

www.iom.eduTroyer et al. Am J Clin Nutr 2010172


Sodium DRI for women & men ≥ 70 yrs = 1,200 mg/day Upper Limit = 2,300 mg/day Most Americans consume 3,000 – 4,000 mg/day Delivering meals meeting DASH guidelines can improve

adherence among older adults

High sodium foods to avoid: white breads, chips, soups, processed foods

www.iom.eduTroyer et al. Am J Clin Nutr 2010 173


Vitamin D Vit D RDA for men & women ≥ 70 = 800 IU/day

Classically recommended to prevent osteoporosis Vitamin D levels insufficient in most and deficient in

many older adults At least 800 IU/day associated with decreased risk of

fallingGood sources: sun exposure, salmon, fortified foods

www.iom.eduHolick et al. NEJM 2007 174


Calcium Calcium RDA for men & women ≥ 70 = 1200 mg/day Calcium supplements (not dietary Ca) linked to increased

risk of MI (regardless of dose)

Good sources: broccoli, low-fat yogurt/cheese/milk

www.iom.eduLi et al. Heart 2012 175


B12 RDA for women & men ≥ 19 = 2.4 mcg/day Estimated 6-15% of older adults are deficient Causes: pernicious anemia, atrophic gastritis, associated

with some drugs – metformin, lack of intrinsic factor No mandated fortification Complications of B12 deficiency: neurocognitive,

peripheral neuropathy, macrocytic anemia, elevated homocysteine

176


Folate (fortification since 1998) RDA for women & men

≥ 19 = 400 mcg/day Excessive folic acid

intake could mask B12 deficiency

177


Antioxidants Vitamin E, C, beta carotene, lutein, selenium, others Inconclusive research regarding antioxidant effects on vision

(macular degeneration) and cognition Recent meta-analysis: omega-3 showed modest benefit to

reduce MI risk

Vitamin K AI for women ≥ 19 yrs = 90 mcg/day AI for men ≥ 19 yrs = 120 mcg/day Important for blood clotting, bone health

www.iom.eduRizos et al. JAMA 2012 178

Overweight & Obesity in Older Adults

Weight management complicated in older adultsLoss of excess fat mass can accelerate loss of

muscle risk factor for decrease functional capacity Combining with exercise may help prevent muscle loss

Weight loss (even 5-10%) in overweight/obese older adults can result in improvements: Improved quality of Life Reduced medical complications Lower CVD/diabetes risk factors Reduced disability Less mechanical strain on joints

Frimel et al. Med Sci Sports Exercise 2008 179

Overweight & Obesity in Older Adults

Sarcopenic obesity Coexistence of age-related loss of muscle mass/function

and excess body fat Identification based on grip strength and BMI Likely potentiates effects on disability, morbidity, and

mortality Prevalence ranges from 3.0% - 12.4% depending on the

definition used

Stemholm et al. Curr Opin Clin Nutr Met Care 2008 180

Medical Nutrition Therapy

Provided by a Registered Dietician (RD) or Dietetic Technicians, registered (DTR)

Medical Nutrition Therapy can include: Nutrition assessments Individualized interventions Counseling Management of parenteral feedings End-of-life care

Covered by Medicare for diabetes and renal diseaseAlso can be bundled in some home health servicesScreening Tool: Mini-Nutritional Assessment

181

http://www.mna-elderly.com/

Community-based Resources

Older Americans Act Nutrition Services Title III program started in 1965 Provides congregate and home-delivered meals In 2009, 149.1 million meals were delivered to 880,135

individuals In 2008, 61% of meals delivered to homebound older adults In the Atlanta area – Senior Connections serves about 700,000

meals per year (Meals on Wheels)

Delivery of meals within DASH guidelines increases adherence to dietary recommendations for older adults with CVD

Troyer et al. Am J Clin Nutr 2010 182


USDA Food and Nutrition ProgramsSupplemental Nutrition Assistance Program (SNAP)

Coupons or electronic benefits for nutritionally adequate food Bread, fruit/vegetables, meats, fish, poultry, dairy products,

seeds, or plants that produce food US citizens and legal residents Gross income ≤130% federal poverty level

Seniors’ Farmers Market Nutrition Program Coupons/vouchers to exchange at local farmer’s markets

183


How to access or assess eligibility?Atlanta Area Agency on Aging

www.agewiseconnection.com 24-hour referral line: 404 463 3333

Senior Connections (eligibility varies by county) www.srconn.com Emory Dept of Medicine supports

184

http://www.agewiseconnection.com/

http://www.srconn.com/

http://medicine.emory.edu/faculty-and-staff/mpact/meals-on-wheels.html

Paying Homage

Julia Child Remixed

185

http://www.youtube.com/watch?v=80ZrUI7RNfI

Jonathan M. Flacker MD AGSFAssociate ProfessorDivision of General Medicine and Geriatrics(with thanks to Dr. Adam Herman)



Stock (JNJ)

Board of Directors or officer No


Nope


Absolutely not

Other Nah

*Consulting, scientific advisory board, industry-sponsored CME, expert witness for company, FDA representative for company, publishing contract, etc.**Does not include stock in publicly-traded companies in retirement funds and other pooled investment accounts managed by others.

Dr. Jonathan Flacker Personal/Professional Financial Relationships with Industry within the past year

187

By the end of this session the student will be able to:

Describe 3 ways to make the environment conducive to a discussion about bad news

Demonstrate how to begin a discussion of bad news

Compare and contrast effective techniques for delivering bad news with good techniques

188

An iterative processAll components revolve around

knowledge and communication Common symptoms Individual preferences Cultural beliefs and values

Recognized and communicate to patients that they are dying

189

Communication is key Ethical obligation to discuss dying with

patients

“Physicians have the DUTY to inform their patients about their illness and

patients have a RIGHT to know.“ (Nicholas Christakis MD)

Why?

190

If you are not prepared you can not plan

For a gameFor a school For a babyFor a death

Must we must tell our patients (and families?) How can they prepare otherwise?

191

So how do you broach such a sensitive topic?

You know they are dyingPatients and family often knowEvery one’s afraid to talk about it

… not discussing death and dying is the elephant in the room

192

Components:ActorsSetting/environmentCommunication (language)

193

Mrs. Benford is here today to discuss tests resultsShe knows she

Has cancer

Is weak, in pain, and has lost 20 lbs Doctor knows

Despite treatment cancer has spread

There is no curative therapies We will have ‘time-outs’ to discuss key points in discussing death and dying

194

What do you think?

195

Who should be present?

Doctor Patient Family Other

196

What is appropriate environment?Quiet

Undivided attention (no interruptions) Focus on patient and family (body

language) Limit topics Kleenex

Let’s fix what’s happened and watch some more…

197

What do you think?

198

Rule #1: Attentive Listening Listen Listen ListenCorollary : Avoid information overload

- they won’t hear it anyway

Let them tell you what they understand and what they want to know

199

The one minute managing test

200

Rule #2: Open ended questions More information in less time Allows patient and family to prioritize Listen and reflect concerns

Corollary to Rule #2: Close ended questions assumes the doctor knows the priorities of patient and family

201

Examples:

“What changes have you noticed… ?”

“What has changed for you… ? How?”

“What do you understand about your

illness(es)?

“How has it changed recently?”

202

Examples (cont):

“What do you think is happening to you”

“… Tell me more about that…”

Let’s watch some more…

203

What do you think?

What is NOT being said?

204

Rule #3: Acknowledge the elephant in the room Say the words Let it lie… Allow time for response

Corollary : Avoiding the elephant prevents you from fulfilling your duty as a physician

If accomplished, you have the ability to move forward and set priorities and goals of care 205

Rule #4: Give patient (and family) some wiggle room

Absolutes lead to polarization and

confrontation

Allows patient and family to talk

‘hypothetically’

Corollary : People put in a corner may become defensive, angry, and distrustful

206

Rule #5: Silence is your friend Let your statement and questions hang

Let your statement and questions sink in

Corollary : If there is no silence, you forgot Rule #1 and your patient can’t process

PracticeDon’t just do something…sit there…..

207

How do we acknowledge the elephant?First…

Combine direct language (“death”, “dying”)WITH…

ambiguous modifiers (“might”, “possible”) This allows ‘wiggle’ roomSecond…

Silence is your friend This allows time to consider your statement

208

Examples:“Have you ever thought that you might be

dying?”

“Have you ever thought about your own death?”

(let it hang…)

209

“No one can know for sure exactly what’s going to happen. But it’s

possible you might be dying. So, it’s important to be prepared. That way all

the bases are covered and you and your family will be ready whenever it

occurs.”

(silence…)210

“All of us need to be prepared for death so that when it happens nothing is left unsaid or undone. Whether you die today or 10 years from now, it’s

good to be prepared…”“If (hypothetically) you died today, what

would be left unsaid or undone…”(let it lie…)

211

“No matter what you choose (treatment or no treatment), your life is limited. The

task is still to get prepared for your death so you will be ready and that’s a good

thing.”

(let it hang out there…)

212

“Every day from today until the day you die is very precious. The fact that you have this __(insert condition/illness)_ means you may have even fewer days, which makes each day even

more precious… How do you want to spend that time?”

(silence…)

213

“Pretend like you knew you were going to die today. What hopes would you have?

What is your idea of a ‘peaceful’ death…”

(let it hang out there…)

214

“…I’m a bit hesitant to bring this up, yet I know it can be very important to patients in your situation to talk about. Most patients tell me they think about death as they are growing

older and getting weaker. That’s a healthy thing to do…so we can be prepared for it…”

(silence…)

215

What is the goal? …

… to acknowledge death and dying and allow patients and their families to set priorities and goals of care with this knowledge in hand.

Let’s see what happens…

216

Two major ways: The Living Will Power of Attorney for Health Care

217

Usually covers specific directives course of treatment forbidding treatment

Effective ONLY if the person can’t give informed consent

218

Appoints individual (a proxy) to direct health care decisions

Effective ONLY if the person can’t give informed consent

219

Recognizes that: Dying is a normal process of living Affirms life - neither hastens nor

postpones death Belief that through appropriate care,

individuals and their families will attain a degree of satisfaction in preparation for death

220

Hospice is a formalized way to deliver palliative care

www.hospicecare.com 221

Acknowledge the elephant

Tell patients what to expect

Act as a guide through the dying process

Continue to be their doctor (do not abandon)

Let’s see what happens…

222

By the end of this session the student will be able to:

Describe 3 ways to make the environment conducive to a discussion about bad news

Demonstrate how to begin a discussion of bad news

Compare and contrast effective techniques for delivering bad news with good techniques

223

Documents

Introduction to Geriatric Medicine Carolyn Clevenger, DNP, GNP-BC Assistant Professor, NHW School of Nursing VA Geriatric Research, Education, & Clinical