The Librarian as Gerontologist Rosanne M Leipzig MD

The Librarian as Gerontologist Rosanne M Leipzig MD Ph. D Professor and Vice Chair Departments of Geriatrics and Medicine Mount Sinai School of Medicine

Aging: The Numbers

There were 3 million Americans over age 65 in 1900 • What’s the estimated number for 2030? *** A. B. C. D. 10 million 30 million 50 million 70 million

Medical Librarians Are Also Aging Medical Library Association. Hay Group/MLA 2005 salary survey [Web document]. 2005 [cited 10/12/2007].

Projected Population Distribution

What percent of those 65+ are high school graduates? A. B. C. *** D. 10% 30% 50% 70%

Education level of older population

Percentage of all persons over 65 living in nursing homes? *** A. 5% B. 10% C. 15% D. 20%

Nursing Home Population By Age: 2000 %

Percentage of all persons over 65 living with their spouses? A. B. *** C. D. 20% 35% 50% 65%

Living Arrangements of Persons 65+

Social Activities

Leisure-time Physical Activity 65+ 2004 -5 % engaged in REGULAR ACTIVITY CDC http: //209. 217. 72. 34/aging/Table. Viewer/table. View. aspx? Report. Id=383

Reporting Good to Excellent Health

Disability in Aging: The Good News in the U. S. • age 65 -74: 89% report no disabilities • age 85+: 40% report no disabilities • In 1999, there were 1. 4 million fewer disabled persons than there would have been if health status had not improved since 1982.

The Librarian As Gerontologist: What Do You Need To Know • How does aging affect one’s health and wellbeing? • What might physicians and other health care professionals be asking you about aging? • What might the public be asking about aging?

AAMC/John A. Hartford Foundation Consensus Conference on Geriatric Competencies: July, 2007 • Rationale: – Almost every graduate of every medical school will be providing care to older adults – Faculty who received little exposure and training in the care for the elderly are uncomfortable teaching geriatrics to students- don’t know where to start – Lists of geriatric curriculum topics exist, but are extensive and imprecise

AAMC/John A. Hartford Foundation Consensus Conference on Geriatric Competencies: July, 2007 • Goal: Consensus on minimum standards for graduating medical students • Input provided by many non-geriatric educators • Results – 8 content domains identified – 26 minimum geriatric competencies identified within these domains

Competency Domains • • Atypical Presentation of Disease Medication Management Cognitive and Behavioral Disorders Falls, Balance, Gait Disorders Self-Care Capacity Health Care Planning and Promotion Palliative Care Hospital Care for Elders

Atypical Presentation of Disease

Acute MI: 30 Day Mortality % Adjusted ORs 2. 00 1. 69 1. 49 1. 21 Ref Adapted from Mehta RH et al. J Am Coll Cardiol 2001; 38: 736 -41

Presentation of MI: Chest Pain 80 70 60 50 40 30 20 10 0 <70 70 -74 75 -79 80 -84 Adapted from Bayer et al JAGS 1986; 34: 263 -266 >85

Painless MI in Patients>70 yrs: Presenting Symptoms Dyspnea Syncope Stroke Confusion Weakness Giddiness Vomiting Sweating Palpitations Bayer et al. JAGS 1986; 34: 263 -266

Atypical Presentation of Disease • Generate a differential diagnosis based on recognition of the unique presentations of common conditions in older adults, including – Acute coronary syndrome – Dehydration – Urinary tract infection – Acute abdomen – Pneumonia.

Compensatory Response to Orthostatic Hypotension 1. Compensate for hypovolemia: – Thirst response – ADH secretion – Increase urine concentration 2. Increase heart rate

Compensatory Response to Orthostatic Hypotension in Elders 1. Compensate for hypovolemia: – Thirst response – ADH secretion – Increase urine concentration 2. Increase heart rate

Atypical Presentation of Disease • Identify at least 3 physiologic changes of aging for each organ system and their impact on the patient, including their contribution to homeostenosis (the agerelated narrowing of homeostatic reserve mechanisms).

Medication Management

Medication Management: Drugs to Watch Out For • Identify medications, including – – – Anticholinergic Psychoactive Anticoagulant Analgesic Hypoglycemic Cardiovascular drugs that should be avoided or used with caution in older adults and explain the potential problems associated with each.

Medication Management • Explain impact of age-related changes on drug selection and dose based on knowledge of agerelated changes in: – renal and hepatic function – body composition, – and Central Nervous System sensitivity.

Why you become a cheaper drunk as you age • As you get older, – Higher blood alcohol concentrations – Worse for women than men – Less tolerance for quantities previously enjoyed • Brain more sensitive • Balance worse even without the alcohol

Common Diseases 65+ 2004 -5 % CDC http: //209. 217. 72. 34/aging/Table. Viewer/table. View. aspx

Medication Management • Document a patient’s complete medication list, including: – prescribed, – herbal and – over-the-counter medications, and for each medication provide the dose, frequency, indication, benefit, side effects, and an assessment of adherence.

Anti-Aging Medicine

Growth Hormone Levels Decline with Age

Growth Hormone • Review of 18 studies (31 publications) • 220 participants; Mean age 69 • Positive Results – Fat Mass decreased 2. 1 kg – Lean Mass increased 2. 1 kg • No change: cholesterol, BMD, other lipids Liu H et al. Annals Int Med 2007; 146: 104 -115

Growth Hormone: Down Side • Increased – Soft tissue swelling – Joint pain – Carpal tunnel syndrome – Breast swelling – New onset diabetes – Impaired fasting glucose Liu H et al. Annals Int Med 2007; 146: 104 -115

Cognitive and Behavioral Disorders

Severe Memory Impairment

Severe Depressive Symptoms

Cognitive and Behavioral Disorders • Define and distinguish among the clinical presentations of delirium, dementia, and depression • Perform and interpret a cognitive assessment in older patients for whom there are concerns regarding memory or function. • Formulate a differential diagnosis and implement initial evaluation in a patient who exhibits cognitive impairment.

Cognitive and Behavioral Disorders • Urgently initiate a diagnostic work-up to determine the root cause (etiology) of delirium in an older patient. • Develop an evaluation and non-pharmacologic management plan for agitated demented or delirious patients.

Falls, Balance, Gait Disorders

I Fall To Pieces $200 % of healthy elders in the community that fall annually A. B. *** C. D. 5% 15% 30% 45%

Falls, Balance, Gait Disorders • Ask all patients > 65 y. o. , or their caregivers, about falls in the last year, watch the patient rise from a chair and walk (or transfer), then record and interpret the findings.

Significant Risk Factors for Falls in Elders • • • Medications Cognitive impairment Lower extremity disabilities Balance and gait abnormalities Poor vision and/or hearing Medical Disorders Previous Falls Level of activity Upper extremity weakness

Multiple Falls vs. Number of Risk Factors Percent with Two or More Falls in One Year Number of Risk Factors* * White, previous falls, arthritis, parkinsonism, difficulty rising, poor tandem gait. Nevitt JAMA, 1989. (n=325)

Falls, Balance, Gait Disorders • In a patient who has fallen, construct a differential diagnosis and evaluation plan that addresses the multiple etiologies identified by history, physical examination and functional assessment.

Self-Care Capacity

Functional Status Impairment

Performance Impairment >70 yos Community-dwellers On feet for 2 hrs; sit for 2 hrs; Reach out to shake hands; Use fingers to grasp or handle; Lift or carry 10#s

Self-Care Capacity • Assess and describe baseline and current functional abilities – instrumental activities of daily living – special senses in an older patient by collecting historical data from multiple sources and performing a confirmatory physical examination.

Functional Status: Activities of Daily Living • ADLs – – – Dressing Eating Ambulation Transfer Hygiene • Bathing • Toileting • Instrumental ADLS – Telephone use – Getting to places beyond walking distance – Grocery shopping – Preparing meals – Housework/handyman work – Taking medications – Managing money

Mobility Disability Women Men 1) Unable to walk up and down the stairs to the 2 nd floor without help or 2) Unable to walk half a mile without help Leveille SG et al. J Gerontology: SOCIAL SCIENCES 2000; 55 B; s 41 -50

Self-Care Capacity • Develop a preliminary management plan for patients presenting with functional deficits, including adaptive interventions and involvement of interdisciplinary team members from appropriate disciplines, such as social work, nursing, rehabilitation, nutrition, and pharmacy.

Self-Care Capacity • Identify and assess safety risks in the home environment, and make recommendations to mitigate these.

Health Care Planning and Promotion

Life Expectancy 2003 Years CDC http: //209. 217. 72. 34/aging/Table. Viewer/table. View. aspx

Health Care Planning and Promotion • Accurately identify clinical situations where – life expectancy – functional status – patient preference or – goals of care should override standard recommendations for screening tests or for treatment in older adults.

Hospital Care for Elders

Adults Over 65 years Old

Outcomes of Acute Care for Older Adults • 31% lose >1 basic ADL at baseline c/w preadmission (see card) – 2/5 of these remained impaired 3 months later • 40% have IADL decline at 3 months

Hospital Care for Elders • Identify potential hazards of hospitalization for all older adult patients including: – Immobility – Delirium – Medication side effects – Malnutrition – Pressure ulcers – Procedures – Peri and post operative periods – Hospital acquired infections and identify potential prevention strategies.

Hospital Care for Elders • Explain the risks, indications, alternatives, and contraindications for indwelling (Foley) catheter use in the older adult patient. • Explain the risks, indications, alternatives, and contraindications for physical and pharmacological restraint use. • Conduct a surveillance examination of areas of the skin at high risk for pressure ulcers and describe existing ulcers.

Acute vs Chronic Disease • Acute – Short duration – Severe Symptomatology – Singular etiology • Infection • Injury • ‘No matter how you pinch and squeeze……” – Goal of care is cure • Return to pre-acute illness functional status • Chronic – Longer duration (>3 -6 months) – Not always symptomatic • Symptoms can exacerbate and remit – Can have multiple etiologies • Diabetes and ASCVD • Frailty – Goal of care is symptom control and maximizing function • Incurable, but ‘manageable’ • Unlikely to return to pre-acute illness functional status • Require ongoing interactions between patients and healthcare team

Hazards of Hospitalization • Chronic disease and function decompensate • Longer hospitalization • Can’t return home without help or subacute admission

Which are reasonable discharge destinations for a patient? Hospital Home with Services Acute Rehab Nursing Home Sub-Acute Rehab

Hospital Care for Elders • Communicate the key components of a safe discharge plan (e. g. , accurate medication list, plan for follow-up), including comparing/contrasting potential sites for discharge.

Managing Chronic Illness • • Adapting to change Mastery and sense of control Social support network Meaning of life and illness

RWJ Chronic Care Model http: //www. improvingchroniccare. org/change/model/components. html

Chronic Care Model • Health System – That promotes safe, high quality care • Delivery System – Assures effective, efficient clinical care and self-management support • Clinical Information Systems – Organize patient and population data to facilitate efficient and effective care • Community resources – Mobilize community resources to meet needs of patients • Self-Management Support – Empower and prepare patients to manage their health and health care • Decision Support – Clinical care that is consistent with scientific evidence and patient preferences http: //www. improvingchroniccare. org/change/model/components. html

The Librarian As Gerontologist: What You Need To Know • How does aging affect one’s health and well being ? • What might physicians and other health care professionals be asking you about aging? • What might the public be asking about aging?

The Librarian as Gerontologist What You Need to Know • High-quality sources of info on: – Demographics of aging – Age-related changes in function – CAM – Geriatric Drug Dosing – Drug Interactions – Community Resources – Patient self-management – Caregiver support

Doris Lessing “The great secret that all old people share is that you really haven't changed in seventy or eighty years. Your body changes, but you don't change at all. And that, of course, causes great confusion. ”

What is Old Age? “To Me, Old Age is always 15 years older than I am” Bernard M. Baruch Oliver Wendell Holmes, Jr.