The Aging Adult
Practicing
Primary Care Geriatrics
Introduction
Introduction
- In
the late nineteenth century, Kaiser Wilhelm chose the age of “three score
and five” to identify Prussians who qualified for “old age” benefits.
- Now,
more than a century later, it is the norm rather than the exception among
Western populations to reach that age.
- Yet
our culture clings to the concept that the sixty-fifth year marks the end
of productivity and the beginning of decrepitude.
- In
truth, the modern equivalent of Kaiser Wilhelm’s three score and five is
probably around 80 years of age.
- When
we think about older populations, we should divide them into two groups:
- The
relatively healthy elderly, more of whom are between the ages of 65 and
80 and whose health care needs are not very different from those persons
of late middle age
- The
frail elderly, most of whom are 75 years and older and require special
monitoring and services
Practicing Primary Care Geriatrics: Priorities of Care
·
Respond to
patient’s concerns/ presenting problems
·
Monitor
known health problems (DM, HTN, CHD, osteoarthritis, dementia, depression)
·
Health
maintenance and disease prevention
·
Monitor
psychological status, living situation, sources of social support
Prevalent issues among the elderly
Geriatrics differs from traditional internal medicine because it emphasize
certain issues that are more prevalent among the elderly than among younger
persons. These issues include:
·
Broad
syndromes such as confusion,
falls, dizziness, dysmobility, and incontinence;
·
A high
prevalence of disability;
·
With a
concomitant need to maintain a rehabilitative focus; and
·
An
ever-present concern about iatrogenesis
Underlying all of these issues is the presence of multiple problems, and
the frequent presence of multiple causes for each problem
Office Visits:
Principal Reasons
AGE 65-74
·
Postoperative
visit
·
General exam
·
Vision
dysfunction
·
Glaucoma
·
Cough
·
Diabetes
·
Back
symptoms
·
HTN
AGE 75+
·
General exam
·
Vision dysfunction
·
Postoperative
visit
·
Glaucoma
·
BP check
·
Cough
·
Cataract
·
Vertigo/dizziness
Most Common Final Diagnoses
AGE 65-74
·
Essential
HTN, DM
·
Glaucoma,
Cataract
·
Heart
disease
·
Osteoarthritis
·
Dermatoses
·
Cardiac
dysrhythmia
·
Lipid
disorders
·
Bronchitis
AGE 75+
·
Essential
HTN
·
Glaucoma,
Cataract
·
DM, Heart
disease
·
Osteoarthritis
·
Cardiac
dysrhythmia
·
Organ
replaced
·
Dermatoses
·
Heart
failure
Demographics
- Since
the turn of the last century, the absolute number of Americans,
and older Americans in particular, has increased considerably: an increase of 10 times the number of
individuals over 65 and a tripling of the % of Americans who are over 65.
- By
the year 2000, 13% of the US
population was over 65, but only 30 years later, 20% of the population
will be over 65.
- This
particularly rapid increase in older Americans between 2010 and 2030 will
occur because those persons in the “baby-boom” generation will be reaching
age 65.
- The
growth of the older population was a little slower in the 1990s because of
the reduced birth rate during the Depression of the 1930s.
- In
total, by 2030, there will be twice as many individuals over 65 as
there were in 1990.
Terms
- “Young
Old” = ages 65-74
- “Middle
Old” = ages 75-84
- “Old Old” = age 85+
From 1985-2000, the over-85 population doubled in absolute number…much more
likely to be ill, frail, or dependent.
Why? Increased life expectancy.
Current life expectancy at age 65 is about 19 years for a woman and 15
years for a man.
- Gender: Older men are twice as likely to be
married as older women, and half of older women are widows.
- Living
arrangements: 68% of older
people not living in an institution live in a family setting; 30% live
alone
- The
proportion of older individuals living in nursing homes increases with
age: in 1990, 1% of those aged
65-74, 6% of those aged 75-84, and 24% of the 85+ group lived in nursing
homes
- Income
and Poverty: One in five elders
are poor or near poor. The poverty rate is double in women.
- Ethnic
diversity: Whereas in 1990
approximately 13% of those over 65 were minorities, by 2030 one in 4
elders will be a minority
- Geography
of old age: Certain states have
a higher population of elders
o
States with > 14% >65 yrs.
1.
Florida (18.6%)
2.
Pennsylvania (15.8%)
3.
Iowa
4.
Rhode Island
5.
West Virginia
6.
Arkansas
7.
North and South Dakota
o
States with the Most Individuals > 65 yrs.
1.
California (> 3 million)
2.
Florida, New York
(> 2 million)
3.
Pennsylvania, Texas, Ohio,
Illinois, Michigan,
New Jersey
(> 1 million)
Health and
Functionality: Most Common Chronic Conditions
in Elderly (1992)
o
Arthritis
o
HTN
o
Heart disease
o
Hearing impairment
o
Orthopedic impairment
o
Cataracts
o
Sinusitis
o
Diabetes
o
Tinnitus
o
Visual impairment
Normal Aging
Only by listening carefully to the patient’s personal life history can
you learn who the patient is, what he or she values, and how health care
providers can best relate to the person.
In response to the times in which its members have lived,
each generation carries with it distinctive attitudes and health patterns.
- For
example, even when they were younger, the elderly of today have tended to
take fewer financial risks and to express depressive symptoms less often
than succeeding generations. Such
differences between generations are termed cohort effects.
Aging is a process that gradually leads to noticeable
changes in many body systems. In the
past, considerable decline in major body systems was attributed to normal
aging. However, it has become
increasingly apparent that much of what was previously ascribed to aging is the
result of disease or disuse.
Rule of Thirds:
Of changes in physiological function observed with advancing age:
o
1/3 due to disease
o
1/3 due to disuse
o
1/3 due to normal aging
Skin Changes
o
Wrinkling
o
Decreased subcutaneous support
o
Hair loss and graying
o
Increased frequency of benign and malignant skin
conditions
Sexuality and Aging
o
Physical responsiveness and ability to perform
sexually diminish
o
Thinning of vaginal mucosa and diminished vaginal
secretions
o
Erectile dysfunction (ED)
Cardiovascular System
o
BP tends to rise
o
Contractile function declines
o
Cardiac reserve diminishes
Pulmonary System
o
Physiological reserves are so great that aging
alone rarely leads to significant impairment
Urinary System
o
Peak bladder capacity reduced
o
Amount of residual urine increases
o
Renal blood flow nearly halved
o
Renal tubules less able to concentrate urine
o
Prostatic hypertrophy
o
Creatinine clearance decreases
Gastrointestinal System
o
Dental changes
o
Peristalsis is diminished
o
Reduced gastric acid secretion
Musculoskeletal System
o
Average loss of 2 inches between ages 40 and 80
o
Decline in bone density
o
Osteoarthritis
Neurological System
o
Cerebral blood flow reduced by 20%
o
Brain weight reduced by7%
o
Declines in performance measures (handwriting
speed, hand grip strength, vibratory sensation, foot reaction time)
Special Senses
o
Presbyopia
o
Reduced contrast sensitivity
o
Impaired adaptation to darkness or daylight
o
Delayed recovery from glare
o
Modest lens opacification
o
Presbycusis
Others
o
Host defenses against infection are decreased
o
Changes in sleep patterns
Social/Psychological Losses
o
Retirement
o
Death of spouse/close family member
o
Children moving away
o
Friends dying, becoming disabled, or moving away
o
Moving into an apt./retirement
home
o
Inability to socialize due to sensory or physical
impairments
Laboratory Tests and Aging
o
Postprandial blood sugar (40% rise)
o
Serum cholesterol in women (17% rise)
o
ESR (>100% rise in men and >170% rise in
women)
o
Serum T3 (20% fall)
Typical Altered
Presentations
o
Depression without sadness
o
Silent malignancy
o
Infectious disease without leukocytosis,
fever, or tachycardia
o
Silent surgical abdomen
o
MI without chest pain
o
Nondyspneic pulmonary edema
o
Apathetic thyrotoxicosis
Principles of
Geriatric Primary Care
o
Accessibility
o
Comprehensiveness
o
Coordination
o
Continuity
o
Accountability
o
Clinical alertness
o
Advocacy
o
Integrating family
o
Emphasize function
o
Accurate diagnosis
o
Serial observation
o
Avoid harm
o
Set clear goals
o
Allow time
o
Postpone dependency
o
Communication
Preventive
Screening
o
BP
o
Mammogram
o
Breast exam
o
Pap smear
o
Tetanus/diphtheria
o
Pneumococcal immunization
o
Hearing test
o
Vision screen
o
Dental examinations
o
Smoking history and education
o
Weight education
o
Diet history and education
o
Physical exercise education