Age in a Graying America

Question 1

Why we have a gray crisis

Answer 1

• Improved life expectancy
• Decrease in birth rate
• Public health improvements
  
  • Antibioitics
  • Vaccination
  • Decrease in cardiac deaths

Question 2

Life expectancy

Answer 2

• 1900 à 47.3
• 1950 à 68.2
• 2000 à 77
• 2017 à 78.5

Question 3

Life expectancy at age 65

Answer 3

• 1900 –> 11.9
• 1950 –> 13.9
• 2000 –> 18.2
• 2017 –> 19.3

Question 4

Those over 85yo

Answer 4

• 1995 –> 1.4 %
• 2030 –> 2.4 %

Question 5

Baby boomers

Answer 5

• 2010-2050 we will double the number of people of 65 years old
• By 2050, 30% of the population will be over 65yo, 82.5 million people

Question 6

Biology of aging

Answer 6

• 2 key theories
  
  • Genetic predisposition
  • “wear and tear”
• Rule of fourths
  
  • ¼ disease
  • ¼ disuse
  • ¼ misuse
  • ¼ physiology

Question 7

Characteristics of aging

Answer 7

• Increased mortality with age after maturation
• Biochemical composition of tissues changes with age
• Physiological capacity decreases
• Decrease in response to environmental stimuli
• Increased vulnerability to disease
• Epigenetics

Question 8

Age-related physical changes

Answer 8

• Blood pressure regulation: orthostasis
• Volume regulation: dehydration
• Thermoregulation: generally colder
• Impaired immune response: increased infection

Question 9

Age related sensory changes

Answer 9

• Vision: reduced lens elasticity
• Hearing: increase vestibular sensitivity, reduced acoustic sensitivity
• Taste: reduced
• Smell: reduced
• Touch: reduced reflex

Question 10

age related physical changes

Answer 10

• Heart: max hr 195 as adult reduces to 155 as geriatric
• Skin: reduced elasticity
• Kidneys: reduced by 50% perfusion
  
  • Important because we give medications that are cleared renally or are toxic to the kidney
• GI: reduced peristalsis/secretions

Question 11

Diminished reserve

Answer 11

• Physiological examples
  
  • Pulmonary capacity
  • Renal clearance 1/10 of pop: CKD, 8^th cx of death
• Clinical examples
  
  • Increased sleep requirement
  • Decreased calorie needs (less activity)
  • Skin alterations that results in decreased protection
  • Nocturia

Question 12

Brain atrophy

Answer 12

• CT brain sections
• Loss of brain parenchyma
• Enlargement of ventricles
• Widened sulci

Question 13

Bones and aging

Answer 13

• AP hand
• Not normal bone density and trabecula
• Ostophyte à bone spur (frayed edge)

Question 14

Osteoporosis

Answer 14

• Thinned cortex from inside out
• Scanty trabecula

Question 15

Congestive heart failure

Answer 15

• PA chest
• LEADING CAUSE OF DEATH
  
  • Blood pressure increase, valve degeneration, infection in the heart
  • If the blood backs up in the R side of the heart, you get lower leg edema (pitting), hepatomegaly and splenomegaly
• Interstitial pulmonary edema
• Cardiomegaly –> often reported on chest x ray which is suggestive of CHF
• Redistribution of pulmonary blood to upper lungs
• Indistinct hilar margins and blurring of pulmonary vessels
• Kerley B lines at costophrenic angles
• Increased central interstitial markings

Question 16

Consequences

Answer 16

• Atypical presentation of disease
• Failure of occam’s razor
  
  • Among competing hypothesis, the one with the fewest assumptions should be selected
  • i.e. seldom is a single unifying diagnosis possible, i.e. assume things are multifactorial
• decreased physiological compensation
• increased risk of iatrogenic (3^rd leading cause) consequences of illness (polypharmacy, d/t increased problem list)

Question 17

Leading causes of death 2017

Answer 17

• Heart disease
• Cancer
• Iatrogenic
• COPD
• Accidents
• CVA
• Dementia
• Diabetes
• PNA
• CKD
• Suicide

Question 18

Prevention of aging

Answer 18

• Disengagement
  
  • Let go of trappings of earlier life
  • Popular driver of retirement communities of the 50s-80s
• Activity
  
  • Stay active and fit to stay young
  • Much more prevalent today
  • Still less integration in community

Question 19

Elders and the health care system

Answer 19

• PCPs and elders
  
  • Benefits of continuity:
    
    • Much easier to see changes over time
  • Improved preventive services
    
    • Flu and pneumonia vaccination
    • Herpes zoster vaccination
    • Osteoporosis prevention

Question 20

Screening

Answer 20

• Breast CA:
  
  • Bienneal mammography 50-74yo
  • > 75 no evidence
  • No manual breast screening > 40?
• Colon CA:
  
  • FOBT (fecal occult blood test), sigmoidoscopy or colonoscopy annual 50-75yo
  • Not routine 76-85yo
  • No screening >85yo
  • Edematous polyps 90% premalignant for 5-10 years
• Cervix and prostate
  
  • No screening over 65yo
    
    • Eg no PAP or PSA
  • Exception is if female has never had a pap the no pap if there are 2x negative paps

Question 21

Flaws in the care of elders

Answer 21

• Agism
  
  • Eg: withholding rx or intervention 2/2 age
  • Lack of respect of cognition
• Failure to recognize acute change of mental status (continuity vs baseline)
• Poor communication from setting to setting (emr, polst, fu)
  
  • Hospitalists
  • Specialists
  • Long-term care
• Failure to utilize critical team members:
  
  • Pharmacy
  • Rehabilitation
    
    • Physical therapy
    • Occupational therapy
    • Speech therapy
  • Nutrition
• Failure of providers to accept medicare/medical
  
  • Eg: coverage of PT/OT
• Medicare
  
  • Difficult to navigate
  • Medicare D: prescription drug coverage

Question 22

Diagnosis vs treatment

Answer 22

• Looking for a solution to disease
• Quality of life
• Risks versus benefits
  
  • Eg coumadin/anticoagulation
• Polypharmacy
  
  • >65yo 13% of population but 33% of Rx
  • Majority of 65yo plus have over 5 rx

Question 23

Iatrogenic disease: 3rd leading cause of death

Answer 23

• ADE: side effects vs intended effects
  
  • 1/3 of 65 and older have had ADE
• AKI: 2/3 of pt over 65 yo and 7-10% of those hospitalized have had AKI
• Reduced surgical outcomes across the board
• Careful what you look for!
• Send to a specialist… or not?
  
  • Falls: neuro (hydro) cards (arrhythmia), ortho spin (stenosis)

Question 24

Difficulties in geriatric medicine

Answer 24

• The demographic burden: ethnic, cultural and socioeconomic
• The medical perspective
  
  • Different diseases
  • Different presentation of diseases
  • Different treatment needs of older patients
  • Multiple concurrent chronic diseases

Question 25

Diversity issues from a geriatric medicine perspective

Answer 25

• California diversity
• Elder diversity:
  
  • Young old versus 85+
  • Singles versus couples
  • Fit versus disabled
  • Independent living versus institutional
  • $ secure versus $ worried
  • Cognitively fit versus impaired

Question 26

Age bias and medicine: a multi-issue problem

Answer 26

• Training
  
  • Lack of training to manage multi-problem patient
  • Lack of training to manage psychosocial issues
• Time
• Communication issues
  
  • Sensory (diminished hearing, vision and speech)
  • Cognitive reliability
• Reimbursement: ~60%

Question 27

TB and the elderly

Answer 27

• Common, especially in long-term care
• Seek history of prior disease and immune limitations
• Screening
  
  • PPD x 2
  • Blood
  • CXR
  • Check for weight loss, fever, night sweats