3Aging

Quality Education

Quality of Life

Quality Care

Aging Q3

Characteristics of the 21st Century Health Care System

• Safe• Effective• Patient-centered• Timely• Equitable• Efficient

Aging Q3 Quality Education

Quality education is focused on learners attaining specific evidence-based knowledge and skills about health care for older adults, and

establishing a positive attitude toward aging and health care for the elderly.

Aging Q3 Quality Care

Quality care is focused on translating knowledge, skills and attitudinal changes into practice,

using effective quality improvement implementation

strategies.

Aging Q3 Quality of Life

Quality of life seeks to demonstrate improved care outcomes, such as maximized cognitive and functional status, reduced prevalence of aging

associated syndromes, and compassionate end of life care.

Table 2. MUSC Internal Medicine Resident self-reported confidence with managing selected ACOVE conditions/issues in Frail elderly.*

ACOVE issue PGY 1 PGY 2 PGY 3 Overall

Continuity of Care 2.5 3.5 3.4 3.2

Dementia 2.0 3.3 3.2 2.9

Depression 3.4 3.9 3.5 3.6

Diabetes mellitus 3.8 4.4 4.7 4.4

End of Life Care 3.0 3.9 4.2 3.8

Falls and mobility 2.7 2.6 3.4 2.9

Hospital care 3.7 3.9 4.5 4.1

Hearing impairment 2.2 2.0 2.2 2.2

Heart failure 3.8 4.2 4.5 4.3

Hypertension 3.8 4.4 4.8 4.4

Ischemic heart disease 3.7 4.4 4.6 4.3

Malnutrition 3.2 3.3 3.5 3.3

Osteoarthritis 3.7 3.7 3.8 3.7

Osteoporosis 3.4 3.5 3.6 3.5

Pain management 3.1 3.9 4.0 3.8

Pharmacologic mgmt. 3.1 3.7 3.9 3.7

Pneumonia / influenza 3.5 4.4 4.4 4.2

Pressure ulcers 2.8 3.1 3.3 3.1

Screening/ prevention 2.5 3.5 3.8 3.5

Stroke/a-fib 2.7 4.0 4.0 3.7

Urinary incontinence 2.5 2.9 2.8 2.8

Vision impairment 2.1 2.5 2.3 2.3

Mean by PGY year 3.0 3.5 3.7 3.5

* Average for italicized conditions is at or below overall mean (1=not confident, 5=very confident, n=39, PGY=post-graduate year). Bold indicates 16 ACOVE conditions included in Aging Q3 program.

Assessing care of Vulnerable Elders (ACOVE)

• Focus on quality of care in elders

• Loss of physiologic reserves make elderly more susceptible to adverse effects of lower quality of care

• Elderly may be more susceptible to side-effects/complications of guideline-based care

Aging Q3: ACOVE areas• End of life care• Falls and mobility• Hospital care• Hearing impairment• Malnutrition• Osteoporosis• Pain management• Pressure ulcers• Continuity of care

• Dementia• Delirium• Depression• Pharmacologic

mgmt• Screening /

prevention• Urinary

incontinence• Vision impairment

Aging Q3 process• Faculty will focus on content• Traditional didactics• Detailing • Nurse assessment communicated to

MDs• Data fields in Practice Partner• Evaluation:

• Survey monkey questionnaires• Patient surveys

“To see or not to see….”

Vision and Aging

Vision and Aging

• Vision related changes occur through life like similar to other physiologic systems

• Vision loss is not normal aging• Vision loss dramatically impacts QOL• Vision loss reduces safety

• MVAs, accidents, falls

• Vision loss leads to social isolation

Causes of Worldwide Blindness• Cataract 17 million

• Trachoma 6.0 million

• Glaucoma 3.0 million

• Xerophthalmia 0.5 million

• Onchocerciasis 0.5 million

• AMD 1.0 million

• Diabetic retinopathy 0.25 million

• Leprosy 0.25 million

• Others 2.5 million

• 85% of blindness is in Africa and Asia

• 85% of cases are potentially treatable or preventable

• Prevalence: • 0.125-0.25% in Western world

• 0.2-1.5% (av 0.75%) in Asia

• 0.3-3.1% (av 1.2%) in AfricaAllen Foster in Clinical Ophthalmology - Duane, ed. (1991)

What is the definition of blindness?

• 20/10 - 20/25: Normal• 20/30 - 20/60: Near-normal• 20/70 - 20/160 : Moderate vision impairment - eligible for education

assistance in US• 20/200 - 20/400: Severe vision impairment - legal blindness in US

(visual field < 20 degrees)• 20/500 - 20/1000: profound vision impairment - WHO and several

European countries definition of blindness (visual field < 10 degrees), CF < 3m

• < 20/1000: Near-total visual impairment: used by some developing countries as definition of blindness (visual field < 5 degrees), HM, LP

• NLP: Total visual impairment

Vision and Aging

• Changes with normal Aging• Vision loss and Aging

• Prevalence• Functional Impact and complications

• Pathologic causes of low vision• Aging-related Macular Degeneration• Cataracts• Glaucoma• Diabetic retinopathy

Eyelid anatomy: Entropion and Ectropion

Ectropion - sagging and eversion of the lower lid

Entropion—turning inward of the lid

Visual Changes with Aging:Pupil

• Pupil Decreases in Size

• Slower Light and Dark Adaptation

Clinical Considerations

• Caution• Rapid Changes in Lighting• Low Light / Night Driving

Visual Changes With Aging :Lens

• Yellowing of the Lens

• Increased:• Scatter• Fluorescence

• Loss of Flexibility / Accommodation

Blue and Yellow less distinguishable

Increased Scatter

Increased Reflections

Presbyopia

Cataract

Central Cataract

Monet: Bridge at Giverny 1899

Adapted from Morley,et al

Monet: Bridge at Giverny 1900

Adapted from Morley,et al

Monet: Bridge at Giverny 1923

Adapted from Morley,et al

Monet: Bridge at Giverny 1923

Adapted from Morley,et al

1899

1923

Adapted from Morley,et al

Adapted from Morley,et al

Cataract Prevention and Treatment

• Avoid Ultraviolet Light• Sun Exposure

• Sunglasses

• Surgery With Lens Implant

Impact of cataract surgery with lens implantation on vision and physical function in elderly patients

W. B. Applegate, S. T. Miller, J. T. Elam, J. M. Freeman, T. O. Wood and T. C. Gettlefinger

We conducted a prospective study of 293 elderly patients undergoing cataract surgery with intraocular lens implantation to determine the impact of the surgery on vision and on subjective and objective measures of patient function. Visual acuity in the surgical eye improved from a mean of 20/100 before surgery to 20/40 four months after surgery; improvement was maintained at one year. Positive changes occurred in some subjective measures of patient function, such as reported activities of daily living and patient report of vision-dependent activities, but these changes were modest. The most marked changes in patient function occurred in objective measures of function. Mental status had improved not quite significantly at four months but significantly at one year. Timed manual performance improved dramatically and significantly at four months and one year. Cataract surgery was associated with improved vision and improved objective function in most patients by four months after surgery, and these improvements were maintained at one year.

Young Adult Older Adult

Retinal Changes

Macular Degeneration

Leading Cause of Blindness in the United States

Leading causes of blindness in Western societies

Age-related macular degeneration

• (aka: AMD, ARM, SMD)• Dry versus Wet • Atrophic versus Exudative

(CNVM)• Most common cause of

blindness• Majority of cases are “dry”

form (>80%), however 88% of those registered as legally blind (in Germany) from AMD had exudative disease.

Macular Degeneration

• Oxidative Damage to the Retinal Pigmented Epithelium

Macular Degeneration:What Helps?

• Green Leafy Vegetables

• Antioxidant Supplements

• Cholesterol Lowering Agents?

Figure 1 (a)Macula Lutea and Ocular Structures with Age-Related

Macular Degeneration (AMD)

JAMA, May 24/31, 2006 – Vol. 295, No 20

Jorge G. Arroyo, MD, MPH

Figure 1 (b)Macula Lutea and Ocular Structures with Age-Related

Macular Degeneration (AMD)

JAMA, May 24/31, 2006 – Vol. 295, No 20

Jorge G. Arroyo, MD, MPH

Figure 1 (c1)Macula Lutea and Ocular Structures with Age-Related

Macular Degeneration (AMD)

JAMA, May 24/31, 2006 – Vol. 295, No 20

Jorge G. Arroyo, MD, MPH

JAMA, May 24/31, 2006 – Vol. 295, No 20

Jorge G. Arroyo, MD, MPH

Figure 1 (c2)Macula Lutea and Ocular Structures with Age-Related

Macular Degeneration (AMD)

Intravitreous Injection

n

Steinbrook, Robert, The Price of Sight – Ranibizumab, Bevacizumab, and the Treatment of Macular Degenderation, The New England Journal of Medicine. Vol. 355 Number 14. October 5, 2006. pp 1409-1414.

87 female admitted with a hip fracture, after tripping over her blind, deaf dog.

Glaucoma• Second Leading Cause of Blindness in

the US

• “Silent”

• Increased Intraocular pressure (IOP)

• Screen every 2 years after Age 50

• Treatment • Topical Medications• Surgery• Oral agents

Glaucoma: Increased

Cupping of the Optic Disc

Normal Abnormal

Circulation of the Aqueous Humor. This anterior segment of the eye shows the circulation of the aqueous humor from the ciliary body through the pupil into the anterior chamber. The aqueous humor then passes through the trabecular meshwork into Schlemm's canal and travels from there into the episcleral venous system. A smaller amount of aqueous humor leaves the eye through the face of the ciliary body, just below the trabecular meshwork.

Optic Disks and Corresponding Visual Fields in a Patient with Primary Open-Angle Glaucoma and a MYOC Mutation.

The Optic-Nerve Head and Proposed Events Leading to Retinal Ganglion-Cell Death in Glaucoma.

Glaucoma: Tunnel Vision

79 year old man in ED with nausea, vomiting and eye pain

• Exam – left eye• reduced vision, conjunctival injection, mild

corneal edema• Fixed, mid-dilated pupil

• Diagnosis?

Closed-angle glaucoma

• Mechanical obstruction of outflow• Common among Asians• Rapid increase in intra-ocular pressure

• Eye pain, nausea, halos around lights• Exam reduced vision, conjunctival hyperemia,

corneal edema• Fixed, mid-dilated pupil• Increased intraocular pressure• Narrow anterior chamber

• Treatment – topical pilocarpine or timolol, IV acetozolomide

Diabetic Retinopathy

cotton wool spots venous loop

Diabetic Retinopathy

Exudates New vessels at the disk

Diabetic Retinopathy

tractional retinal  preretinal  haemorrhage

97 year old woman seen in UIM for weakness for 2 weeks

• mostly when getting up at night - concerned pass out • Diarrhea for 2 days• Daytime symptoms of weakness become less noticeable,• No SOB, PND, mild leg swelling, palpitationsPMH• 1969 MI• 1996 Dx Glaucoma• 2007 fractured left arm

97 year old woman seen in UIM for weakness

• hydrochlorothiazide 25 mg daily • lisinopril 10 mg daily • diltiazem XT 240 mg • Methyldopa 500 mg q.i.d., • aspirin 81 mg daily• lorazepam 1 mg p.o. t.i.d.    • Travoprost eyedrops daily • Cosopt eyedrops twice a day 

97 year old woman seen in UIM for weakness

• BP 146/63 lying 157/76 sitting 

152/63 standing

• Pulse 42

• EKG sinus bradycardia 

• Admitted

97 year old woman seen in UIM for weakness

• hydrochlorothiazide 25 mg daily • lisinopril 10 mg daily • diltiazem XT 240 mg • Methyldopa 500 mg q.i.d., • aspirin 81 mg daily• lorazepam 1 mg p.o. t.i.d.    • Travoprost eyedrops daily • Cosopt eyedrops twice a day 

Other Considerations

• Increased susceptibility to physiologic effects of ophthalmic medications

• Medication Effects on vision• Blurred Vision

• Changes in Color

Van Gough’s Starry Night

Dr Gauchet (Van Gough)

Note Foxglove Plant

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