1 an overview of geriatric health care dr. m.l. donnelly division of community geriatrics...

1

An Overview of An Overview of Geriatric Health Geriatric Health

CareCare

Dr. M.L. DonnellyDivision of Community Geriatrics

Vancouver-Fraser Medical ProgramDepartment of Family PracticeUniversity of British Columbia

2

Today’s ScheduleToday’s Schedule• 1:00 – 2:001:00 – 2:00

– An Overview of Geriatric Health CareAn Overview of Geriatric Health Care• Dr. M.L. Donnelly (VFMP)Dr. M.L. Donnelly (VFMP)

• 2:15 – 3:152:15 – 3:15– local site: Geriatric Health Care resourceslocal site: Geriatric Health Care resources

• VFMP: Dr. M.L. DonnellyVFMP: Dr. M.L. Donnelly• IMP: Dr. David Evans, Clinical Instructor, UBC Dept. of IMP: Dr. David Evans, Clinical Instructor, UBC Dept. of

Family PracticeFamily Practice– Division of Geriatric Psychiatry – VIHADivision of Geriatric Psychiatry – VIHA

» Medical Consultant to Seniors Mental Health and Medical Consultant to Seniors Mental Health and Addictions ProgramsAddictions Programs

• NMP: Dr. Ian SchokkingNMP: Dr. Ian Schokking– Clinical Associate Professor – UBC Dept. Family Clinical Associate Professor – UBC Dept. Family

PracticePractice

3

Asking questions in Asking questions in today’s lecturetoday’s lecture

““4 words or 4 words or less” less”

otherwise otherwise use the mikeuse the mike

4

5

An Overview of An Overview of Geriatric Health CareGeriatric Health Care

1. Demography

2. Normal aging

3. Disability and frailty

4. Values (theirs & ours)

5. Epidemiology

6

An Overview of Geriatric An Overview of Geriatric Health Care (cont’d)Health Care (cont’d)

6. Comprehensive geriatric assessment

7. Caregiver issues

8. Health promotion & prevention for

seniors

7

8

9

Health, illness and disease may overlap, but they are uniquely different facets of experience.Labonte, 1993

10

11

12

13

14

15

Statistic Canada’s 1986 Health Statistic Canada’s 1986 Health and Activity Limitation Surveyand Activity Limitation Survey

• 83% of those 75 to 84 and 89% of those 85+ reported mobility and agility related disabilities

• 47% of those 75 to 84 and 65% of those 85+ reported hearing disabilities

16

17

The CSHA Clinical Frailty Scale

1. Very fit – robust, active, energetic, well motivated and fit; these people commonly exercise regularly and are in the most fit group for their age.

2. Well – without active disease, but less fit than people in category 1

3. Well, with treated comorbid disease – disease symptoms controlled compared with those in category 4.

18

The CSHA Clinical Frailty Scale

4. Apparently vulnerable – although not frankly dependent, these people commonly complain of being ‘slowed up’ or have disease symptoms

5. Mildly frail – with limited dependence on others for instrumental activities of daily living.

6. Moderately frail – help is needed with both instrumental and noninstrumental activities of daily living

7. Severely frail – completely dependent on others for the activities of daily living or terminally ill

19

20

Three Greatest Fears of SeniorsThree Greatest Fears of Seniors

1. Poor health

2. Loss of independence

3. Inadequate income

21

Determinants of IndependenceDeterminants of IndependenceMarshall, 1995

• Health

• Wealth

• Social integration

22

23

Predictors of InstitutionalizationPredictors of Institutionalization

• Availability of long-term care beds• Absence of caregiver• Functional incapacity• Advancing age• Presence of dementia• Recent hospital admission• Physical health deteriorationNote: lack of informal support is main predictor

24

The average age of

admission into a long-

term care facility rose

from 75 in 1977 to 85

in 1997

25

26

Geriatric GiantsGeriatric Giants

1. Delirium2. Dementia3. Depression4. Incontinence5. Falling6. Medications7. Illness interactions8. Atypical presentations in the elderly

27

Incidence of Delirium in the Incidence of Delirium in the Acute Care Hospital >65Acute Care Hospital >65

1988 Francis 25.4% med

1992 Francis 22% med

1995 Chonchubhair 10% elderly gen/sx

20% elderly ortho/sx

1991 Levkoff up to 51% med/sx

28

Canadian Study of HealthCanadian Study of Health and Aging and Aging

Prevalence of DementiaPrevalence of Dementia

29

Common Causes of DementiaCommon Causes of Dementia

• Alzheimer’s disease

• Vascular dementia

• Frontal temporal dementia

• Dementia with Lewy Bodies

• Parkinson’s disease with dementia

30

Prevalence of DepressionPrevalence of Depression

31

32

Typical Altered Presentations of Typical Altered Presentations of Specific Illness in the ElderlySpecific Illness in the Elderly

• Depression without sadness• Infectious disease without leukocytosis,

fever, or tachycardia• Silent surgical abdomen• Silent malignancy (“mass without

symptoms”)• Nondyspneic pulmonary edema• Apathetic thyrotoxicosis

33

34

35

36

Comprehensive Comprehensive Geriatric AssessmentGeriatric Assessment

37

Comprehensive Geriatric Comprehensive Geriatric AssessmentAssessment

• HX• Collateral• Fe• Pex• Msex

38

Comprehensive Geriatric Comprehensive Geriatric AssessmentAssessment (cont’d)

• Functional assessment• Informal supports• Formal supports• DRUG review• Nutritional review

39

Activities of Daily LivingInstrumental ADL Scale

• Ability to use telephone• Mode of transportation• Responsibility of own medications• Ability to handle finances• Shopping• Food preparation• Housekeeping• Laundry

40

Activities of Daily LivingPhysical Self-Maintenance Scale

• Toileting

• Feeding

• Dressing

• Physical ambulation

• Bathing

• Hobbies, leisure activities

41

42

43

Comprehensive Geriatric Comprehensive Geriatric AssessmentAssessment (cont’d)

• Investigations• HOME assessment• Risk assessment• Health prevention/

promotion issues• Advance directives

44

Information obtainedInformation obtained from a home visit from a home visit

• Suitability and safety of home for patient’s functional level

• Attitudes and presence of other persons at home

• Proximity and helpfulness of neighbors and relatives

• Emergency assistance arrangements

45

Information obtained from a Information obtained from a home visit home visit (cont’d)(cont’d)

• Nutritional and alcohol habits• Actual and required daily living skills• Hygiene habits• Safety and convenience

modifications needed• Problems in getting to local

stores and service

picture

46

RISK RISK

47

Comprehensive Geriatric Comprehensive Geriatric AssessmentAssessment (cont’d)

1. Problems

2. Priorities

3. Goals

4. Care Plan

48

Quality of LifeQuality of Life

49

Informal CaregivingInformal Caregiving

• 80% of care provided for seniors is informal care by family and friends

• Government policies shifting care to the community increase caregiver responsibilities

• The majority of informal caregivers are women (most are either the spouse or daughters)

50

Informal caregiving Informal caregiving (cont’d)(cont’d)

• Women find caregiving more stressful than men

• Most caregivers are over 60 themselves and suffer from their own health care problems

• Care for the caregiver” “talk or action”

51

Informal Caregiving Informal Caregiving (cont’d)(cont’d)

• In a US study 52% of caregivers were under significant strain (Marchi-Jones 1996)

• Caregiver groups and education• Respite care

52

Prevention and Health Promotion Prevention and Health Promotion for Seniorsfor Seniors

1. Health Enhancement• exercise• diet• coping skills (eg. stress reduction techniques, assertiveness

skills)• Socialization

2. Risk Avoidance• oral health• driving competency assessments• flu shots, pneumococcal vaccines• powers of attorney, advanced directives, levels of intervention• foot care• falls risk assessment

53

Prevention and Health Promotion Prevention and Health Promotion for Seniors for Seniors (cont’d)(cont’d)

3. Risk Reduction• smoking• alcohol• medication knowledge, management• mobility aids• home safety• sun screens• optimize sensory input (sigh, hearing)• incontinence• osteoporosis management

54

Prevention and Health Promotion Prevention and Health Promotion for Seniors for Seniors (cont’d)(cont’d)

4. Early Identification• pap smears• mammograms• rectal examinations• blood pressure• thyroid status

5. Complication reduction

55

Friend or EnemyI can look

At my bodyAs an old friend

Who needs my helpOr an enemy who frustrates me

In every wayWith its frailty

And inability to cope.

Old friend,I shall try

To be of comfort to youTo the end.

May Sarton, Coming into Eighty

56

Geriatrics Mentoring Group

Interested? Contact Martha Donnelly (

marthad@interchange.ubc.ca) or Jacquie Bailey (jacquie.bailey@familymed.ubc.ca)