This presentation by Alicia I. Arbaje, M.D. was given at the 2010 RWJF Local Funding Partnerships Annual Meeting in St. Paul, MN. Aging is a time of physical, emotional, cognitive, psychosocial and health care transitions that vary in rate and severity from one individual to another. We are actively learning about the way the human brain changes in the later years of our lives. What can older individuals, their families, and our human service organizations do to maintain or improve quality of life as older adults navigate these transitions? This presentation looks at how decisions at times of transition can make the difference between independence and isolation, socialization and loneliness, maintaining vigor and declining health. It will focus on how best practices may be influenced by rural or urban locations, economic status and nonprofit versus commercial interests. We will also look at issues related to housing, physical activity, recovery from loss or illness and intergenerational relationships.forth
Transcript of The Aging Brain: Maturity & Making Health Transitions
The Aging Brain: Maturity & Making Health Transitions
Alicia I. Arbaje, MD, MPHAssistant Professor of MedicineAssociate Director of Transitional Care ResearchDivision of Geriatric Medicine and Gerontology
Learning Objectives• Understand demographics and special
needs of older adults
• Discuss the 3 “D’s” of the aging brain—Dementia, Depression, Delirium
• Discuss experiences from graduating programs
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Mary• 81 years old
• Completed 8th grade
• Cares for husband with dementia
• Daughter lives 20 miles away
• Six chronic conditions
• Four physicians
• Nine medications
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Presenter
Presentation Notes
Allow me to introduce to you Ms. Mary… Bridge: As you can see, Mary has a complex physiology, a complex medical regimen, and a complex social situation.
During the past 6 months…
Multiple settings
• 3 hospitalizations• 2 rehabilitation
stays
Several providers
• 8 physicians• 25 nurses• 7 therapists
Changes to plan of
care
• 4 medication lists• 3 new
prescriptions
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Presentation Notes
Then we add a complex health care system. 3 hospitalizations for exacerbations of her CHF in the setting of poorly controlled DM and old CVA. These have required 6 weeks of rehabilitation in 2 different facilities During this time, she has been seen by numerous providers in each setting, and she has undergone various changes in her plan of care. Meanwhile, it is likely that her primary care physician is not aware of these changes. Bridge: Now you can see why some older adults are heavy users of the system and have higher costs. Now I will talk about why they do worse.
Increasing Number of Older Adults 5
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Presentation Notes
This chart for Indicator 1 - Number of Older Americans shows the large growth of the population 65 and older from 1900 to 2008 and the even greater projected growth from 2008 to 2050. It also shows the growing numbers of persons 85 and older and their large projected growth to 2050.
Where Older Adults Live 6
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Presentation Notes
This map chart for indicator 1 - Number of Older Americans – shows the percentage of persons 65 and older by county. The highest percentages are in rural areas of the central and western part of the country, some areas of the eastern states, and Florida.
How Older Adults Live 7
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This chart for Indicator 5 - Living Arrangements – shows that most men over 65 live with spouses (72 percent), although there are racial and ethnic variations. Only 19 percent of older men live alone. However, only 42 percent of women 65 and over live with spouses and 40 percent live alone. There are also racial and ethnic differences among older women.
Sensory Impairments and Oral Health 8
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Presentation Notes
This chart for Indicator 17 - Sensory Impairments and Oral Health – shows that in 2008 42 percent of men and 30 percent of women reported any trouble hearing; 15 and 19 percent respectively reported any trouble seeing, and 24 and 27 percent respectively report that they had no natural teeth.
How Do Older Adults Spend Their Time? 9
Presenter
Presentation Notes
This second chart for Indicator 28 - Use of Time – shows that in 2008 watching TV was the activity that occupied the most leisure time—about one-half the total—for Americans age 55 and over. Americans age 75 and over spent a higher percentage of their leisure time reading (14 percent versus 9 percent) and relaxing and thinking (10 percent versus 5 percent) than did Americans age 55–64. The proportion of leisure time that older Americans spent socializing and communicating—such as visiting friends or attending or hosting social events—declined with age. For Americans age 55–64, 13 percent of leisure time was spent socializing and communicating compared to 9 percent for those age 75 and over.
Residential Services 10
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Presentation Notes
This first chart for Indicator 36 - Residential Services – shows that in 2007, 2 percent of the Medicare population aged 65 and over resided in community housing with at least one service available. Approximately 4 percent resided in long term care facilities. The percentage of people residing in community housing with services and in long-term care facilities was higher for the older age groups; among individuals age 85 and over, 7 percent resided in community housing with services, and 15 percent resided in long-term care facilities. Among individuals age 65–74, 98 percent resided in traditional community settings.
Residential Services 11
Presenter
Presentation Notes
This second chart for Indicator 36 - Residential Services – shows that People living in community housing with services had more functional limitations than traditional community residents, but not as many as those living in long-term care facilities. Forty-six percent of individuals living in community housing with services had at least one activity of daily living (ADL) limitation compared with 25 percent of traditional community residents. Among long-term care facility residents, 83 percent had at least one ADL limitation. Thirty-six percent of individuals living in community housing with services had no ADL or instrumental activities of daily living (IADL) limitations.
Older Adults Are Different• More chronic conditions• More medications• More healthcare providers• More hospitalizations• More susceptible to diseases• More difficult to diagnose• More sensitive to medications• More sensitive to changes in their environment
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CHF
Stroke
DM
Functional decline
COPD
Stroke
Older Adults are Heterogeneous
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Presentation Notes
One reason is that older adults are heterogeneous. Just like 80-90 years ago, pediatricians argued that children were not small adults, geriatricians point out that older adults are different from younger adults and from each other in their internal physiology as well as in their abilities to recover from illness. They each have an individual cluster of conditions that interact with each other in different ways. The challenge for caring for Mary and other older adults is that treating one condition often affects the state of another condition. For example, Mary and her husband both have a history of stroke, but with her husband, the stroke and subsequent cognitive impairment combined with COPD lead to functional decline as his overarching problem. Treatment for him focuses on cardiovascular risk reduction, occupational and physical therapy for functional decline. He is not on warfarin for anticoagulation because of his frequent falls. The focus for Mary is on cardiovascular risk reduction, including anticoagulation, and careful titration of her volume status for her CHF. Bridge: This complexity makes it difficult to apply a clinical guideline across the board to older adults.
Common Geriatric Syndromes
• Confusion
• Constipation
• Delirium / hallucinations
• Depression
• Dizziness
• Drowsiness / fatigue
• Falls and fractures
• Incontinence
• Insomnia
• Loss of coordination
• Malnutrition/dehydration
• Memory loss
• Pain
• Vision/hearing problems
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Common Consequences• Decreased quality of life• Emergency room visits• Hip fractures and other physical disabilities• Hospitalization• Loss of functional ability• Loss of independence• Nursing facility placement• Death
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Where Do They Receive Care?• Across all aspects of the care continuum▫ Emergency department▫ Hospital▫ Rehabilitation facility▫ Nursing home▫ Ambulatory care clinic▫ Hospice▫ Home
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Transitional Care
• A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location.▫ Logistical arrangements▫ Patient/caregiver education▫ Coordination among the health professionals
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Brought to you by the letter D.
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The 3 D’s in Older Adults
• Common
• Difficult to seek help due to social stigma
• Difficult to diagnose
▫ Symptoms similar to other conditions
• Difficult to treat
▫ Take longer before seeking treatment
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What Can You Do to Impact the Brain?
• Connect older adult to the social environment
• Help deal with “retirement blues”, especiallymen
▫ Activities, hobbies, senior center
▫ Counseling
• Exercise! Just as good as medication.
• Volunteer! Can actually remodel the brain.
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What Can You Do to Impact the Brain?
• Treatment of underlying medical conditions
▫ Caveat: not too little, not too much (HTN, DM)
▫ Prevention of delirium
• Adequate nutrition
▫ Hydration
▫ Vitamin D
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Summary• Older adults have special needs from the
community
• The 3 D’s are common and can impact the success of your program
• There are several targets for intervention
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Questions for Group• How did you deal with transitions in leadership?
• How has the economy impacted your program?
• How are you reaching out to the “younger” old?
• What is the importance of data?
• What are your plans for sustainability?
• How do you help older adults feel like there are