THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.

1. ! See Slides: 12,13,14,15,17,18,22,29,35,36,52,53! What Every Ophthalmologist Needs to Know about GeriatricsAndrew G. Lee, MDChair of OphthalmologyThe Methodist Hospital, Houston, TX Professor of Ophthalmology, Neurology, and NeurosurgeryWeill Cornell Medical College AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.

2. Objectives • Discuss scope of the problem (demographic shift disproportionately affects ophthalmology) • Describe comorbidities in elderly • Depression • Dementia • Hearing loss • Fall risk and prevention • Elder abuse • Screening tips for elderly eye patients

3. Geriatrics as a model for the ACGME Competencies in Ophthalmology • Unique needs of geriatric patients in medical knowledge & patient care domains • Professionalism (avoiding ageism) • Communication skills (teaming with caregivers and primary care, dealing with hearing loss and dementia) • Practice-based learning (age-specific evidence) • Systems-based practice (nursing home, comorbidities, fall prevention)

4. Competencies • Patient care • Medical knowledge • Professionalism • Communication and interpersonal skills • Practice-based learning • Systems-based practice

5. THE COMPETENCIES ALIGN WITH EVOLUTION OF DOCTOR-PATIENT RELATIONSHIP • Doctor-patient • Doctor-patient • Patient-doctor • Patient-doctor • Person-doctor • Person-person • Practice-based learning • Medical knowledge • Patient care • Systems-based learning • Communication • Professionalism Slide 5

6. Case-based learning • Case vignettes to emphasize key points • Platform for discussion of competencies • Ophthalmologists do not have to be geriatricians but need to recognize specific geriatric syndromes

11. Geriatric patients are NOT just older adults • Different responses to disease & treatment • Different systems-based issues (transportation, mobility, comorbidities) • Different communication needs (hearing loss, dementia, depression, nursing home) • Different effects on functional outcome

12. Case vignette • A 75-year-old man is brought in by his family for “poor vision” • Only says very slow “yes” or “no” to questions • Blunted affect & seems withdrawn • 3 ophthalmologists said “he’s just getting older” • Geographic atrophy retinal pigment epithelium • Barely able to give visual acuity of 20/70 OU, constricted visual field OU, slow responses

13. Competency issues • Medical knowledge • Patient care • Communication skills • Professionalism • Practice-based learning • Systems-based practice ???

15. Screening for depression • Geriatric Depression Scale (15 items) • “Do you feel sad or depressed often?”

16. IMPORTANT RISK FACTORSFOR SUICIDE INDEPRESSED ELDERLY PATIENTS • Greater severity of depression • Symptoms of psychosis • Alcoholism • Abuse of sedatives • Recent loss or bereavement • Recent development of disability • White male • Age over 80 Apfeldorf et al. Principles of Geriatric Medicine and Gerontology. 5th ed. New York: McGraw-Hill, Inc; 2003: 1443-1458.

17. Depression & VISION lossin THE elderly • Elderly patients with depression may present with vision loss (or other somatic symptoms) • Depression is a common comorbidity with vision loss (vision loss can cause depression) • Depression is under-recognized in the elderly • Depression in elderly may lead to suicide • Screening by ophthalmologists might help to identify patients at risk • Depression is NOT a normal part of aging

18. Outcome • Patient responded yes to screening depression question (“Do you feel sad or depressed often?”) • Referred to primary care service • Underwent counseling & pharmacotherapy for depression • Returned to ophthalmologist “a different man” • 20/20 OU! Full Goldmann visual field OU

19. Case vignette • 65-year-old woman with age-related macular degeneration • Lives in nursing home and doesn’t hear very well • During exam, she seems very hard of hearing • Technician has to shout to get any response • ARMD at 20/200 level OU • She is told “nothing more can be done”

20. Competency issues • Medical knowledge • Patient care • Communication skills • Professionalism • Practice-based learning • Systems-based practice ???

21. Hearing loss • Hearing loss = common comorbidity with vision loss in elderly • Combination deficits worse than either alone • Hearing loss makes it more difficult to test visual acuity • Hearing loss makes it difficult to obtain the history (tempting to give up) • Many forms of hearing loss are amenable to treatment

22. Outcome • Hearing assessment with hearing aids • Amazingly, her affect & mood improved • She became more engaged & active • She wrote a wonderful thank-you note to her ophthalmologist for referring her for hearing aids

23. Case vignette • A 66-year-old college professor is brought in by his wife • Chief complaint: “He cant see” (patient is asymptomatic) • 20/20 OU • Normal eye exam • 10 pairs of glasses over last 4 months

24. Competency issues • Medical knowledge • Patient care • Communication skills • Professionalism • Practice-based learning • Systems-based practice ???

25. What can’t he see? • Doesn’t see road signs (wife won’t drive with him anymore) • Loses place in lecture (he is tenured) & students complain that he rambles in class • Used to write the checks & do the bills but gets confused and writes “date” in “amount” line • Gets lost easily on way to class • No one wants to tell him because he holds a named professorship & is chair of his department

26. CLOCK DRAW FOR DEMENTIA Instructions to patient: • Draw a clock • Put in time in numbers (1 through 12 o’clock) • Draw hands at 11:10 AM Slide 26

27. WHEN TO DO CLOCK DRAW TEST • Brought in by spouse • “Can’t read” despite many new glasses & 20/20 OU • Homonymous hemianopsia with negative neuroimaging • Loss of executive function & memory (visual variant of Alzheimer’s disease) Slide 27

28. Dementia & VISION loss • Vision loss may worsen dementia symptoms (analogous to “sundowning”) • Vision loss may be presenting sign of Alzheimer dementia (visual variant) • Dementia = common comorbidity with vision loss in elderly • Clock draw = easy & fast screening test • Treatment may slow progression of dementia (earlier recognition is better)

29. Case vignette • 70 y/o woman with Fuchs’ corneal dystrophy • 20/80 OU Stable • Glaucoma on 3-drop therapy Stable IOP • Glaucomatous cups 0.9 OU Stable • Glaucomatous field loss OU Stable • S/P PKP OU clear grafts OU Stable • S/P CE/IOL OU Stable • Frequent falls (2x in 3 months) Not stable!

30. Visual risk factors for falls • Decreased visual acuity • Glare • Altered depth perception • Decreased night vision • Loss of peripheral visual field

31. I―Inflammation of joints (or joint deformity) H―Hypotension (orthostatic blood pressure changes) A―Auditory and visual abnormalities T―Tremor (Parkinson's disease or other causes of tremor) E―Equilibrium (balance) F—Foot problems A―Arrhythmia, heart block or valvular disease L―Leg-length discrepancy L―Lack of conditioning (generalized weakness) I—Illness N―Nutrition (weight loss) G―Gait disturbance I HATE FALLING Sloan JP. Mobility failure. In: Protocols in primary care geriatrics. New York: Springer, 1997:33-8. Slide 31

32. Falls are bad in elderly • Falls = leading cause of injury deaths & disabilities among persons aged >65 years • US: 1 in 3 older adults falls each year • 1997: 9,000 (aged >65 years) died from falls • 20%-30%: moderate to severe injuries that reduce mobility & independence • Hospitalized for falls 5x more than for other causes • Women: 3x more likely than men to be hospitalized for a fall-related injury

33. Falls & fractures • 19881996: hip fx increased from 230,000 to 340,000 • Hip fracture hospitalization rates are substantially higher for white women • Cost of hip fracture: $16,300$18,700 • 1991: hip fractures = $2.9 billion for Medicare • Could reach $82 billion$240 billion by 2040

34. Fall rate per 100,000 PEOPLE MMWR 2006

35. Take-home messages • Vision loss increases risk for falling • Ask about falls • Fall prevention is superior to fall treatment • Fall  fracture  hospitalization  loss of mobility & independence  nursing home or death • Fall checklist for all vision-impaired elders • Stable eye exam ≠ stable patient (Unstable patient at risk for falls)

36. Case vignette • 75-year-old woman with Alzheimer’s disease • She is brought in by her pastor (but son has power of attorney) for “falling” & hitting her eye • She has ecchymoses OD, a hyphema, and a retinal detachment OD • She appears disheveled & unkempt • Pastor is concerned about her health • The patient tells you she is afraid to go home

37. Competency issues • Medical knowledge • Patient care • Communication skills • Professionalism • Practice-based learning • Systems-based practice ???

38. Case vignette • When you call the son regarding your concerns, he tells you to “mind your own business” • Son tells you that he is in charge of his mother and how he treats her is his own business • The pastor feels that she might be neglected or the victim of abuse, & he believes the son might be taking her Social Security check

39. Elder abuse (umbrella term) • Physical abuse: inflict or threat to inflict harm • Sexual abuse: non-consensual sexual contact • Emotional or psychological abuse: verbal or nonverbal • Exploitation: financial or material • Neglect: refusal or failure to provide food, shelter, health care, or protection • Abandonment: desertion of a vulnerable elder

40. http://www.ruralhealth.utas.edu.au/padv-package/module2-5.htmlhttp://www.ruralhealth.utas.edu.au/padv-package/module2-5.html

41. http://www.ruralhealth.utas.edu.au/padv-package/module2-5.htmlhttp://www.ruralhealth.utas.edu.au/padv-package/module2-5.html

42. Reporting elder abuse • Legislatures in all 50 states have passed some form of elder abuse prevention laws • All states have set up reporting systems • Adult protective services (APS) investigates reports of suspected elder abuse

43. Elder abuse:a growing problem • 19.7% increase in reports from 2000–2004 • 15.6% increase in substantiated cases from 2000–2004 • Two in 5 victims (42.8%) are >80 years

44. Take-home messages • Beware elder abuse • As in child abuse, suspect if story doesn’t match • Adult Protective Services = equivalent of Child Protective Services • Physical abuse is not the only type of abuse • Neglect is a form of abuse

45. Summary (1 of 2) • Demographic shift disproportionately affects ophthalmology • Geriatric patients are not just older adults • ACGME competencies (model for implementation) • Recognize, triage, & refer comorbidities in the elderly • Depression • Dementia • Hearing loss

46. Summary (2 of 2) • Screening tips for elderly ophthalmology patients • Whether they look depressed or not, ask about depression • If you have to shout, they need a hearing assessment • Clock draw test for dementia • If they have fallen or are at risk of falling, provide fall checklist • Think about elder abuse (especially if story doesn’t add up)

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