Principles of Aging PDF

Principles of Aging Clinical Sciences IV Geriatrics Paul B. Volker, MD, FAAFP Assistant Professor Dept. of Osteopathic Clinical Medicine 29 March 2024 Disclosures 29 March 2024 Volker Prinicples of Aging 2 Principles of Aging Outline Biology Demographics The Four (or Five) Ms – – – – (Multimorbidity...

Principles of Aging Clinical Sciences IV Geriatrics Paul B. Volker, MD, FAAFP Assistant Professor Dept. of Osteopathic Clinical Medicine 29 March 2024 Disclosures 29 March 2024 Volker Prinicples of Aging 2 Principles of Aging Outline Biology Demographics The Four (or Five) Ms – – – – (Multimorbidity) Medication (polypharmacy) Mentation (dementia) Mobility Frailty 29 March 2024 ADLs Frailty/robustness/resilience – What Matters Most Dependency Socialization/spirituality The purpose of today’s lecture is to provide an overview of the topics that are core to the understanding and treatment of the older adult The foundation of the practice of Geriatrics is the 4 Ms. In today’s lecture you will be introduced to several concepts which are also foundational and will be dealt with more deeply in upcoming lectures Volker Prinicples of Aging 3 Objectives Differentiate normal from abnormal aging in human biological systems Give a synopsis of the financing of health care in the United States and the unique demographics affecting its near future Explain the social determinants of health as they apply to geriatric care Explain the concept of multimorbidity and how it differs from disease models in younger humans Define the Four Ms and explain their importance in geriatric care Define dependency and vulnerability and how ADLs and IADLs can be descriptors of those concepts Describe the burden of dependency and its care, both in terms of economics and human resources 29 March 2024 Volker Prinicples of Aging 4 BIOLOGY 29 March 2024 Volker Prinicples of Aging 5 Normal vs. Abnormal Aging Normal Aging Progressive and broadly predicable processes resulting in decreased function and homeostasis of biologic systems, leaving those systems with increased susceptibility to disease. 29 March 2024 Abnormal Aging Accelerated loss of function and homeostasis in one or more biologic systems leading to accumulation of disease. Volker Prinicples of Aging 6 Normal vs. Abnormal Aging Normal Aging Slower recall and problemsolving ability; diminished reflexes Loss of renal function ~8% per decade Lower maximum heart rate Preserved cardiac output 29 March 2024 Abnormal Aging Dementia Renal failure; indications for dialysis Symptomatic dysrhythmia Atrial fibrillation Myocardial infarction Volker Prinicples of Aging 7 Demographics People are living longer, in better health, with less infant and midlife mortality The effect is columnizing the pyramid 29 March 2024 Volker Prinicples of Aging 8 Population Pyramids http://www.lewishistoricalsociety.com/ 29 March 2024 Volker Prinicples of Aging 9 America is Graying America’s average age is rising The population of 85+ is growing faster Soon a quarter of our population will be 65+ 29 March 2024 Volker Prinicples of Aging 10 Demographics: Resources and Cost People are living longer, in better health, with less infant and midlife mortality The effect is columnizing the pyramid This will put an enormous stress on the public financing of our health care system – Medicare and Social Security costs for our retirees are being paid for by today’s workers – Not like a bank account or a 401k – Current systems, given the current demographics, are unsustainable 29 March 2024 Volker Prinicples of Aging 11 Worker Funding Ratio Social Security and Medicare are “pay as you go” systems 1.9 2030 29 March 2024 Volker Prinicples of Aging 12 Medicare and Social Security Funds Medicare Payment Advisory Commission 29 March 2024 Volker Prinicples of Aging 13 Medicare Largest Single Purchaser of Health Care Medicare Payment Advisory Commission 29 March 2024 Volker Prinicples of Aging 14 Nursing Home Costs Medicare does NOT pay for long term nursing home care!!! Pts must pay out of their savings until exhausted Medicaid then will pay 29 March 2024 $475 Billion in 2023 Volker Prinicples of Aging Source: MartinCare 15 29 March 2024 Volker Prinicples of Aging 16 Determinants of Health World Economic Forum 29 March 2024 Volker Prinicples of Aging 17 Social Determinants of Health Employment Status Family Support Education Income Transportation Food Security Housing Security 29 March 2024 Volker Prinicples of Aging 18 Poverty Rates in Older Adults 29 March 2024 Volker Prinicples of Aging 19 Poverty in Older Adults Older adult singles are at twice the risk for economic insecurity than couples 29 March 2024 Volker Prinicples of Aging 20 Poverty in Older Adults About half of older adults are economically insecure Women are at higher risk 29 March 2024 Volker Prinicples of Aging 21 Poverty in Older Adults Non-white singles are at highest risk for economic insecurity 29 March 2024 Volker Prinicples of Aging 22 Bottom Line The longer Americans live, the greater the number of people who rely on the government healthcare and social welfare systems These systems are not presently designed to be sustainable for more than another 1-12 years There is no clear or legislated plan for how our society will respond to this You will be practicing in a healthcare and financial environment which is unpredictable for you and your patients You have a responsibility to understand this environment so that you can advocate for your patients and our society; it is a fallacy to assume the problem will “work itself out” 29 March 2024 Volker Prinicples of Aging 23 We do not have a good health care system in the United States. We have a good sick care system. —Sen. Tom Harkin, D-IA, 2008 29 March 2024 Volker Prinicples of Aging 24 Medication Mentation Mobility What Matters THE FOUR M’S 29 March 2024 Volker Prinicples of Aging 25 Multimorbidity (the 5th M) 50% of geriatric patients have three or more chronic illnesses Clinical practice guidelines usually focus on best management of single diseases There are generally no guidelines for the optimal treatment of multiple concurrent chronic illnesses 29 March 2024 Volker Prinicples of Aging 26 Multimorbidity Guiding Principles Elicit and incorporate patient preferences (What Matters) Interpret best evidence, recognizing limitations of the evidence base vis-à-vis the older age group Frame decision within context of risk, benefit, and prognosis Feasibility (complexity) Optimize benefit, minimize harm, enhance QOL 29 March 2024 Volker Prinicples of Aging 27 Medication (Polypharmacy) This is a real patient I see frequently in the DMU clinic 29 March 2024 Volker Prinicples of Aging 28 Mentation—Dementia Not a normal aspect of aging Prevalence: 5.8 million (66K in Iowa) in 2021 5th leading cause of death in older adults 16M family members provided 18.5B hours of care in 2018 $290B for care in USA in 2019 Testing Treatment Cost Source: Alzheimer’s Association 3/8/2019 29 March 2024 Volker Prinicples of Aging 29 Demographics of Alzheimer Disease Now 6.5M Americans with AD $332B public money spent annually on medical care $500M public money spent annually on research 29 March 2024 Volker Prinicples of Aging 30 At 90, Paul’s mind slowed to lightning speed. 29 March 2024 Volker Prinicples of Aging 31 Mobility Movement defines us as humans Loss of strength Loss of muscle mass (sarcopenia) Stiffness, contractures, pain, fatigue Loss of confidence Dependence, institutionalization Hydration, electrolyte, nutrition imbalance Pressure sores Death 29 March 2024 Volker Prinicples of Aging 32 Move like a toddler Washington Post 29 March 2024 Volker Prinicples of Aging 33 Activities of Daily Living Transferring – Functional mobility – “Get up and go” aka “Timed up and Go (TUG) test” Sit, stand, walk 3 meters, return, sit Bathing or Showering Hygiene/Grooming Toileting Dressing Eating 29 March 2024 Volker Prinicples of Aging 34 Instrumental Activities of Daily Living Housekeeping (cleaning, kitchen, laundry) Meal preparation Managing medication Checkbook (managing money) Shopping (groceries) Telephone Transportation 29 March 2024 Volker Prinicples of Aging 35 Just ask anybody who is getting old-everything starts hurting. For me, it’s my shoulders, thumbs, knees, and feet. --Meatloaf Rock ‘n’ Roller 29 March 2024 Volker Prinicples of Aging 36 29 March 2024 Volker Prinicples of Aging 37 What Matters Most Living in your own place? Driving? Being near family/friends? Enjoying a hobby? Free of Pain? Being cognitively intact? 29 March 2024 Volker Prinicples of Aging 38 FRAILTY IS A CLINICAL SYNDROME AND A CORE CONCEPT 29 March 2024 Volker Prinicples of Aging 39 Frailty as a core concept Frail older adults are at high risk from stressors such as extremes of heat/cold, acute infection/injury, hospitalization, or surgery (loss of homeostasis) As a group, frail older adults are more likely to: – Have delayed recovery from illness – Fall – Develop greater functional impairment, including becoming disabled or dependent – Be hospitalized, with worse outcomes once hospitalized, including dependency – Die 29 March 2024 Volker Prinicples of Aging 40 Frailty and Vulnerability All geriatric-oriented definitions of frailty agree: – Frailty involves ↑ vulnerability to adverse outcomes, which may most likely manifest in the face of stressors – Regardless of cause, frail older adults have decreased reserves with which to compensate for, or recover from, stressors Aggregate loss of physiologic function is the process thought to underlie the high risk of adverse outcomes An emerging research agenda focuses on identifying physiologically vulnerable people before frailty becomes clinically apparent 29 March 2024 Volker Prinicples of Aging 41 Kaplan-Meier Survival What were the physical and physiological differences between these three cohorts? Are there ways to identify physiological vulnerability and risk before the appearance of poor outcomes? 29 March 2024 Volker Prinicples of Aging 42 Social Determinants of Health The frail are likely to be Poor Women African American 29 March 2024 Volker Prinicples of Aging 43 Defining Frailty Potential definitions of frailty abound, defining frailty as synonymous with disability, comorbidity, or advanced old age. This viewpoint is too simplistic 29 March 2024 Volker Prinicples of Aging 44 Frailty is Multifactorial Rather, these are overlapping health deficits, each of which require attention for successful health care. 29 March 2024 Volker Prinicples of Aging 45 …or even more factorial Strength Balance Motor processing Nutrition Endurance Physical activity Mobility Cognition (possibly) 29 March 2024 Volker Prinicples of Aging 46 One Definition Increasingly, geriatricians define frailty as a biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems, causing heightened vulnerability to adverse outcomes. 29 March 2024 Volker Prinicples of Aging 47 Cycle of Frailty Fried et al. 29 March 2024 Volker Prinicples of Aging 48 Main Points of the Cycle Decreased muscle mass (sarcopenia) Slowed motor performance Decreased physical activity Decreased exercise tolerance Inadequate nutritional intake (negative nitrogen balance) 29 March 2024 Volker Prinicples of Aging 49 Qualifying Frailty Weight Loss Exhaustion Slowness Low activity level Weakness unintentional > 10 lbs over 6 mos. “Everything I did was an effort” slow “get up and go” test expends < ~270 kcal/wk decreased grip strength Precise scoring varies by BMI and gender, refer to Fried et al. 29 March 2024 Volker Prinicples of Aging 50 Quantifying Frailty Functional Markers Not Frail Frail Timed up and go 20 sec Four Square Step test 15-20 sec 30 second Chair rise >15 1m/s- complete yardwork, climb stairs 30 kg men, >18 kg women grip strength < 30 kg men,