Unlocking the Mysteries of the Aged

1. Unlocking the Mysteries of the Aged John van der Steeg MD Putnam Hospital Center

2. Overview • We have met the enemy and the enemy is us • How to communicate • Pitfalls • Physiologic changes of aging • It’s not always the years that matter but the mileage • Elder abuse

3. The enemy is us !

4. Death twitches my ear. “Live,” he says; “I am coming.” Virgil [Publius Vergilius Maro], 70 – 19 B.C.

5. Communicate Effectively

6. Speaking With Your Elders • Identify yourself • Speak at eye level • Make sure they can see, hear, and talk to you • Turn on the lights • Find their eyeglasses, hearing aid, and dentures if needed • Speak slowly, distinctly, and respectfully • Listen closely • Be patient • Preserve the patient’s dignity

7. Speaking With Your Elders (Cont.) • Be gentle • Look around the surroundings • Bottles of alcohol? • Pill bottles? • Syringes for meds? • Does mechanism of injury go with story?…things that make you go hmmm? • Bag it, tag it and bring it!

8. Pitfalls

9. Pitfalls • Geriatric patients are likely to suffer from concurrent illnesses • Chronic illness may make assessment of an acute illness difficult • COPD->DIB->Pneumonia? vs. MI? vs. CHF? vs. PE? vs. etc. • Signs or symptoms of a chronic illness may be confused with signs or symptoms of an acute problem • Chronic lower extremity edema vs. DVT

10. Pitfalls • Aging can affect an individual’s response to illness and/or injury • Patient or paramedic may underestimate the severity of the condition … why? • Pain may be diminished or absent • Vital sign changes may be blunted or masked by medications or changes in physiology • Healthcare provider may be misled by caregiver

11. Pitfalls • Emotional and social factors may contribute to symptom minimization • Patient has financial concerns about health care • Patient fears the hospital • Patient fears losing autonomy • Patient may have substance abuse problems • Patient may fear angering caregiver/family

12. Physiologic Changes

13. Appearance “Here’s look’in at You Kid.” Humphrey Bogart • Skin • Decreased elasticity • Decreased Collagen • Shrinking Sweat glands • Pigment deposition (age spots) • Above contribute to wrinkles, increased risk if injury • Eyes • Cataract formation • Macular degeneration • Pigment deposition (Arcus senilis) • Above contribute to poor peripheral vision and decreased visual acuity

14. Appearance(continued) • Musculoskeletal • Decrease in muscle mass • Loss of strength • Increased joint breakdown (DJD) • Arthritis, loss of flexibility, increased risk of falls • Tendon breakdown • Ditto above • Bone demineralization • Increased risk of fracture • Decrease in bone strength and size • Decreased fluid content of discs, synovium • Arthritis, increased spinal curvature

15. Pulmonary “Be on your guard against a silent dog and still water.” Latin Proverb • Decreased surface area • Decreased oxygen exchange • Decreased compliance of lung and chest wall • Decreased maximal oxygen uptake • Increased of injury due to trauma • Decreased ciliary activity • Increased risk of infection • Decreased elasticity • Decreased breathing capacity

16. GI tract“When the well’s dry, we know the worth of water.” Benjamin Franklin, 1706 – 1790 • Decreased saliva and fewer taste buds • Loss of food enjoyment and decreased appetite • Delay/decrease in GI motility • Absorption problems and constipation • Early satiety • Decreased HCL acid production • Difficulty with digestion • Gum atrophy and tooth loss • Decline in Liver Function • Drug toxicity • Poor blood clotting

17. Cardiovascular“The man who can’t dance thinks the band is no good.”Polish proverb • Decrease in cardiac output • Decreased exercise tolerance • Increased risk of MI • Increased cholesterol deposits • CAD and PVD • Internal thickening of arteries • Hypertension • Increased risk of CVA and MI

18. Central nervous system“A man who is ‘of sound mind’ is one who keeps the inner madman under lock and key.” Paul Valery, 1871 - 1945 • Increased synapse time • Decreased complex learning • Slowing of nerve conduction velocity • Slowed reflexes, increased risk of falls • Decreased psychomotor skills • Brain atrophy • Increased risk of subdural hematomas • Loss of cortical cells • Dementia/ memory impairment

19. Hearing“Well timed silence hath more eloquence than speech.”Martin Farquhar Tupper, 1810 – 1889 • Ossicle degeneration • Loss of high frequency hearing • Atrophy of cochlear hair cells and auditory neurons • Decreased sense of balance • Decreased pitch disrimination • Atrophy of auditory meatus • Loss of high frequency hearing

20. Vision“There is no darkness, only ignorance.” Italian proverb • Loss of accomodation • Loss of depth perception… increased risk of falls and accidents • Decrease in pupil size • Decreased visual acuity and loss of color perception • Cataract deposition • Farsightedness • Opacification of vision • Growth of lens • Loss of ability to focus

21. Genitourinary“The mass of men lead lives of quite desperation.”Henry David Thoreau, 1817 – 1862 • Prostate enlargement • Urinary retention • Tumors • Loss of bladder control • Urinary infections • Social embarrassment, shame • Hygiene issues, skin breakdown

22. Renal Function??????? • Decreased renal blood flow • Increased risk of toxicity from medications, drugs, and toxins • Decreased glomerular function • Decreased renal clearance… see above

23. Psychological / Social“Children begin by loving their parents. After a time they judge them. Rarely, if ever, do they forgive them.” Oscar Wilde, 1845 – 1900 • Loss of physical function • Decreased activity • Decreased autonomy • Increased dependence on others • Loss of social support • Depression • Increased isolation and anxiety • Increased risk of suicide attempts

24. Elder Abuse “The worst form of tyranny the world has ever known: the tyranny of the weak over the strong. It is the only tyranny that lasts.” Oscar Wilde, 1845 - 1900

25. How big of a problem? • >500,000 Americans aged 60 and over were victims of domestic abuse in 1996. * • Only 16% of abusive situations are referred for help…84% remain hidden.* • *National Elder Abuse Incidence Study

26. How big? (continued) • Multiple studies estimate that between 3 and 5 percent of elderly population has been abused • Senate Special Committee on Aging estimates that there may be as many as 5 million victims a year • One consistent finding, over a ten year study period, is that reports have increased each year.

27. What is elder abuse? • Any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult

28. Types of elder abuse? • Physical Abuse - Inflicting, or threatening to inflict, physical pain or injury on a vulnerable elder, or depriving them of a basic need. • Emotional Abuse – Inflicting mental pain, anguish, or distress on elder person through verbal or nonverbal acts. • Sexual Abuse – Non-consensual sexual contact of any kind. • Exploitation – Illegal taking, misuse, or concealment of funds, property, or assets of a vulnerable elder.

29. Types of elder abuse? (continued) • Neglect - Refusal or failure by those responsible to provide food, shelter, health care or protection for a vulnerable elder. • Abandonment - The desertion of vulnerable elder by anyone who has assumed the responsibility for care or custody of that person.

30. Who are the abusers ? • Most incidents of elder abuse DO NOT happen in a nursing home. At any one time, only about 4 percent of older adults live in nursing homes. • Abusers are both women and men. Family members are more often abusers than any other group. • Initial data demonstrated adult children were the most common abusers; recent information indicates spouses are the most common abusers when state data is combined.

31. What makes an older adult vulnerable to abuse?

32. What makes an older adult vulnerable to abuse? • HIGH RISK SITUATIONS • SAVED • SStress/social isolation • AAlcohol/other drug abuse • VViolence (previous history) • EEmotions (psychiatric illness) • DDependency/dynamics in family

33. What makes an older adult vulnerable to abuse? (continued) • It isn’t just infirm or mentally impaired elderly people who are vulnerable to abuse. Elders who are ill, frail, disabled, mentally impaired, or depressed are at greater risk of abuse, but even those who do not have these obvious risk factors can find themselves in abusive situations and relationships.

34. Clues to Abuse

35. Clues to Abuse • Conflicting or implausible accounts of events • History of similar suspicious episodes • Improper administration of medicine • Patient not accompanied by caregiver • Delay in seeking medical care • History of “doctor shopping” or no doctor • Visits to multiple different emergency departments

36. Clues to Abuse (continued) • Broken eyeglasses/frames, physical signs of being retrained • An elder’s report of being hit, slapped, mistreated • Caregiver refuses to allow visitors to see elder’s alone

37. Physical signs of abuse

38. Physical signs of abuse • Multiple injuries in various stages of healing • Unusual soft tissue injuries • Facial injuries: eye, teeth, or head trauma • Burns with representative shape or demarcation • Malnutrition or dehydration

39. Physical signs of sexual abuse

40. Physical signs of sexual abuse • Sexually transmitted disease • Unexplained vaginal or anal bleeding • Bruises around the breasts or genital area • Torn, stained, or bloody underclothing • An elder’s report of being sexually assaulted or raped

41. Signs of neglect

42. Signs of neglect • Dehydration, malnutrition, untreated bed sores, and poor personal hygiene • Unattended or untreated health problems • Hazardous or unsafe living condition/arrangements(faulty wiring, no heat or running water) • Unsanitary and unclean living conditions(ie. Dirt, fleas, lice on person, soiled bedding, fecal/urine smell, inadequate clothing) • An elder’s report of being mistreated

43. What to do?“Take time to deliberate; but when the time for action arrives, stop thinking and go in.” Andrew Jackson, 1767 - 1845 • Do not put the older person in a more vulnerable position by confronting the abuser yourself unless you have the victims permission and/or are in a position to help the victim by moving him or her to safe place.

44. What to do ? (Continued) • NY state Elder Abuse Hotlines • N. Eastern 800-342-9871, 800-220-7184 • Buffalo 800-425-0314 • Rochester 800-837-9018 • Syracuse 800-425-0319 • New York 800-425-0316 • L. Hudson Vly800-425-0320 • Long Island 800-425-0323

45. What to do? (Continued) • Even if these agencies determine that there is only potential for abuse, they will make referrals for counseling. Another resource is the Eldercare Locator by telephone at 1-800-677-1116. Specially trained operators will refer you to a local agency that can help. The Eldercare Locator is available Monday through Friday, 9 a.m. to 8 p.m. Eastern time

46. “A professor is one who talks in someone else’s sleep.” W. H. Auden, 1907-1973