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Federation of State Physician Health Programs. 2012 Annual Meeting. The Aging Physician: . A New Challenge for Physician Health Programs. The Aging Physician: A New Challenge for Physician Health Programs. Betsy White Williams PhD MPH Assistant Professor

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the aging physician

The Aging Physician:

A New Challenge for Physician Health Programs

the aging physician a new challenge for physician health programs
The Aging Physician: A New Challenge for Physician Health Programs

Betsy White Williams PhD MPH

Assistant Professor

Director of Outcomes and Research

Office of Continuing Medical Education

Rush University Medical Center

Clinical Program Director

Professional Renewal Center

1421 Research Park Drive, Suite 3B

Lawrence, KS 66049

William C. Nemeth, MD

Fellow American Academy of Orthopaedic Surgeons

Fellow American Academy of Disability Evaluating Physicians

Diplomat American Board of Addiction Medicine

Medical and Executive Director

Texas Physicians Health Program

333 Guadalupe Tower II Ste 520

Austin, TX 78701

John A. Fromson, M.D.

Massachusetts General Hospital

Harvard Medical School

One Bowdoin Square, 7th Floor

Boston, Massachusetts 02114

Michael V. Williams, PhD

Professional Renewal Center

Director of Organizational Consulting

1421 Research Park Drive, Suite 3B

Lawrence, KS 66049

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

learning objectives
Learning Objectives
  • Learning Objective 1:
    • Understand the changes (positive and negative) associated with normal aging and how these may affect physician practice.
  • Learning Objective 2:
    • Be familiar with the presentation and symptoms of pathological aging to ensure that proper resources are identified and utilized.
  • Learning Objective 3:
    • Understand the importance of workplace changes and support systems including monitoring to mitigate the changes associated with normal aging.

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

presentation context
Presentation Context
  • The demographic profile of physicians is radically changing
    • demand for physicians being greater than the supply of physicians entering the workforce.
    • Physicians may choose to remain longer in the workforce due to the heightened demand as well as the recent economic downturn.
  • This aging medical workforce poses many challenges
    • acknowledging the contributions of older practitioners while
    • ensuring that those who are dyscompetent by virtue of impairment are identified, assessed and either rehabilitated or encouraged to retire.
    • Currently much of the focus in dealing with the older physicians is tertiary prevention based, that is, reducing the negative influence of established impairment.
  • This workshop will assist participants in identifying the differences between normal aging and pathological aging, and review approaches and best practices for identification, remediation, and monitoring. Exploration of ways to identify physicians earlier in the process will also be discussed.

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

setting the context workforce issues shortage
Setting the context: Workforce Issues - Shortage
  • The expected future shortage of physicians is driven by likely changes in both the supply and the demand for physicians.
    • Demand Side factor:
      • growing U.S. population;
      • rapid growth in people over the age of 65 (those that consume the greatest resources); and
      • rising expectations of Americans along with increasing wealth that will motivate and enable them to use more services.

Testimony to United States House of Representatives Committee on the Judiciary

Subcommittee on Immigration, Border Security, and Claims

By Edward Salsberg

Director, Center for Workforce Studies, Association of American Medical Colleges

May 18, 2006

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

setting the context workforce issues shortage1
Setting the context: Workforce Issues - Shortage
    • Supply side, key factors include:
      • Aging of the physician workforce (1 of 3 active physicians over the age 55 and they are likely to retire by 2020); and
      • Change in physician practice tendencies
  • At current levels of training, the physician–to-population ratio will peak by 2020 and then fall, just as the baby boomers begin to reach 75 years of age.

Testimony to United States House of Representatives Committee on the Judiciary

Subcommittee on Immigration, Border Security, and Claims

By Edward Salsberg

Director, Center for Workforce Studies, Association of American Medical Colleges

May 18, 2006

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

setting the context workforce issues aging
Setting the context: Workforce Issues - Aging
  • Changes in age distribution of physician workforce over the next decade and a half:
    • 2000 12% of active physicians over 65;
    • Currently 15% of active physicians over 65;
    • By 2020 20% of anticipated physician workforce over 65.

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

setting the context healthcare issues
Setting the context: Healthcare Issues
  • Yet, the demands by patients are more intense and more complicated:
    • Proportion of the population over 65 expected to grow rapidly over the next 15 yrs;
    • Increased use of medical services (3 to 5 x’srate of middle aged individuals).

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

setting the context healthcare issues1
Setting the context: Healthcare Issues
  • More patients with more complex issues:
    • Need for PCPs doubles in the later decades of life;
    • Need for surgical specialists increases by an order of magnitude.
  • Requiring several specialties at once
    • greater cognitive requirements on physician caregivers.

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

setting the context disciplinary issues
Setting the context: Disciplinary Issues
  • Relationship between age and discipline
    • Khaliq et al:
    • The estimates of unadjusted rate of disciplinary action were found to be
      • 1.3% within 10 years since licensure,
      • 2.8% within 20 years,
      • 4.3% within 30 years,
      • 6.6% within 40 years,
      • 8.6% within 50 years, and
      • 11.0% within 60 years.

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

movie clip
Movie Clip

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

normal aging
Normal Aging
  • Normal aging also causes a number of changes that can affect a physician’s ability to deliver care:
    • Changes in physical capacity; as well as,
    • Changes in cognitive functioning
    • Increased heterogeneity in functioning
    • Increased slowing with age

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

normal aging physical changes
Normal Aging-Physical Changes
  • Aging - a universal and progressive physiologic phenomenon characterized by degenerative changes in structure and function:
    • Cardiovascular system
    • Respiratory system
    • Musculoskeletal system
    • Hematological and immune systems
    • Renal System
    • Central Nervous System
    • Sensory

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

normal aging physical changes1
Normal Aging-Physical Changes
  • SENSORY-Hearing:
    • Presbycusis-is the loss of hearing that gradually occurs in most individuals as they grow older
    • Abnormal loudness perception
    • tinnitus
    • Impairment sound localization
    • Difficulty with higher frequencies
      • Exacerbated by background noise

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

normal aging physical changes2
Normal Aging-Physical Changes
  • SENSORY-Vision:
    • Presbyopia-the eye's diminished ability to focus
    • Reduction static visual acuity
    • Impaired dark adaptation
    • Decreased depth perception
    • Reduced color discrimination
    • Increase in various diseases of the eye
      • Glaucoma
      • Cataracts
      • Macular degeneration

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

normal aging other physiological changes
Normal Aging-Other Physiological Changes
  • SLEEP:
    • Earlier wake time
    • Difficulty initiating sleep
    • Greater need for late afternoon nap
    • Less REM sleep
    • Prevalence of primary sleep disorders
      • 35% 65 and older have periodic leg movement
      • Approximately 3% men and women over 50 have sleep apnea
    • More night time awakenings
    • Lighter sleep
    • More difficulty adjusting to shift changes and jet lag

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

normal aging neuropsychological changes
Normal Aging -Neuropsychological Changes
  • Variability on both neuropsychological and physiological measures are greater in older versus younger adults
    • Decreased speed
      • Processing speed
      • Reaction time
      • Psychomotor speed
      • Fine motor skills/dexterity
    • Changes in Memory
      • Decreased episodic memory (specific events)
        • recall worse than recognition
      • Slower pace of learning
      • Increased need for repetition

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

normal aging neuropsychological changes1
Normal Aging -Neuropsychological Changes
  • Variability on both neuropsychological and physiological measures are greater in older versus younger adults
    • Decreased Attention
      • Selective attention-appears due to speed (older are slower)
      • Divided attention particularly in complex situations
      • Attention switching
      • NOT impaired on sustained attention
    • Language
      • Good language skills
        • Problems with word retrieval
        • Word finding difficulty/fluency

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

normal aging neuropsychological changes2
Normal Aging -Neuropsychological Changes
  • Variability on both neuropsychological and physiological measures are greater in older versus younger adults
    • Executive control (planning/organization/coordination/evaluation of non-routine activities)
      • Decreases with age
      • Functional imaging studies show preferential decline in volume and function of prefrontal areas

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

normal aging neuropsychological changes3
Normal Aging -Neuropsychological Changes
  • Variability on both neuropsychological and physiological measures are greater in older versus younger adults
    • Decision making
      • Differences in how decision reached
      • More reliance on prior knowledge

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

normal aging neuropsychological changes4
Normal Aging -Neuropsychological Changes
  • Crystallized intelligence: knowledge and skills that are accumulated over a lifetime, for example vocabulary.
    • Less affected by age and disease
      • Involves less effortful tasks
      • Acquired through education and life experience
      • Nonanalytic/automatic/implicit mental processes

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

normal aging neuropsychological changes5
Normal Aging -Neuropsychological Changes
  • Fluid intelligence/reasoning: the capacity to think logically and solve problems in novel situations, independent of acquired knowledge.
    • necessary for all logical problem solving, especially scientific, mathematical and technical problem solving..
    • Sensitive to age related changes
      • analytic/effortful processing

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

normal aging neuropsychological functioning
Normal Aging - Neuropsychological functioning
  • Factors affecting cognitive performance
    • Educational level
    • Physical activity level
    • Mental activity level
    • Peak pulmonary function
    • No comorbid physical or mental health issues
    • self-efficacy

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

normal aging how might this effect physician functioning
Normal Aging – How might this effect physician functioning?
  • And, how is this different from aging with a health condition?
    • And what health conditions might we expect?

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

normal aging how might this effect physician functioning1
Normal Aging – How might this effect physician functioning?
  • Increased age one of the strongest predictors of poor clinical performance
  • Physician ability to assess risk as a function of years of practice. Older physicians had the lowest knowledge scores but the greatest confidence in their knowledge
  • Physicians with greater experience appear to weigh their first impressions more heavily than those with less experience.

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

normal aging how might this effect physician functioning2
Normal Aging – How might this effect physician functioning?
  • Broadly speaking, experience increases quality on the procedural side
  • However, data on performance on procedures as a function of age show mixed results and warrant further study

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

health effects of age correlated disease
Health effects of age correlated disease
  • A number of diseases that increase in frequency with age directly or indirectly affect cognitive functioning:
    • Degenerative neurological diseases; and,
    • Vascular disease
  • As the population of physicians ages; these become a more common threat to the quality of medical care.

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

the epidemiology of age related mental disorders alzheimer s disease
The Epidemiology of Age Related Mental Disorders - Alzheimer’s Disease
  • Alzheimer’s disease
    • Most common form of dementia
    • Affects 8-15% adults over 65
    • Prevalence doubles every 5 years after age 60
    • is the most common cause of dementia in older people.
  • Diagnosis based on
    • Clinical characteristics of disease
    • Exclusion other causes of dementia
    • Neuropsychological testing
    • Imaging
    • Using appropriate diagnostic criteria AD has been confirmed at autopsy in 85-90% cases

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

neuropsychological functioning alzheimer s disease
Neuropsychological Functioning-Alzheimer’s Disease
  • Neuropsychological Performance
    • Significant decline versus estimated premorbid levels of functioning
    • Memory Problems
    • Language Problems
    • Executive function
    • Visuospatial difficulties

Salmon, DP and Filoteo, JV. Neuropsychology of Cortical versus

Subcortical Dementia Syndromes.Seminars I Neurology/Volume 27, Number 1 (7-21) 2007.

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

the epidemiology of age related mental disorder mild cognitive impairment
The Epidemiology of Age Related Mental Disorder – Mild Cognitive Impairment
  • MCI- the transitional state between the cognitive changes of normal aging and the fully developed clinical features of dementia
    • Originally described by Reisberg and colleagues in 1980’s,
    • Concept expanded in 1990’s
      • Memory complaint
      • Memory impaired for age and education
      • Preserved general cognitive abilities
      • Intact daily functioning
      • Not demented

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

the epidemiology of age related mental disorder mild cognitive impairment1
The Epidemiology of Age Related Mental Disorder – Mild Cognitive Impairment
    • Criteria expanded in 2003 at Stockholm Conference on MCI
    • Current understanding
    • MCI
      • A cognitive function not normal for age
      • Not demented
      • Normal overall functioning
    • Two subtypes
      • Amnestic
      • Non-Amnestic
    • 10-15% Amnestic MCI progress to AD
  • Peterson, RC. (2007). Mild Cognitive Impairment:Current Research and Clinical Implications. Seminars in Neurology, 27, 1: 22-31.

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

the epidemiology of age related mental disorder frontotemporal dementias
The Epidemiology of Age Related Mental Disorder – Frontotemporal Dementias
  • FrontotemporalDementias-agroup of diseases that are commonly misdiagnosed as Alzheimer's Disease (AD). A general term to refer to disorders that are also referred to as:
    • Pick's Disease
    • Frontotemporal Lobar Degeneration
    • Progressive Aphasia
    • Semantic Dementia
  • PREVALENCE
    • affects an estimated 250,000 Americans
    • prevalence of FTD among people ages 45 to 64 was estimated to be 6.7 per 100,000
    • Most common form of dementia after Alzheimer’s Disease
    • Accounts for 20% of presenile dementia cases
    • affects both sexes equally
    • mean duration of the illness is about eight years

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

the epidemiology of age related mental disorders frontotemporal dementias
The Epidemiology of Age Related Mental Disorders – Frontotemporal Dementias
  • FrontotemporalDementias –Diagnosis based on
    • Insidious onset with gradual decline
    • Clinical characteristics of disease
    • Salient clinical characteristic is profound alteration in character and social conduct
      • Early decline social/interpersonal conduct
      • Early impairment in regulation personal conduct
      • Early emotional blunting
      • Early loss of insight
  • Supportive Characteristics
    • Decrease in personal hygiene and grooming
    • Mental rigidity and inflexibility
    • Distractibility and impersistence
    • Relative preservation of memory
  • Snowden, JS, Neary D, and Mann DA. FrontotemporalDementia.British Journal of Psychiatry (2002) 180, 140-143.

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

neuropsychological functioning frontotemporal dementias
Neuropsychological Functioning - Frontotemporal Dementias
  • Neuropsychological Functioning
    • Relatively preserved memory
    • Language disorder-word finding difficulty, anomia (semantic errors greater than perceptual)
    • In some variants can see significant decline in semantic knowledge
    • Qualitative aspects consistently suggest frontal lobe dysfunction

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

the epidemiology of age related mental disorders vascular dementias
The Epidemiology of Age Related Mental Disorders – Vascular Dementias
    • Originally thought of as multi-infarct dementia in 1980’s,
    • 1990’s became clear that there were subtypes of vascular dementias
    • Associated with changes in vasculature in the cerebrum
    • Classic course involves sudden onset
    • Stepwise/fluctuating course
    • Symptoms vary depending on area of brain affected
    • History and progression of symptoms are critical in diagnosis
    • May co-occur with AD
    • Presence of subtypes lead to term Vascular Cognitive Impairment (Bowler, 2002)
  • O’Brien, JT (2006). Vascular Cognitive Impairment. American Journal of Geriatric Psychiatry, 14:9.724-733.

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

neuropsychological and neuropsychiatric changes vascular dementia vascular cognitive impairment
Neuropsychological and Neuropsychiatric changes – Vascular Dementia/Vascular Cognitive Impairment
    • Neuropsychological pattern variable-depends on location of lesions
      • More typical pattern seen in those with sub cortical vascular disease
        • Slowness in thought
        • Impaired attention
        • Psychomotor slowing
        • Deficiency in planning
        • Difficulty sustaining effort
        • Decreased fluency-reflective of retrieval deficit
        • Difficulty with retrieval
      • Focal or lateralized findings
      • Depression
      • Anxiety
      • Requires extra time to complete tasks but able to complete successfully
  • O’Brien, JT (2006). Vascular Cognitive Impairment. American Journal of Geriatric Psychiatry, 14:9.724-733.

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

one state s data
One State’s Data
  • Probability of violations increases in the later deciles of age.

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

one state s data1
One State’s Data
  • When restricted to cognitive related issues such as negligence, the effect of age is even more marked.

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

data from surveys indicate too few referrals
DATA from Surveys Indicate Too Few Referrals

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV

case studies
CASE STUDIES

FSPHP 2012: Williams, BW, Nemeth, WC, Fromson, JA, and Williams MV