Tae J Lee, MD, CMD, AGSF Medical Director Palliative Care and Hospice Vidant Medical Center

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1 Tae J Lee, MD, CMD, AGSF Medical Director Palliative Care and Hospice Vidant Medical Center

2 Objectives Discuss important healthcare issues for aging population Review long term care options Discuss advance care planning Discuss resources available for patients and families

3 Disclosure No financial/commercial conflict of interest

4 Demographics From 1946 to 1964: 76 million people born About 1/4 of all US population (314 million) Average life expectancy is 78.8 years Once 65, one lives on average 20 more years Once 80, one lives on average 8 to 10 more years

5 Demographics

6

7

8 Where/how do older people live? Living Situation by Age and Sex Men 65 Y 65 to 74 Y 75 to 84 Y 85 Y 85% 12% 3% 90% 9% 1% 82% 14% 4% 54% 15% 31% Women 78% 89% 72% 38% 16% 6% 10% 1% 21% 7% 37% 25% Living at Home, Independent Living at Home, Needs Help of Another Person In Nursing Home Schneider, EL, Guralnik, JM, THe Aging of America, JAMA, May 2, 1990: VOl 263, No. 17; pp

9 Dependency

10 Caregiving

11 Places of caregiving Independent Living (home health, personal care, hospice) Adult Day Center Independent Senior Living Assisted Living Intermediate Care Facilities Skilled Care Facilities

12 Medicare Coverage

13 Average LTC costs Home Health Aides Assisted Living Adult Day Care Nursing Home $ 120/8 hour shift $ 44,000/year $ 25,800/yr = $70/day $18,250/yr = $50/day $ 60,000/yr = $165/day

14 Personal care assistance Adult day service centers Hospice care Respite care Assisted living facilities Alzheimer s special care facilities Nursing homes Long Term Care Insurance

15 Elderly Abuse Physical Abuse inflicting physical pain or injury on a senior, e.g. slapping, bruising, or restraining by physical or chemical means. Sexual Abuse non-consensual sexual contact of any kind. Neglect the failure by those responsible to provide food, shelter, health care, or protection for a vulnerable elder. Exploitation the illegal taking, misuse, or concealment of funds, property, or assets of a senior for someone else's benefit. Emotional Abuse inflicting mental pain, anguish, or distress on an elder person through verbal or nonverbal acts, e.g. humiliating, intimidating, or threatening. Abandonment desertion of a vulnerable elder by anyone who has assumed the responsibility for care or custody of that person. Self-neglect characterized as the failure of a person to perform essential, self-care tasks and that such failure threatens his/her own health or safety.

16

17 Causes of Death in US Heart disease: 611,105 Cancer: 584,881 Chronic lower respiratory diseases: 149,205 Accidents (unintentional injuries): 130,557 Stroke (cerebrovascular diseases): 128,978 Alzheimer's disease: 84,767 Diabetes: 75,578 Influenza and Pneumonia: 56,979

18 Breast CA Colorectal CA Cervical CA Lung CA Prostate CA Cancer Screen

19 Cancer Over-screening Don t recommend screening for breast or colorectal cancer, nor prostate cancer (with the PSA test) without considering life expectancy and the risks of testing, overdiagnosis and overtreatment. For patients with a life expectancy under 10 years, screening for these three cancers exposes them to immediate harms with little chance of benefit. (Am Geriatrics Society)

20 Over-treatment

21 The High Cost of the Frail Elderly (average Medicare spending) $28, $1,340 $4,020 0 Healthiest 90% of beneficiaries All Medicare beneficiaries Sickest 10% of beneficiaries Source: The Commonwealth Fund, from HCFA s Medicare: A Profile, February 1995.

22 Over-treatment Medicare spent about $600 billion last year. About 80% of Medicare dollars spent on the sickest 10% of patients For many, life expectancy is less than 6 to 12 months

23 Polypharmacy 65 and older use 30% of all prescription meds Average meds between 4-5. More than 10 to 12 meds are not uncommon. Elderly are more sensitive to side effects. Drug-drug interactions Drug-condition interactions are common.

24 Polypharmacy

25 Hidden Illnesses Vision Hearing Dentition Sleep Disorders Constipation Falls Mentation Incontinence Foot problems Dizziness Depression Sexual Dysfunction

26 Death from falls

27 Alzheimer s, vascular, Lewy Body, Parkinson s, etc 50% of dementia diagnosis after age 85 There is no cure Dementia Treatment is focused on support, safety, and quality of life Caregiver and LTC issues Driving concerns Advance care planning

28

29 What is advance care planning? 1. Discussion about future medical goals of care 2. Discussion about end of life issues 3. Designating a healthcare power of attorney

30 Historical background Events Challenges Result 1975 Karen Quinlan 1983 Nancy Cruzan Physicians and hospital refused to withdraw life-support despite family wishes Right to refuse treatment 1990 Terri Schiavo Individual, state, and federal conflicts in right to die with dignity Various states began accepting advance directives (CA in 1976, NC in 1977) 1990 Self Determination Act (allow for advance directive) 1991 NC allowed the use of advance directives and HCPOA 2007 NC House Bill 634

31 Advance Care Planning It is a planning and discussion process Paperwork is never the ultimate goal Advance directives can prevent confusion and conflict over healthcare decisions It is imperative that patients discuss their decisions with the family or designated surrogate decisionmakers

32 Resources NC Living Will HCPOA form DNR form MOST form (Medical Orders for Scope of Treatment) Five Wishes

33 In North Carolina ACP registries https://www.secretary.state.nc.us/ahcdr/ In US In local regions and hospitals

34 If no ACP??? 1. Patient 2. Healthcare agent (from HCPOA) 3. Guardian 4. A general power of attorney with powers to make healthcare decisions 5. The patient s spouse 6. A majority of the patient s reasonably available parents and children over age A majority of reasonably available siblings over age Individuals who has established relationship with patient

35

36 Summary The first wave of the silver tsunami is already here The rest of the tsunami is coming! Strategies needed for LTC options and adequate caregiver Consider LTC insurance Monitor for elder abuse Screen but don t overscreen Treat but don t overtreat Avoid polypharmacy Dementia and caregiving will become societal issue Falls can be fatal ACP is important ACP takes time

37 Best and easiest resource Area Agency on Aging (for each region) Council on Aging (for each county) Information and referrals Home delivered meals Senior centers Caregivers Medical transportation Healthcare and insurance questions Nutritional supplement program Other caregiving supplies

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