Eye Care Professional. Disclosure Statement Nothing to disclose

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1 Understanding Your Challenging Geriatric Cases: Gerontology Insights For the Eye Care Professional John E. Kaminski, OD, FAAO Mid-Michigan Eye Care in Midland, MI Adjunct Faculty Central Michigan University h Disclosure Statement Nothing to disclose Please silence all mobile devices. Unauthorized recording of this session is prohibited. Learning Objectives: To understand the relevance of gerontology in clinical practice. To become familiar with key aging concepts and demographics. To better gather and utilize information from the patient social history. To review how common medical conditions affecting older adults impact geriatric care. To understand the interdisciplinary treatment plan. 1

2 Introduction Why study gerontology? We do already. Convincing demographics. Needs of older adults increasing: More eye and vision problems. Adaptive p examination techniques. Specialized treatment plans. Stereotypes affect patient care. Key Aging Concepts An increased succeptibility to the environment. Successful Aging (Rowe and Kahn, 1997): 3 Attributes t Involves individual activity combined with societal policies and arrangements. Generally, living independently. Extending an active life expectancy (for quality of an extended life). Living arrangements of your patients: Level of care required. Family structure and values. Socioeconomic status. Interdisciplinary Care Model 2

3 Ms. R., an 86 year old with hearing impairment, COPD, limited mobility, and cataract. Ms. R. lives with her spouse in a retirement community. Subjective CC/HCC: blur with reading fine print and when moving around home. Hard to get glasses right when locating items in bag attached to her walker. POH: last eye care 2 years ago, FT-28 spectacle design with add, dx with cataract 4 years ago, uses magnifier (now ineffective). PMH: S/P hip replacement 1 year ago, severe hearing impairment (part time use of old hearing aid), COPD, HTN. SH: smoked for 30 years, retired teacher, lives with spouse (deteriorating health) in a CCRC, D/C driving 4 years ago. MED: Theophylline, Atrovent, Alberterol, Lisinopril, Tylenol #3, Oxygen Ms. R., an 86 year old with hearing impairment, COPD, limited mobility, and cataract. Ms. R. lives with her spouse in a retirement e e t community. Objective Vision Function: 20/60 OD, 20/50 OS. Mild refractive error change OU. Reads 20/25 at 30cm with add and supplemental lighting. Adopts near working distance well. Full visual field. Ocular Health: Gr III NSC OD>OS. Mood/ Effect: Slow responses. Lack of motivation. Directions misunderstood during testing. Oriented to PPT (asked slow and low). 3

4 Ms. R., an 86 year old with hearing impairment, COPD, limited mobility, and cataract. Ms. R. lives with her spouse in a retirement community. Assessment Mild vision impairment (WHO classification) secondary to cataract. Current flat top bifocal spectacle design interferes with mobility, use of walker, and increases risk for falls. Cataract surgery candidate, patient overwhelmed to pursue. IADL limitations. Ms. R., an 86 year old with hearing impairment, COPD, limited mobility, and cataract. Ms. R. lives with her spouse in a retirement community. Plan Rx DVO and NVO spectacle lens designs. Rx higher add power (+4.00 net add). Recommend direct lighting for reading activities and improve diffuse lighting in living area. Educate and reassure about the benefits of cataract surgery. Communication with caregivers at CCRC: Larger print items (e.g. menu) can help overcome her visual limitations. Hospice assistance. 4

5 Ms. R., an 86 year old with hearing impairment, COPD, limited mobility, and cataract. Ms. R. lives with her spouse in a retirement community. Gerontology Insights CCRC living arrangement. Needs of those with ADL and IADL losses. PPT significance and MMSE. Falls: 5 th leading cause of death in the elderly AAO Plenary session: Multifocal wearers 2.29 times more likely to fall as non-multifocal wearers (Lord, et al, 2002, JAGS). 3 stages of widowhood. Mr. E., a 73 year old with moderate dementia and macular degeneration. Mr. E. is a widower and lives with his daughter. Subjective Cc/HCC: Blurred vision since glasses broken (pt provides little information). POH: LEE 1 month ago. Spectacles 1 year old: mild astigmatism, add. Daughter (present) asserts that spectacles are not worn all the time. Mr. E s ophthalmologist follows him for AMD. PMH: Moderate dementia, multiple TIAs with mild hemiparesis, HTN, hypercholesterolemia. SH: Retired factory worker, D/C driving 1 year ago, lives with only daughter (her and her husband work, have 3 children), daily in- home health care. Mr. E. s activities are limited to TV and listening to music. MED: Aricept, ASA, Tenormin, Atorvastatin, Plavix. 5

6 Mr. E., a 73 year old with moderate dementia and macular degeneration. Mr. E. is a widower and lives with his daughter. Objective Vision Function: 20/30 OD, 20/25 OS with stable astigmatic refractive error. 20/25 near acuity. Full peripheral visual field, moderate central visual field metmorphopsia. Ocular Health: Maculopathy (soft and hard scattered drusen). Mood/ Effect: Nervous and agitated. Does not assert his position. Pauses during testing, looses concentration. Questionable orientation to PPT. Mr. E., a 73 year old with moderate dementia and macular degeneration. Mr. E. is a widower and lives with his daughter. Assessment Cognitive impairment reduces spectacle use. Spectacle use indicated part time. AMD, high risk of visual impairment. Suspect significant caregiver stress. ADL < IADL limitations. 6

7 Mr. E., a 73 year old with moderate dementia and macular degeneration. Mr. E. is a widower and lives with his daughter. Plan Spectacle use for occasional near tasks, educate caregiver. Continue ocular health management with retinal specialist. Above and Beyond? Inquire about caregiver stress. Recommend adult day care or respite care services. Mr. E., a 73 year old with moderate dementia and macular degeneration. Mr. E. is a widower and lives with his daughter. Gerontology Insights Adult day care arrangement. Older adults with dementia. TIA increase risk. Prevalence in 70 year old population. High caregiver demand. Caregiver stress and the sandwich generation. 1/3 work full or part time. Average period for caregiving 5-7 years. Elder abuse potential. 7

8 Ms. N., an 88 year old with advanced Alzheimer s disease and glaucoma. Ms. N. is a widow living in a specialized unit for Alzheimer s patients in a nursing home. Subjective CC/HCC: glaucoma progress examination. Uncertain visual status. Nursing staff suspects Ms. N. had glasses per discussions with family (out of state). The staff also is concerned about chronic discharge on eyelids. POH: COAG by tx hx, probable history of spectacle use. PMH: Advanced Alzheimer s disease, HTN. SH: Retired homemaker. Widowed 11 years. Nursing home resident 4 years, 24 hour care for ADL and IADL. Wears tether to control wandering. Unpredictable behavior. MED: Namenda, HCTZ, Xalatan QHS OU Ms. N., an 88 year old with advanced Alzheimer s disease and glaucoma. Ms. N. is a widow living in a specialized unit for Alzheimer s patients in a nursing home. Objective (caregiver assisted with examination). Vision Function: 20/30 range OU (acuity taken with near number acuity card), retinoscopy 2.25 OD, OS, alert to peripheral stimulus OU. Ocular Health: Perkins tonometry refused, globes soft to palpation. C/D =.80 range OU with Gr II pallor OU. Mood/ Effect: Easily agitated. Tactile defensiveness. Limited responsiveness. Not oriented to PPT 8

9 Ms. N., an 88 year old with advanced Alzheimer s disease and glaucoma. Ms. N. is a widow living in a specialized unit for Alzheimer s patients in a nursing home. Assessment Limited potential for subjective findings Objective testing difficult. Correction of high refractive error likely to aid visual attention. COAG, IOP and VF history uncertain. No gross mobility deficits noted. Significant blepharitis OU. Advanced ADL and IADL losses. Ms. N., an 88 year old with advanced Alzheimer s disease and glaucoma. Ms. N. is a widow living in a specialized unit for Alzheimer s patients in a nursing home. Plan Obtain and review old records then renew glaucoma medication Rx. Rx Polysporin and lid scrubs BID. Return visit (sedation?) to complete examination, check progress of blepharitis tx. Examine in different environment? Caregiver recommendations: Periodic lid scrubs during bathing. Incorporate spectacles into morning routine. 9

10 January 2005 AOA Journal Spectacles Used On Follow Up Examination By Right Eye Sphere Amounts n=35 th in R e fra c tiv e Group % Wi >=+/-0.25 n=35 of 76 >=+/-1.00 n=26 of 51 >=+/ n=19 of 28 >=+/-3.00 n=14 of 18 Figure 4 Ms. N., an 88 year old with advanced Alzheimer s disease and glaucoma. Ms. N. is a widow living in a specialized unit for Alzheimer s patients in a nursing home. Gerontology Insights Alzheimer patient care and behaviors. Demands on nursing staff. Preserving and maximizing vision function relevant. 10

11 Mr. L., a 67 year old with depression, moderate macular degeneration and has his driving status in jeopardy. Mr. L. is a recent widower and lives in his house of 40 years. Subjective CC/HCC: Mr. L. is angry after being told recently by his ophthalmologist that he could no longer drive despite having a good driving record. Mr. L. states that his glasses were not checked. Son and daughter (present) want their father to stop driving. POH: Slowly progressive dry AMD over past 3 years, current spectacles 1 year old (Rx: x 010 OD, x 177 OS, add OU). PMH: cardiac arrhythmia, sinusitis, depression, HTN, hypercholesterolemia. SH: Retired chemist with years of community service, spouse died 1 year ago, good financial resources, good family support system. MED: Paxil, Xanax, Ambien, Flonase, ASA, Simvastatin, Zetia Mr. L., a 67 year old with depression, moderate macular degeneration and has his driving status in jeopardy. Mr. L. is a recent widower and lives in his house of 40 years. Objective Vision Function:20/60 OD, 20/100 OS, refraction x 021 OD, x 176 OS. Reads 20/30 at 30cm!! Central visual field metmorphopsia OU. Ocular Health: Mild NSC OU. Maculopathy: Gr II RPE mottling and drusen OD<OS. Mood/ Effect: Mr. L. is upset and defensive about his vision. The loss of his wife has made the past year difficult. Oriented to PPT. Feels helpless and frustrated. Suspected (+) findings on GDS. 11

12 Mr. L., a 67 year old with depression, moderate macular degeneration and has his driving status in jeopardy. Mr. L. is a recent widower and lives in his house of 40 years. Assessment Good near fxn for add. Does not meet vision standards for drivers license. Bioptic driver candidate? AMD with secondary mild vision impairment OD and moderate vision impairment OS. Risk of loosing independence. Uncontrolled depression? Polypharmacy? Mr. L., a 67 year old with depression, moderate macular degeneration and has his driving status in jeopardy. Mr. L. is a recent widower and lives in his house of 40 years. Plan Refer for low vision eval. or Rx new distance powers with maintaining net add of OD (sph changed from to +1.50). Continue management with retinal specialist. Push for PE PC IOL? Above and beyond? Depression reevaluation or counseling? Medication rearrangement? Bereavement services of Hospice. 12

13 Mr. L., a 67 year old with depression, moderate macular degeneration and has his driving status in jeopardy. Mr. L. is a recent widower and lives in his house of 40 years. Gerontology Insights Males losing status and identity in society. Family support structure. Fear of moving. Widower with bereavement. GDS Conclusions Understanding common themes about aging can lead to better patient interactions. Sensitive geriatric case management techniques assist our view of the aged patient as an individual with a wide range of health care needs. 13