An Overview of Health Care Issues Specific to the Elderly

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An Overview of Health Care Issues Specific to the
Elderly

• John Puxty
• Queens University
• puxtyj_at_post.queensu.ca

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Problems Facing Hospitals Regarding Services to
the Elderly

• Demographic pressures

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Population Age Distribution
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Distribution of Elderly in 2001
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Distribution of Elderly in 2021
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Use of Hospitals in Ontario by Age 1995-96

• 65-74 age group (7.2) account for 18-22 AE use
  and 14 hospital separations
• 75 age group (5.6) account for 22-26 AE use
  and 23 separations

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Use of KGH Emergency Department 1998-99

• 65 group accounted for 21 emergency room use
  and 48.6 admissions from emergency
• Over 40 of those over 75 years attending
  emergency were admitted compared to less than 12
  below 65 years of age

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Problems Facing Hospitals Regarding Services to
the Elderly

• Demographic pressures
• Budget constraints

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Average Per Capita Expenditure on Health
N.B. Aging of pop. accounts for less 5 rise in
hospital cost 1961-90 (Angus et al 1995)
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Problems Facing Hospitals Regarding Services to
the Elderly

• Demographic pressures
• Budget constraints
• Acute and Complex Continuing Care cuts

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HSRC Directed Hospital and LTC Changes
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Problems Facing Hospitals Regarding Services to
the Elderly

• Demographic pressures
• Budget constraints
• Acute and complex continuing care cuts
• Systems change lacks synchronization

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Normal Aging

• Despite stereotype most of the elderly age well!

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Normal Aging

• Despite stereotype most of the elderly age well!
• Most of our images are based on the frail sub-set
  who frequently use medical services

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Normal Aging

• Despite stereotype most of the elderly age well!
• Most of our images are based on the frail sub-set
  who frequently use medical services
• Generally normal aging in associated with a
  reduction in functional reserve capacity in
  tissues and organs

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Age related change in function reserves
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Normal Aging

• Despite stereotype most of the elderly age well!
• Most of our images are based on the frail sub-set
  who frequently use medical services
• Generally normal aging in associated with a
  reduction in functional reserve capacity in
  tissues and organs
• At advanced age more common to see evidence of
  impaired homeostasis and response to external
  insults eg illness

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Presentation of Disease in the Elderly

• Classical
• Silent
• Pseudosilent
• Atypical Presentations Weakness/Fatigue Dwin
  dles Falls/Immobility Incontinence Co
  gnition/Mood Change Social Crisis

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Traditional medical approaches do not cater for
the heterogeneity of disease in the elderly!
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Significance of the Atypical Presentation

• Presence associated with delay in diagnosis and
  increased mortality (Puxty et al 1984)
• Predictive of future functional declines in
  community elderly (Choo et al 1998)
• Functional decline (dwindles) increases
  likelihood of further decline and increased
  mortality (Hebert et al1997)

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Predictors of Atypical Presentation (Frailty)

• Extreme age
• Visual loss
• Impaired cognition/mood
• Limb weakness
• Abnormalities of gait and balance
• Malnutrition
• Sedative use
• Multiple chronic diseases

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Acute illness superimposed on Frailty

• Multiple organ stress
• Failure of homeostasis
• Potential exacerbation of chronic diseases
• Increased potential for drug interactions and
  adverse effect
• Increased vulnerability to delirium, falls and
  incontinence with caregiver stress

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Clinicians general approach to the Atypical
Presentation

• Consider recent change in function a result of
  disease or drugs until proven otherwise
• Longitudinal multiple assessments often necessary
• Additional informants often invaluable
• Appropriate screening investigations have a role
• Multiple pathologies are the rule

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Problems Facing the Elderly admitted to Hospital

• Diagnostic Challenge
• Hospitalization creates problems

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Problems Facing the Elderly admitted to Hospital
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Functional Decline Associated With
Hospitalization
(Sager et al 1996)
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Frailty is a dynamic state
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Negative Consequences of Reduced LOS
Polypharmacy Less rehabilitation Multiple
admissions Community services stressed Crisis
admissions to LTC
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Problems Facing the Elderly admitted to Hospital

• Diagnostic Challenge
• Hospitalization creates problems
• Lack of bench marks for geriatric services

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Lack of Accepted Bench Marks

• BGS recommended 6-7 beds per 1000 over 75.
  Equivalent to 3,423-3,994 beds for Ontario
  compared to 310 within RGP services!
• HSRC declined to comment on specialized
  geriatric services

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Evidence for Improved Outcomes of GAU

• Reduce mortality 37 (Rubinstein LZ et al JAGS
  1991 3917s-18s)
• Increased likelihood of home discharge odds
  ratio 1.68 and functional outcome (stuck AE et
  al lancet 1993 3421032-6)
• Reduced LOS (Pawson G JAGS 1988)

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Examples of Best Practice Models

• ACE Hospital units (Landerfield et al, NEJM 1997)
• Rehabilitation in sub-acute care units
• Case management of CCF in the elderly (Rich et
  al, NEJM 1995)
• Case identification in emergency dept using ISAR
  (McCusker et al JAGS 1999)

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Small changes can result in major functional
gains!
Medications Foot wear Walking aides Surface
heights Chairs/bed Wall bars Lighting Flooring/mat
s
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Conclusions (1)

• Aging of the population will result in 25 of the
  population being over 65 by 2030
• The majority of the elderly are well and enjoy a
  reasonable socio-economic status
• A small but significant subset of frail,
  vulnerable elderly account for an excess of
  adverse socio-economic and health care outcomes
• A typical profile is the very old, female, living
  alone, with multiple chronic diseases and taking
  multiple medications
• The presence of acute illness should be suspected
  with recent unexpected functional decline

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Conclusions (2)

• Acute care hospitals are in the aging business
• Present care systems do not respond to needs of a
  significant subgroup of the ill elderly who
  present atypically
• High-risk groups in emergency and hospital can be
  identified
• Specialized geriatric services through clincial,
  education and evaluation are cost-effective parts
  of the health care continuum