Geriatric Medicine

Laura DeFina, M.D., a geriatric medicine doc at Cooper Clinic gave a great presentation this afternoon. Part Nancy Drew, part Girl Scout, I'm convinced that DeFina is the "go to" person for anyone who is older and has a complex medical situation. On top of her book smarts, DeFina is also someone who clearly likes hands-on patient care - in addition to being competent, she's also compassionate and concerned.

DeFina started out by stating that the goal for the geriatric patient is to maintain independence, while being in a safe and happy living environment. A lot of factors and moving parts are involved in making this happen. Some of the moving parts are:

• Memory Loss - 1 in 10 Americans over 65 years of age have some memory loss. 50 percent of those 85+ have memory loss. From a genetic standpoint, researchers are seeing that a family history of memory loss on our maternal side increases our personal risk of memory loss.
• Mood Disorders - Depression is under diagnosed and under treated. Part of the problem is a generational thing - younger people walk in and announce they are depressed/blue/sad, while older people are more likely to not offer the information. There's a geriatric depression test with 30 questions that's available. I found a copy of the test online at this link http://www.depression-help-resource.com/geriatric-depression-scale.pdf.
• Osteoporosis
• Vitamin B-12 deficiency seems to be more common in seniors. DeFina covered a bunch of reasons this might be true, but my take away was that it's important to get tested as getting a B-12 deficiency back to normal can get more difficult the worse it is. (Normal is 250 - 1,100 pg/ml; for seniors the level should probably be 400 pg/ml and higher.)
• Falls
• Urinary Incontinence is apparently a giant and under-reported issue for older women, and tends to result in increased isolation since there are fears of being smelly, having accidents, being too far from a bathroom, etc. Behavioral interventions are the first line of treatment though, with medication and surgery possibilities if that doesn't work. (I hope if I end up with this problem I will have the trust in my doctor that I'm willing to report the problem and attempt to get help.)
• Vision & Hearing Loss - The number one recommendation for maintaining good eye health/vision is to wear UV protecting sunglasses. (This is the second time I have heard this in a week.) As for hearing loss, apparently ear wax is a huge problem. DeFina apparently helps patients get their ear wax under control when she sees them, but says that good ear wax removal products are available at the drug store. We also need to wear earphones when we're in loud environments.
• Polypharmacy - Lots of seniors are taking 6, 8 or 10 drugs. Many of the drugs are unnecessary, many of the drugs are generally obsolete (with patients having been on them for decades!), and there's a long list of drugs that "worsen activities of daily living." While DeFina says that sometimes the drugs on this list are appropriate for certain seniors, we need to really think about what we're doing when we make these particular drug choices - http://www.dcri.duke.edu/ccge/curtis/beers.html
• Over the Counter Meds need to be included in the mix of information we share with our doctors. For example, DeFina says that seniors should not take Benedryl because it carries too much of a risk for general 'fuzziness.' According to her, lots of seniors take the allergy medication because of insomnia. However, there are apparently good, safe prescription medications that can help with insomnia and don't have the bad side effects.
• Failure to Thrive!
• Pain - While it's unrealistic to expect a complete absence of pain for some ongoing pain conditions, it is reasonable for seniors to expect good pain management. I was surprised that Tylenol "around the clock" on an ongoing long term basis is said to be so helpful in managing pain.

From a preventive standpoint, it's imperative that we aggressively manage cardiovascular risk factors. And, seniors need encouragement to stay physically, mentally, spiritually and socially active.

As far as exercise goes, seniors need cardio (walking, aquatics, recumbent cycle), strength training and flexibility training. Tai Chi is also great. For someone new or returning to exercise after a long absence, increasing exercise time by 2- to 5 minutes is appropriate. Also, a couple of 10-minute exercise periods each day are as effective as one block of 30- or 40 minutes.

Finally, we heard about how to make emergency care easier. To make emergency medical treatment more effective, keep a typed list of medications (include dosage) and supplements, and other critical medical info either on- or in- the refrigerator. According to DeFina, lots of EMT folks know to look on the refrigerator or in the refrigerator for this info if they come to our house. Listing medical conditions, and all the names/phone numbers/addresses of all our doctors also makes sense.