Kaminski - Summary Underst Chall Geri · PDF fileEye Care Professional John E. Kaminski, OD, FAAO ... Alzheimer’s patients in a nursing home. Plan ... blepharitis tx

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Understanding Your Challenging Geriatric Cases:

Gerontology Insights For the Gerontology Insights For the Eye Care Professional

John E. Kaminski, OD, FAAOMid-Michigan Eye Care in Midland, MI

Adjunct Faculty Central Michigan University

D t B dK j h k i ki@ hwww.DoctorsBandK.com [email protected]

Disclosure Statement

• Nothing to disclosePlease silence all mobile devices.Unauthorized recording of this session is prohibited.

Learning ObjectivesLearning Objectives::

To understand the relevance of gerontology To understand the relevance of gerontology in clinical practice.in clinical practice.in clinical practice.in clinical practice.

To become familiar with key aging concepts To become familiar with key aging concepts and demographics.and demographics.

To better gather and utilize information To better gather and utilize information from the patient social history.from the patient social history.

To review how common medical conditions To review how common medical conditions To review how common medical conditions To review how common medical conditions affecting older adults impact geriatric care.affecting older adults impact geriatric care.

To understand the interdisciplinary To understand the interdisciplinary treatment plan.treatment plan.

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IntroductionIntroductionWhy study gerontology?Why study gerontology?

––We do already.We do already.––Convincing demographics.Convincing demographics.––Needs of older adults increasing:Needs of older adults increasing:

More eye and vision problems.More eye and vision problems.Adaptive examination techniques.Adaptive examination techniques.p qp qSpecialized treatment plans.Specialized treatment plans.

––Stereotypes affect patient care.Stereotypes affect patient care.

Key Aging ConceptsKey Aging Concepts•• An increased succeptibility to the environment.An increased succeptibility to the environment.•• Successful Aging (Rowe and Kahn, 1997): Successful Aging (Rowe and Kahn, 1997):

3 Att ib t3 Att ib t3 Attributes3 Attributes Involves individual activity combined with Involves individual activity combined with

societal policies and arrangements.societal policies and arrangements.Generally, living independently.Generally, living independently.

•• Extending an Extending an activeactive life expectancy (for quality of life expectancy (for quality of an extended life).an extended life).))

•• Living arrangements of your patients:Living arrangements of your patients: Level of care required.Level of care required. Family structure and values.Family structure and values. Socioeconomic status.Socioeconomic status.

•• Interdisciplinary Care ModelInterdisciplinary Care Model

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Ms. R., an 86 year old with hearing impairment, Ms. R., an 86 year old with hearing impairment, COPD, limited mobility, and cataract.COPD, limited mobility, and cataract.

Ms. R. lives with her spouse in a retirement Ms. R. lives with her spouse in a retirement community.community.

SubjectiveSubjective CC/HCC: blur with reading fine print and when CC/HCC: blur with reading fine print and when

i d h H d t t l i ht i d h H d t t l i ht moving around home. Hard to get glasses right moving around home. Hard to get glasses right when locating items in bag attached to her when locating items in bag attached to her walker.walker.

POH: last eye care 2 years ago, FTPOH: last eye care 2 years ago, FT--28 spectacle 28 spectacle design with +2.50 add, dx with cataract 4 years design with +2.50 add, dx with cataract 4 years ago, uses magnifier (now ineffective). ago, uses magnifier (now ineffective).

PMH: S/P hip replacement 1 year ago, severe PMH: S/P hip replacement 1 year ago, severe hearing impairment (part time use of old hearing hearing impairment (part time use of old hearing aid), COPD, HTN.aid), COPD, HTN.), ,), ,

SH: smoked for 30 years, retired teacher, lives SH: smoked for 30 years, retired teacher, lives with spouse (deteriorating health) in a CCRC, with spouse (deteriorating health) in a CCRC, D/C driving 4 years ago.D/C driving 4 years ago.

MED: Theophylline, Atrovent, Alberterol, MED: Theophylline, Atrovent, Alberterol, Lisinopril, Tylenol #3, Oxygen Lisinopril, Tylenol #3, Oxygen

Ms. R., an 86 year old with Ms. R., an 86 year old with hearing impairment, COPD, hearing impairment, COPD,

limited mobility, and cataract.limited mobility, and cataract.Ms. R. lives with her spouse Ms. R. lives with her spouse in a retirement community.in a retirement community.a et e e t co u tya et e e t co u ty

ObjectiveObjective Vision Function: 20/60 OD, 20/50 OS. Mild refractive error change Vision Function: 20/60 OD, 20/50 OS. Mild refractive error change

OU. Reads 20/25 at 30cm with +4.00 add and supplemental OU. Reads 20/25 at 30cm with +4.00 add and supplemental lighting. Adopts near working distance well.lighting. Adopts near working distance well.

Full visual field.Full visual field. Ocular Health: Gr III NSC OD>OS.Ocular Health: Gr III NSC OD>OS. Mood/ Effect:Mood/ Effect: Mood/ Effect:Mood/ Effect:

–– Slow responses.Slow responses.–– Lack of motivation.Lack of motivation.–– Directions misunderstood during testing.Directions misunderstood during testing.–– Oriented to PPT (asked slow and low).Oriented to PPT (asked slow and low).

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AssessmentAssessmentAssessmentAssessment Mild vision impairment (WHO Mild vision impairment (WHO

classification) secondary to classification) secondary to cataract.cataract.

Current flat top bifocal spectacle Current flat top bifocal spectacle design interferes with mobility, design interferes with mobility, use of walker, and increases risk use of walker, and increases risk ,,for falls.for falls.

Cataract surgery candidate, Cataract surgery candidate, patient overwhelmed to pursue.patient overwhelmed to pursue.

IADL limitations.IADL limitations.



PlanPlanPlanPlan Rx DVO and NVO spectacle lens Rx DVO and NVO spectacle lens

designs. Rx higher add power designs. Rx higher add power (+4.00 net add).(+4.00 net add).

Recommend direct lighting for Recommend direct lighting for reading activities and improve reading activities and improve diffuse lighting in living area.diffuse lighting in living area.

Educate and reassure about the Educate and reassure about the Educate and reassure about the Educate and reassure about the benefits of cataract surgery.benefits of cataract surgery.

Communication with caregivers at Communication with caregivers at CCRC:CCRC:–– Larger print items (e.g. menu) can help Larger print items (e.g. menu) can help

overcome her visual limitations.overcome her visual limitations.–– Hospice assistance.Hospice assistance.

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Ms. R., an 86 year old with hearing impairment, COPD, limited Ms. R., an 86 year old with hearing impairment, COPD, limited mobility, and cataract. Ms. R. lives with her spouse in a mobility, and cataract. Ms. R. lives with her spouse in a

retirement community.retirement community.

Gerontology InsightsGerontology Insightsgy ggy g CCRC living arrangement.CCRC living arrangement. Needs of those with ADL and IADL losses.Needs of those with ADL and IADL losses. PPT significance and MMSE.PPT significance and MMSE. Falls: 5Falls: 5thth leading cause of death in the elderly. 2007 AAO leading cause of death in the elderly. 2007 AAO

Plenary session: Multifocal wearers 2.29 times more likely to fall Plenary session: Multifocal wearers 2.29 times more likely to fall as nonas non--multifocal wearers (Lord, et al, 2002, JAGS).multifocal wearers (Lord, et al, 2002, JAGS).

3 stages of widowhood.3 stages of widowhood.

Mr. E., a 73 year old with moderate dementia Mr. E., a 73 year old with moderate dementia and macular degeneration. Mr. E. is a and macular degeneration. Mr. E. is a widower and lives with his daughterwidower and lives with his daughter..

SubjectiveSubjective Cc/HCC: Blurred vision since glasses broken Cc/HCC: Blurred vision since glasses broken

( t id littl i f ti )( t id littl i f ti )(pt provides little information).(pt provides little information). POH: LEE 1 month ago. Spectacles 1 year POH: LEE 1 month ago. Spectacles 1 year

old: mild astigmatism, +2.50 add. Daughter old: mild astigmatism, +2.50 add. Daughter (present) asserts that spectacles are not worn (present) asserts that spectacles are not worn all the time. Mr. E’s ophthalmologist follows all the time. Mr. E’s ophthalmologist follows him for AMD.him for AMD.

PMH: Moderate dementia, multiple TIAs with PMH: Moderate dementia, multiple TIAs with mild hemiparesis, HTN, hypercholesterolemia.mild hemiparesis, HTN, hypercholesterolemia.

SH: Retired factory worker, D/C driving 1 SH: Retired factory worker, D/C driving 1 SH: Retired factory worker, D/C driving 1 SH: Retired factory worker, D/C driving 1 year ago, lives with only daughter (her and year ago, lives with only daughter (her and her husband work, have 3 children), daily inher husband work, have 3 children), daily in--home health care. Mr. E.’s activities are home health care. Mr. E.’s activities are limited to TV and listening to music.limited to TV and listening to music.

MED: Aricept, ASA, Tenormin, Atorvastatin, MED: Aricept, ASA, Tenormin, Atorvastatin, Plavix.Plavix.

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Mr. E., a 73 year old with Mr. E., a 73 year old with moderate dementia and moderate dementia and

macular degeneration. Mr. E. macular degeneration. Mr. E. is a widower and lives with is a widower and lives with

his daughterhis daughterhis daughterhis daughter..

ObjectiveObjective Vision Function: 20/30 OD, 20/25 OS with stable astigmatic Vision Function: 20/30 OD, 20/25 OS with stable astigmatic

refractive error. 20/25 near acuity.refractive error. 20/25 near acuity. Full peripheral visual field, moderate central visual field Full peripheral visual field, moderate central visual field

metmorphopsia.metmorphopsia. Ocular Health: Maculopathy (soft and hard scattered drusen)Ocular Health: Maculopathy (soft and hard scattered drusen) Ocular Health: Maculopathy (soft and hard scattered drusen).Ocular Health: Maculopathy (soft and hard scattered drusen). Mood/ Effect:Mood/ Effect:

–– Nervous and agitated.Nervous and agitated.–– Does not assert his position.Does not assert his position.–– Pauses during testing, looses concentration.Pauses during testing, looses concentration.–– Questionable orientation to PPT.Questionable orientation to PPT.

Mr. E., a 73 year old with moderate Mr. E., a 73 year old with moderate dementia and macular degeneration. Mr. E. dementia and macular degeneration. Mr. E.

is a widower and lives with his daughteris a widower and lives with his daughter..

AssessmentAssessmentAssessmentAssessment Cognitive impairment reduces Cognitive impairment reduces

spectacle use.spectacle use. Spectacle use indicated part time.Spectacle use indicated part time. AMD, high risk of visual AMD, high risk of visual

impairment.impairment.ff Suspect significant caregiver Suspect significant caregiver

stress.stress. ADL < IADL limitations.ADL < IADL limitations.

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PlanPlanS t l f i l S t l f i l Spectacle use for occasional Spectacle use for occasional near tasks, educate caregiver.near tasks, educate caregiver.

Continue ocular health Continue ocular health management with retinal management with retinal specialist.specialist.Ab d B d?Ab d B d? Above and Beyond?Above and Beyond?–– Inquire about caregiver stress.Inquire about caregiver stress.–– Recommend adult day care or Recommend adult day care or

respite care services.respite care services.


Gerontology InsightsGerontology Insights Adult day care arrangementAdult day care arrangement Adult day care arrangement.Adult day care arrangement. Older adults with dementia.Older adults with dementia.

–– TIA increase risk.TIA increase risk.–– Prevalence in 70 year old population.Prevalence in 70 year old population.–– High caregiver demand.High caregiver demand.

Caregiver stress and the “sandwich” generation.Caregiver stress and the “sandwich” generation.–– 1/3 work full or part time.1/3 work full or part time.–– Average period for caregiving 5Average period for caregiving 5--7 years.7 years.–– Elder abuse potential.Elder abuse potential.

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Ms. N., an 88 year old with advanced Ms. N., an 88 year old with advanced Alzheimer’s disease and glaucoma. Ms. N. is a Alzheimer’s disease and glaucoma. Ms. N. is a

widow living in a specialized unit for widow living in a specialized unit for Alzheimer’s patients in a nursing home.Alzheimer’s patients in a nursing home.

SubjectiveSubjectiveSubjectiveSubjective CC/HCC: glaucoma progress examination. CC/HCC: glaucoma progress examination.

Uncertain visual status. Nursing staff Uncertain visual status. Nursing staff suspects Ms. N. had glasses per discussions suspects Ms. N. had glasses per discussions with family (out of state). The staff also is with family (out of state). The staff also is concerned about chronic discharge on concerned about chronic discharge on eyelids.eyelids.

POH: COAG by tx hx, probable history of POH: COAG by tx hx, probable history of spectacle use.spectacle use.

PMH: Advanced Alzheimer’s disease HTNPMH: Advanced Alzheimer’s disease HTN PMH: Advanced Alzheimer s disease, HTN.PMH: Advanced Alzheimer s disease, HTN. SH: Retired homemaker. Widowed 11 SH: Retired homemaker. Widowed 11

years. Nursing home resident 4 years, 24 years. Nursing home resident 4 years, 24 hour care for ADL and IADL. Whour care for ADL and IADL. Wears tether ears tether to control wandering. to control wandering. Unpredictable Unpredictable behavior.behavior.

MED: Namenda, HCTZ, Xalatan QHS OUMED: Namenda, HCTZ, Xalatan QHS OU

Ms. N., an 88 year old with Ms. N., an 88 year old with advanced Alzheimer’s disease advanced Alzheimer’s disease

and glaucoma. Ms. N. is a and glaucoma. Ms. N. is a widow living in a specialized widow living in a specialized

unit for Alzheimer’s patients in a unit for Alzheimer’s patients in a nursing home.nursing home.

Objective Objective (caregiver assisted with examination).(caregiver assisted with examination). Vision Function: 20/30 range OU (acuity taken with near number Vision Function: 20/30 range OU (acuity taken with near number

acuity card), retinoscopy acuity card), retinoscopy ––2.25 OD, 2.25 OD, --3.50 OS, alert to peripheral 3.50 OS, alert to peripheral stimulus OUstimulus OUstimulus OU.stimulus OU.

Ocular Health: Perkins tonometry refused, globes soft to palpation. Ocular Health: Perkins tonometry refused, globes soft to palpation. C/D = .80 range OU with Gr II pallor OU.C/D = .80 range OU with Gr II pallor OU.

Mood/ Effect:Mood/ Effect:–– Easily agitated.Easily agitated.–– Tactile defensiveness.Tactile defensiveness.–– Limited responsiveness.Limited responsiveness.–– Not oriented to PPTNot oriented to PPT

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Ms. N., an 88 year old with Ms. N., an 88 year old with advanced Alzheimer’s disease advanced Alzheimer’s disease

and glaucoma. Ms. N. is a and glaucoma. Ms. N. is a widow living in a specialized widow living in a specialized

unit for Alzheimer’s patients in unit for Alzheimer’s patients in a nursing homea nursing homea nursing home.a nursing home.

AssessmentAssessment Limited potential for subjective findingsLimited potential for subjective findings Objective testing difficult.Objective testing difficult. Correction of high refractive error likely to Correction of high refractive error likely to

aid visual attentionaid visual attentionaid visual attention.aid visual attention. COAG, IOP and VF history uncertain. No COAG, IOP and VF history uncertain. No

gross mobility deficits noted.gross mobility deficits noted. Significant blepharitis OU.Significant blepharitis OU. Advanced ADL and IADL losses.Advanced ADL and IADL losses.

Ms. N., an 88 year old with advanced Ms. N., an 88 year old with advanced Alzheimer’s disease and glaucoma. Ms. N. is a Alzheimer’s disease and glaucoma. Ms. N. is a

widow living in a specialized unit for widow living in a specialized unit for Alzheimer’s patients in a nursing home.Alzheimer’s patients in a nursing home.

PlanPlanPlanPlan Obtain and review old records then Obtain and review old records then

renew glaucoma medication Rx.renew glaucoma medication Rx. Rx Polysporin and lid scrubs BID. Rx Polysporin and lid scrubs BID. Return visit (sedation?) to complete Return visit (sedation?) to complete

examination, check progress of examination, check progress of blepharitis txblepharitis txblepharitis tx.blepharitis tx.

Examine in different environment?Examine in different environment? Caregiver recommendations:Caregiver recommendations:

–– Periodic lid scrubs during bathing.Periodic lid scrubs during bathing.–– Incorporate spectacles into morning Incorporate spectacles into morning

routine.routine.

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Spectacles Used On Follow Up Examination

January 2005 AOA Journal

By Right Eye Sphere Amounts n=35

20

40

60

80

100

thin

Ref

ract

ive

Gro

up

0

20

>=+/-0.25 n=35 of 76

>=+/-1.00 n=26 of 51

>=+/- 2.00 n=19 of 28

>=+/-3.00 n=14 of 18

Figure 4

% W

i

Ms. N., an 88 year old with advanced Alzheimer’s Ms. N., an 88 year old with advanced Alzheimer’s disease and glaucoma. Ms. N. is a widow living in disease and glaucoma. Ms. N. is a widow living in

a specialized unit for Alzheimer’s patients in a a specialized unit for Alzheimer’s patients in a nursing home.nursing home.

Gerontology InsightsGerontology Insights Alzheimer patient care and behaviors.Alzheimer patient care and behaviors. Demands on nursing staff.Demands on nursing staff. Preserving and maximizing vision function relevant.Preserving and maximizing vision function relevant.

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Mr. L., a 67 year old with depression, Mr. L., a 67 year old with depression, moderate macular degeneration and has his moderate macular degeneration and has his driving status in jeopardy. Mr. L. is a recent driving status in jeopardy. Mr. L. is a recent widower and lives in his house of 40 yearswidower and lives in his house of 40 years..

SubjectiveSubjectivejj CC/HCC: Mr. L. is angry after being told recently CC/HCC: Mr. L. is angry after being told recently

by his ophthalmologist that he could no longer by his ophthalmologist that he could no longer drive despite having a good driving record. Mr. L. drive despite having a good driving record. Mr. L. states that his glasses were not checked. Son states that his glasses were not checked. Son and daughter (present) want their father to stop and daughter (present) want their father to stop driving.driving.

POH: Slowly progressive dry AMD over past 3 POH: Slowly progressive dry AMD over past 3 years, current spectacles 1 year old (Rx: +2.50 years, current spectacles 1 year old (Rx: +2.50 --0.25 x 010 OD, +3.00 0.25 x 010 OD, +3.00 --0.25 x 177 OS, +2.50 add 0.25 x 177 OS, +2.50 add OU).OU).OU).OU).

PMH: cardiac arrhythmia, sinusitis, depression, PMH: cardiac arrhythmia, sinusitis, depression, HTN, hypercholesterolemia.HTN, hypercholesterolemia.

SH: Retired chemist with years of community SH: Retired chemist with years of community service, spouse died 1 year ago, good financial service, spouse died 1 year ago, good financial resources, good family support system.resources, good family support system.

MED: Paxil, Xanax, Ambien, Flonase, ASA, MED: Paxil, Xanax, Ambien, Flonase, ASA, Simvastatin, ZetiaSimvastatin, Zetia

Mr. L., a 67 year old with Mr. L., a 67 year old with depression, moderate macular depression, moderate macular

degeneration and has his driving degeneration and has his driving status in jeopardy. Mr. L. is a status in jeopardy. Mr. L. is a

recent widower and lives in his recent widower and lives in his house of 40 yearshouse of 40 years..house of 40 yearshouse of 40 years..

ObjectiveObjective Vision Function:20/60 OD, 20/100 OS, refraction +1.50 Vision Function:20/60 OD, 20/100 OS, refraction +1.50

--0.50 x 021 OD, +2.25 0.50 x 021 OD, +2.25 --0.25 x 176 OS. Reads 20/30 0.25 x 176 OS. Reads 20/30 at 30cm!!at 30cm!!

Central visual field metmorphopsia OU.Central visual field metmorphopsia OU. Ocular Health: Mild NSC OU. Maculopathy: Gr II RPE Ocular Health: Mild NSC OU. Maculopathy: Gr II RPE p yp y

mottling and drusen OD<OS.mottling and drusen OD<OS. Mood/ Effect:Mood/ Effect:

–– Mr. L. is upset and defensive about his vision.Mr. L. is upset and defensive about his vision.–– The loss of his wife has made the past year difficult.The loss of his wife has made the past year difficult.–– Oriented to PPT.Oriented to PPT.–– Feels helpless and frustrated.Feels helpless and frustrated.–– Suspected (+) findings on GDS.Suspected (+) findings on GDS.

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Mr. L., a 67 year old with Mr. L., a 67 year old with depression, moderate macular depression, moderate macular

degeneration and has his driving degeneration and has his driving status in jeopardy. Mr. L. is a status in jeopardy. Mr. L. is a

recent widower and lives in his recent widower and lives in his house of 40 yearshouse of 40 yearshouse of 40 yearshouse of 40 years..

AssessmentAssessment Good near fxn for +2.50 add.Good near fxn for +2.50 add. Does not meet vision standards for drivers Does not meet vision standards for drivers

license. Bioptic driver candidate?license. Bioptic driver candidate? AMD with secondary mild vision impairment OD AMD with secondary mild vision impairment OD AMD with secondary mild vision impairment OD AMD with secondary mild vision impairment OD

and moderate vision impairment OS.and moderate vision impairment OS. Risk of loosing independence. Risk of loosing independence. Uncontrolled depression?Uncontrolled depression? Polypharmacy?Polypharmacy?


PlanPlan Refer for low vision eval. or Rx Refer for low vision eval. or Rx

new distance powers with new distance powers with maintaining net add of +3.50 OD maintaining net add of +3.50 OD (sph changed from +2.50 to (sph changed from +2.50 to +1.50).+1.50).

Continue management with Continue management with retinal specialist. Push for PE PC retinal specialist. Push for PE PC IOL?IOL?IOL?IOL?

Above and beyond?Above and beyond?–– Depression reevaluation or Depression reevaluation or

counseling?counseling?–– Medication rearrangement?Medication rearrangement?–– Bereavement services of Hospice.Bereavement services of Hospice.

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Gerontology InsightsGerontology InsightsGerontology InsightsGerontology Insights Males losing status and identity in society.Males losing status and identity in society. Family support structure.Family support structure. Fear of moving.Fear of moving. Widower with bereavement.Widower with bereavement. GDSGDS

ConclusionsConclusions

Understanding common themes Understanding common themes Understanding common themes Understanding common themes about aging can lead to better about aging can lead to better patient interactions.patient interactions.

Sensitive geriatric case management Sensitive geriatric case management t h i i t i f th t h i i t i f th techniques assist our view of the techniques assist our view of the aged patient as an individual with a aged patient as an individual with a wide range of health care needs.wide range of health care needs.

Documents

Kaminski - Summary Underst Chall Geri · PDF fileEye Care Professional John E. Kaminski, OD, FAAO ... Alzheimer’s patients in a nursing home. Plan ... blepharitis tx