CHAPTER 10

Geriatrics

The median age of the world’s population is increasing almost exponentially. In the United States, the proportion of the population aged 65 years and older is projected to increase from 12.4% in 2000 to 19.6% in 2030, and the number of persons aged 80 years and older is expected to increase from 9.3 million in 2000 to 19.5 million in 2030. Worldwide, over the same period, the population aged 65 years and older is projected to increase by approximately 550 million, to 973 million, from 6.9% to 12.0%. In some regions, projected increases are still greater: from 15.5% to 24.3% in Europe, 12.6% to 20.3% in North America, 6.0% to 12.0% in Asia, and 5.5% to 11.6% in Latin America and the Caribbean. An expanding older population presents a growing challenge to primary care physicians and medical subspecialists in the United States and Western Europe.

Ophthalmology is one specialty that is already significantly affected by this demographic shift. Cataracts, age-related macular degeneration (AMD), ischemic optic neuropathy, giant cell arteritis, diabetic retinopathy, and glaucoma are all diseases that disproportionately affect older persons.

Ophthalmologists may be expert in dealing with ophthalmic problems in the geriatric population, but they do not identify and manage geriatric problems in general. In the past, most medical specialties (including ophthalmology) followed the traditional medical paradigm of diagnosis of illness, treatment of disease, and measurement of objective outcomes. The subspecialty of geriatrics emphasizes a different medical paradigm of functional assessment and a more holistic approach to patient care. Geriatricians focus on the unique needs of older individuals, distinguishing between disease and the effects of normal aging. Ophthalmologists are specifically qualified to work with the geriatrician or primary care physician in evaluating and managing older patients with impaired vision.

The ophthalmologist’s role in this multidisciplinary evaluation is to communicate the visual limitations and visual needs of the older patient to the geriatrician and to contribute to the integrated goals of the care plan. The ophthalmologist should also be able to recognize the effect of vision loss on function. Referral for vision rehabilitation is appropriate for patients with acuity less than 20/40, central scotomata, visual field loss, or contrast sensitivity loss. The SmartSight patient handout, available on the American Academy of Ophthalmology website, can be given to patients to assist in seeking Medicare-funded multidisciplinary vision rehabilitation or other vision rehabilitation services in their community. The Academy’s Preferred Practice Pattern Vision Rehabilitation outlines how comprehensive vision rehabilitation addresses reading, activities of daily living, patient safety, continued community participation, and patient well-being.

American Academy of Ophthalmology. SmartSight. San Francisco: American Academy of Ophthalmology; 2012. Available at: www.aao.org/smart-sight-low-vision.

American Academy of Ophthalmology Vision Rehabilitation Committee. Preferred Practice Pattern Guidelines. Vision Rehabilitation. San Francisco: American Academy of Ophthalmology; 2013. Available at: www.aao.org/preferred-practice- pattern/vision-rehabilitation-ppp--2013.

US Census Bureau. International Data Base [database online]. Midyear population, by age and sex. Revised December 19, 2013. http://www.census.gov/population/international/data/worldpop/table_population.php. Accessed September 2, 2014.

Physiologic Aging and Pathologic Findings of the Aging

Eye

Changes in the eye due to aging affect everyone, but there are marked differences among individuals. The periorbital and eyelid skin and soft tissues atrophy with age. Dermatochalasis and levator dehiscence may produce secondary ptosis. Eyelid laxity may cause entropion, ectropion, and trichiasis. Lacrimal gland dysfunction, decreased tear production, meibomian gland disease, and goblet cell dysfunction may cause dry eye symptoms. As a person ages, the conjunctiva undergoes atrophic changes and corneal sensitivity is reduced. The pupils become progressively miotic and less reactive to light. There is an increasing incidence of presbyopia, cataract, glaucoma, AMD, and diabetic retinopathy. Contrast sensitivity and visual field sensitivity are reduced. In addition, refractive error (of some type) is present in more than 90% of older patients and remains a significant cause of visual disability in the nursing home patient.

The 4 leading causes of vision loss in the older population are AMD, glaucoma, cataract, and diabetic retinopathy. It is estimated that by 2020, 2.95 million persons in the United States will have AMD. Glaucoma becomes more common with increasing age; thus, screening is recommended for patients older than 50 years. It is also estimated that by 2020, 30.1 million Americans will have cataracts and 9.5 million will be pseudophakic/aphakic, an increase of 50% and 60%, respectively, from the year 2000. Diabetic retinopathy is a leading cause of new cases of legal blindness among working-aged Americans. The prevalence of retinopathy in persons aged 40 years and older in the United States is 3.4% (4.1 million persons), and the prevalence of vision-threatening retinopathy is 0.75% (899,000 persons). Assuming a similar prevalence for diabetes mellitus, the projected numbers in 2020 would be 6 million persons with diabetic retinopathy and 1.34 million persons with vision-threatening diabetic retinopathy.

American Academy of Ophthalmology Retina/Vitreous Panel. Preferred Practice Pattern Guidelines. Diabetic Retinopathy. San Francisco: American Academy of Ophthalmology. Available at: www.aao.org/preferred-practice-pattern/diabetic-retinopathy- ppp--2014.

Congdon N, O’Colmain B, Klaver CC, et al; Eye Diseases Prevalence Research Group. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol. 2004;122(4):477–485.

Congdon N, Vingerling JR, Klein BE, et al; Eye Diseases Prevalence Research Group. Prevalence of cataract and pseudophakia/aphakia among adults in the United States. Arch Ophthalmol. 2004;122(4):487–494.

Outpatient Visits

Ophthalmology is largely an outpatient specialty. For older patients, access to the ophthalmologist’s office can be a major physical barrier to eye care. The ideal outpatient office should be designed to accommodate older patients with various disabilities. The geriatric-friendly office environment should include the following:

a safe, well-lit office that is close to drop-off areas and parking

automatic or assisted doors (doorways with pull levers or handles, not doorknobs) large-print, legible, well-placed signs

wheelchair-accessible entryways and waiting rooms

obstacle-free and well-lit, high-contrast walkways, hallways, and waiting areas (free of rugs, electrical cords, and tripping hazards, such as toys)

accessible bathrooms with elevated toilet seats, grab bars, and a wheelchair-accessible sink staff trained to assist patients with disabilities to and from the examination room

a private area where patients with decreased hearing and vision can receive assistance from staff in completing forms

Elder Abuse

Elder abuse is a violation of human rights and a significant cause of illness, injury, loss of productivity, isolation, and despair, according to the World Health Organization. The ophthalmologist may be the first physician to see an older patient who is being abused or neglected. The signs may be subtle, and early recognition is key. In the United States, the prevalence of elder maltreatment has been reported as 7.6%–10% of study participants and is estimated to affect 11.4% of adults aged 60 years and older. The National Elder Abuse Incidence Study, the first major investigation of mistreatment of the elderly in the United States, found that 449,924 persons aged 60 years or older had been physically abused, neglected, or in some way mistreated in 1996. However, the study did not solicit data directly from older adults; rather, it assessed Adult Protective Service records and sentinel (eg, community professionals’) reports. Thus, it is very likely that the results greatly underestimated the true scope of the problem of abuse of older Americans, because a large majority of cases are unreported and are undetected by monitoring agents.

Major risk factors for elder abuse include external stresses due to marital, financial, and legal difficulties; dependent relationships (eg, the abuser may be dependent on the older patient for finances or housing, or vice versa); mental illness and substance abuse; social isolation; and misinformation about normal aging or about the patient’s medical or nutritional needs. Maltreatment can occur at home, in assisted living, or in nursing homes. It can take the form of physical or psychological abuse, material misappropriation, neglect, or sexual attack.

Physical neglect includes withholding of food or water, medical care, medication, or hygiene. Neglect may be intentional or unintentional and may be related to financial constraints or lack of other resources (eg, transportation, supervision). Elder abuse also includes financial abuse or exploitation, deprivation of basic rights (eg, decision making for care, privacy), and abandonment. Actual physical abuse in the form of slapping, restraining, and hitting may cause physical pain or injury.

The ophthalmologist should suspect elder abuse in the following circumstances:

bruises, black eyes, and fractures

broken eyeglasses and report by the patient of being slapped or abused repeated visits to the emergency department or office

conflicting or noncredible history from caregiver or patient unexplained delay in seeking treatment

unexplained, inconsistent, vague, or poorly explained injuries history of being “accident prone”

expressions of ambivalence, anger, hostility, or fear by the patient toward the caregiver poor adherence to follow-up or care instructions

evidence of physical abuse (eg, lacerations, wounds in various stages of healing, burns, welts, patches of hair loss, or unexplained subconjunctival, retinal, or vitreous hemorrhage)

Sometimes it is necessary to obtain the history with the caregiver out of the room. Directed questions for the patient include “Has anyone at home tried to harm you?” “Has anyone tried to make you do things that you don’t wish to do?” and “Has anyone taken anything from you without your consent?”

Any suspected case of elder neglect or abuse should prompt a complete written report. Documentation of any suspicious injuries is mandatory, including type, size, location, and characteristics of injury and stage of healing. Requirements for reporting elder abuse vary from state to state, and many localities have abuse hotlines for reporting maltreatment. The physician should be aware of local services for adult protection, community social services, and law enforcement agencies.

Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health. 2010;100(2):292–297.

Perioperative Considerations in the Management

of Elderly Patients

There are a number of considerations that the ophthalmologist should take into account in the preoperative evaluation and perioperative management of elderly patients. First, loss of vision alone may not be an appropriate sole indication for surgical intervention (eg, cataract surgery). Functional assessment includes determining how vision loss affects instrumental activities of daily living (IADLs) such as reading, driving, taking medications properly, and using the telephone independently. Documentation of impaired IADLs is important for the preoperative assessment. It is also important to document any prescription medications that the patient is taking to ensure that they do not interact with perioperative medications. An elderly patient may have multiple medical conditions that require use of numerous prescription medications. Further, the clinician should be aware that management of informed consent may be different in patients with mild dementia and in those who have legal guardians or caregivers, as they will need to participate in the process.

Elderly patients undergoing surgery may be prone to confusion or delirium perioperatively. Delirium is estimated to occur in approximately 4%–5% of patients after cataract surgery. There are numerous causes for confusion in this setting, but many are preventable. Minimization of preoperative sedation or psychotropic medications, appropriate patient and family orientation by nursing or ancillary staff, and careful supervision and reassurance in the postoperative period can diminish confusion. Often, a confused older patient simply needs a familiar face or reassurance to regain calm. The use of restraints should be minimized.

Confusion may be exacerbated in patients with vision loss or in those who require vision rehabilitation. In a monocular older patient, patching of the eye after surgery may aggravate confusion and disorientation. Having a family member in the recovery room can be very helpful. The patch should be removed as soon as possible and the patient provided with appropriate eye protection. Topical anesthetic may not be indicated because of comorbidities such as cognitive impairment and inability to cooperate during surgery. In addition, patients with decreased vision following

intraocular surgery may experience limited mobility or be at increased risk for falls. Bed rest and immobilization can lead to disuse of extremities, development of pressure ulcers, and other problems. For these patients, active rehabilitation should be encouraged as soon as possible.

Though rare in outpatient ophthalmic surgery, surgical or anesthesia complications may result in life-threatening conditions. The surgeon must pay careful attention to any preexisting directives (eg, do-not-resuscitate order or living will) prior to any surgical intervention (including laser treatments and periocular injections or anesthetics). By discussing possible treatment decisions with the patient and family members early on—preferably before any serious illness arises or, if a serious illness is present, early in its course—the surgeon can avoid emergency decisions.

Some potential issues for discussion include limits of treatment, antibiotics, and changes in the patient’s living situation. Candidly and openly discussing these important issues with the patient and the family (especially in cases of dementia) in the preoperative period allows them to consider these matters in the context of their belief systems and without the disorientation and confusion created by an emergency. The content, context, time, and date of such discussions should be well documented in the medical record and communicated to the patient, the family, and the primary care physician or geriatrician.

Psychology of Aging

The psychology of aging is influenced by a wide range of factors, including physical changes, adaptive mechanisms, and psychopathology. Each older patient has a unique psychological profile and social life history. Deleterious changes are not universal; in fact, in the absence of disease, growth of character and the ability to learn continue throughout life.

As we age, the issue of loss becomes more prevalent. Losses—of status, physical abilities, loved ones, and income—become more frequent. A fear of loss of social and individual power, and the attendant loss of independence, is common. In addition, the reality of death has increasing influence on a person’s psychological status. All of these losses increase the incidence of depression.

Normal Aging Changes

Age-related changes in sensation and perception can have great influence, isolating an individual from the surrounding environment and triggering complex psychological reactions. There may be diminution of hearing and vision, slowing of intellectual and physical response time, and increasing difficulty with memory.

Many physical and intellectual abilities, however, are retained throughout life, and their loss should not be assumed to be part of the normal aging process. These include the senses of taste and smell, intelligence, the ability to learn, and sexuality. Any change in physical, intellectual, or emotional capabilities may reflect underlying organic or psychological disease.

Depression

Depression is the most frequent psychiatric problem in the older population. Approximately onequarter of older patients seen in primary care settings are clinically depressed. The prevalence of depression in patients with macular degeneration is even higher, at 30%–40%. The suicide rate in white American men older than 65 years is 5 times greater than that of the general population; loneliness is the main reason cited, along with financial problems and poor health. Successful suicide

is much less common in older American women, but older women attempt suicide more often than do men.

The criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

(DSM-5), require that depressive symptoms as a result of a general medical condition or the medication used to treat it be separated out from late-life depression. An alternative diagnosis of mood disorder is preferred for the former.

Major depressive disorder is characterized by episodes of at least 2 weeks of depressed mood or loss of interest or pleasure in activities with 4 or more of the following symptoms:

changes in appetite with associated weight loss or gain significant weight loss or gain

sleep disturbance agitation diminished libido

retardation (slowing down) loss of energy

feelings of worthlessness or guilt

difficulties in concentration and decision making recurrent thoughts of suicide or death

The signs and symptoms of depression in older individuals are similar to those seen in younger age groups, although older depressed patients are more likely than younger patients to have somatic or hypochondriacal complaints, minimize depression symptoms (masked depression), and have psychotic delusional disease. However, they are less likely to report symptoms of guilt. The most frequent presentations of subclinical depression include new medical complaints, fatigue, poor concentration, exacerbation of existing symptoms and medical problems, preoccupation with health, and diminished interest in pleasurable activities.

The ophthalmologist’s role is to recognize and refer the patient with depression or to be aware of precipitating factors. For instance, loss of function, such as moderate or severe vision loss, can precipitate depression, as can recent death of a spouse. Red flags may include frequent visits to the ophthalmology office and unexplained vision loss. Though not prevalent in the ophthalmology setting, testing for depression would be enormously helpful in attaining care for those patients who have this disorder.

Many case-finding instruments ask about depressed mood and anhedonia, the latter defined as a psychological condition characterized by inability to experience pleasure in acts that normally produce it. Most of these instruments require more time than is available in the typical office practice. A brief case-finding instrument, the Patient Health Questionnaire-2 (PHQ-2), is a suggested screening device. It is sensitive, but not specific. It does not suggest or establish a final diagnosis or monitor depression severity, but screens for depression in a “first step” approach. The self-report questionnaire consists of 2 questions:

1.During the past month, have you been bothered by feeling down, depressed, or hopeless?

2.During the past month, have you often been bothered by little interest or pleasure in doing things?

The incidence and severity of falls rises with increasing age. Approximately one-third of US adults older than 65 years fall each year, yet less than half talk to their physicians about it. Falls are the leading cause of nonfatal and fatal injuries. In 2010, about 21,700 older adults in the United States died as a result of unintentional fall injuries. In 2010, direct medical costs of falls, adjusted for inflation, was $30 billion. Traumatic brain injury (TBI) in the older adult is most commonly caused by falls. In 2000, 46% of fatal falls among older adults in the United States were due to TBI. Men are more likely to die from a fall. Older whites are 2.4 times more likely to die from falls than are older blacks. Also, there are differences in fatal fall rates among ethnic groups; older non-Hispanic persons have higher fatal fall rates than do older Hispanic persons. Fear of falling causes elderly persons to limit activities, leading to reduced physical fitness, which, in turn, increases the actual risk of falling.

Prevention of falls is key. Older adults may reduce their chances of falling by.

exercising regularly

increasing leg strength and balance

asking their physician or pharmacist to review their medications that might cause dizziness or drowsiness

having their eyes checked annually to update glasses or evaluate for eye diseases that limit vision

getting assistance to make their living areas safer by removing tripping hazards

installing grab bars in the bathroom and railings on the side of stairways (such as the entry to the home)

improving lighting

Visual disorders are the cause of up to 4% of falls. The ophthalmologist’s role in fall prevention is twofold:

ask the patient appropriate questions about the activities listed above that might reduce fall risk recognize and treat visual disorders, including refractive errors to identify and minimize ocular reasons for falls

It is the responsibility of the ophthalmologist to inquire, during the intake history, if the patient has fallen during the past year. Those patients with reduced vision from eye disease, most often macular degeneration, are at the highest risk of falling. Once a history of falls is obtained, it is incumbent upon the ophthalmologist to notify the patient’s primary care physician about this finding or refer the patient to a multidisciplinary medical facility with resources for managing falls in the elderly.

Centers for Disease Control and Prevention. Injury Prevention & Control: Data & Statistics. Web-based Injury Statistics Query and Reporting System (WISQARS). www.cdc.gov/injury/wisqars/. Accessed July 10, 2014.

Stevens JA. Fatalities and injuries from falls among older adults—United States, 1993–2003 and 2001–2005. Morb Mortal Wkly Rep. 2006;55(45):1221–1224.

Stevens JA, Ballesteros MF, Mack KA, Rudd RA, DeCaro E, Adler G. Gender differences in seeking care for falls in the aged Medicare population. Am J Prev Med. 2012;43(1):59–62.

Stevens JA, Dellinger AM. Motor vehicle and fall related deaths among older Americans 1990–98: sex, race, and ethnic disparities. Inj Prev. 2002;8(4):272–275.