Clinical Comment, Spring 2001

University Of Chicago Hospitals

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86-006 Spring 2001 Clin_Comment 5/14/01 8:36 AM Page 2UNIVERSITY OF CHICAGO MEDICAL CENTERSpring 2001GERIATRIC MEDICINEWho Should See a Geriatrician? Joseph W. Shega, MD Geriatrics Fellow, Department of MedicineUniversity of Chicago(773) [e-mail] A. Sachs, MD Associate Professor of MedicineChief, Section of GeriatricsCo-Director, Center for Comprehensive Careand Research on Memory Disorders University of Chicago(773) 702-0102IN THIS ISSUE… [e-mail] ONCOLOGYMany family physicians, general internists,Geriatrics and Oncology: and specialists within internal medicineA New Approach to 5 spend a good portion of their time seeingClinical Research and patients who are older than the age of 65Patient Careyears. So it is not surprising for physiciansand the public alike to ask questions such asMEMORY DISORDERS“What is a geriatrician?” and “Who needsMultidisciplinary Team 8 to see a geriatrician?” This article answersTreats Memory Disordersthese questions, in part, by discussingthe range of services provided andGERIATRIC MEDICINEapproaches taken by the geriatricians at New Senior Health Center the University of Chicago. Additional12 Focuses on Total Healthof the Elderly articles in this issue of Clinical Commenthighlight some of the exciting andANNOUNCEMENTS innovative programs in more detail.Continuing Medical 14Education Calendar Several features of geriatrics care set it ...

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• Publié par: Adrie
• Nombre de lectures: 17
• Langue: English

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I N THIS ISSUE … G ERIATRIC O NCOLOGY Geriatrics and Oncology: A New Approach to 5 Clinical Research and Patient Care M EMORY D ISORDERS 8 T M r u e l a ti t d s  is M c e ip m li o n r a y r   y D  T is e o a r m d   ers G ERIATRIC M EDICINE New Senior Health Center 12 Focuses on Total Health of the Elderly A NNOUNCEMENTS 14 E C d o u n c ti a n ti u o in n  g  C M al e e d n i d ca a l r   15 New Appointments University of Chicago 16 to Build New Children’s Hospital

G ERIATRIC M EDICINE Who Should See a Geriatrician? Joseph W. Shega, MD Geriatrics Fellow, Department of Medicine University of Chicago [phone] [e-mail] Greg A. Sachs, MD Associate Professor of Medicine Chief, Section of Geriatrics Co-Director, Center for Comprehensive Care and Research on Memory Disorders University of Chicago [phone] [e-mail] Many family physicians, general internists, and specialists within internal medicine spend a good portion of their time seeing patients who are older than the age of 65 years. So it is not surprising for physicians and the public alike to ask questions such as “What is a geriatrician?” and “Who needs to see a geriatrician?” This article answers these questions, in part, by discussing the range of services provided and approachestaken by the geriatricians at the University of Chicago. Additional articles in this issue ofClinical Comment highlight some of the exciting and innovative programs in moredetail. Several features of geriatrics care set it apart from most other kinds of general medical care: (1) a focus on function; (2) an increased ability to distinguish normal changes caused by aging from those changes caused by

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disease; (3) a greater awareness of how manyand mortality; in fact, functional status is a common diseases have an altered or non-better predictor of these outcomes than most specific presentation in the elderly; (4) specialkinds of information collected by physicians. expertise in the so-called geriatrsicy ndromes; and (5) the practice of working tineams to While many organ systems’ functions (or at least provide coordinated, comprehensive care. Thetheir reserves) tend to decline with increasing patients who are most likely to benefit from age, physicians and patients alike often referral to a geriatrician are the oldest and inappropriately attribute problems to “old age.” frailest i n d i v i d u a l s a n d t h o s e w i t h In its most extreme form, this approach can functional disabilities, multiple geriatric result in ageism and therapeutic nihilism, syndromes, and complex psychosocial needs. through which opportunities to ameliorate conditions are overlooked. Accepting fatigue as The focus on function in geriatrics refers to an inevitable part of aging may mean missing how geriatricians routinely assess older the opportunity to treat depression or patients’ abilities to perform basic activities hypothyroidism. Accepting pain as a normal of dailyliving (ADLs) (e.g., bathingd, ress- accompaniment to conditions such as arthritis ing, transferring from a wheelchair to a may mean pain is undertreated, which in turn, bed, getting tothe bathroom, and feed- diminishes quality of life. Geriatricians are loath ing) and instrumental activities of daily to attribute most problems to aging alone. living (IADLs) (e.g., paying bills, managing medications, shopping, cooking, and usingMany older patients with common conditions the telephone). Functional status relates to thepresent with altered or nonspecific symptoms. setting in which a patient can live, what kinds Confusion, or an altered mental status, may be of services may be required to assist a patient,the chief complaint in up to 20 percent of and how multiple medical illnesses may be patients older than 85 years when they present affecting the patient’s quality of life.to the hospitalw ith a myocardiali nfarction. Functional status is highly correlated with Chest pain may be completely absent. Changes risk of hospitalization, use of medical services,in mental status also are frequently seen with

Source: LaPlante M., Miller K. “People with disabilities in basic life activities.”U .ISn.:   Disability Statistics Abstracts.S   an Francisco, C.A.: Institute for Health & Aging, University of California; 1992. Abstract No. 3.

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Table. — People With Difficulty and Those Who Get Help in Basic Life Activities Age, y  Persons With Any Difficulty  Persons Who Get Help From Others Those With a Total Difficulty  Who Population, %  Get Help, % 4.2 69.9 8.7 73.4 20.3 76.8 50.0 86.7 15.7 77.9

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65 TO 69 70 TO 74  75 TO 79  80 TO 84 85 OR OLDER Note: Definition of severe depressive symptoms: Four or more symptoms out of a list of eight depressive symptoms from an abbreviated version of the Center of Epidemiologic Studies Depression Scale (CES-D) adapted by the Health and Retirement Study. Reference populatio:n These data refer to the civilian noninstitutional population. Source: Federal Interagency Forum On Aging Related Statistics, 2O0l0d0e.r Americans 2000: Key Indicators of Well-Being.

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Figure.— Percentage of Persons Aged 65 Years or Older With Severe Depressive Symptoms, by Age Group and Sex, 1998 22% 23%23%

infections, such aspneumonia. Fever can be years need assistance with at least one ADL 50 surprisingly absent, even in the face of serious percent of the time (Table). About 12 percent of infections, in the oldest old. persons older than 65 years, Nonspecific declines ifnu nc- T HE PATIENTS WHO and up to 50 percent of those tion, weightloss, and decreas- older than 85 years, have ed oral intake — sometimes ARE MOST LIKELY some form of cognitive im- called failure to thrive — are TO BENEFIT FROM pairment. Almost 20 evenmore common in older A GERIATRICIAN ARE THE percent of individuals older patients with dementia. OLDEST AND FRAILEST than 65 yearssuffer from Sorting out the cause of these INDIVIDUALS AND THOSE symptoms ofdepression and presentations requires more WITH FUNCTIONAL may benefit from treatment time, a heightened index of DISABILITIE , S   MULTIPLE (Figure). Up to 15percent of suspicion, and a compre- GERIATRIC SYNDROME , S   community-dwelling older hensive approach to assess- adults suffer from incont- ment.Geriatric training assists AND COMPLEX inence but do not discuss it in the development osfkills to PSYCHOSOCIAL NEED . S   with their physicians be- identify contributing factors cause of embarrassment or and a strategy toeliminate or modify them to the false belief that it is part of the usual improve symptoms and hopefully enhance course of aging. quality oflife. Accidents are the fifth leading cause of death in Disabilities that are present in older persons those older than 65 years, and falls comprise frequently go unrecognized by other specialiststwo-thirds of these accidental deaths. Hearing or general internists, owing to time constraints loss is one of the most common chronic or lack of familiarity with the differences in conditions that affects older adults. The d i s e a s e manifestation. These i n c l u d e prevalence of hearing loss in persons older deterioration of ADLs, cognitive disorders, than 65 years is 25 percent to 40 percent. affective disorders, incontinence, falls, and These elderly experience a continued sensory deterioration. Individualosl der than 85decline in hearing throughout each decade

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until the prevalence reaches about 80 percent Outpatient Senior HealthCenter at South for individuals in their eighth decade. Studies  Shore. These sites offer an array of services consistently link hearing loss todepres-  including primary care, a frail elders sion, irritability, social isolation, and  program,memory center evaluations, support diminished physical mobility. Similarly,  groups, diabetes education, and a number of aging is associated with an increasing on-site subspecialty consultations. The care prevalence of visuali mpairment. After the team consists of geriatricianswho work age of 65 years, adults experience a closely with social workers,n urses, nurse decrease in visual acuity, glare tolerance,  practitioners, physical andoccupational and depth perception. Leading causes therapists, and an audiologist, ina ddition of visual impairment in older  t o p h l e b o t o m y , x - r a y , a n d adults i n c l u d e cataracts, T HE electrocardiographic services. macular degeneration,d ia- U NIVERSITY OF Subspecialtyservices avail- b e t i c retinopathy, and  able on-site at the clinics glaucoma. All of these G ERI C A H T I R C I A C G S O H S A E S C A TIO NA N TI O O F NAL enhance communication conditions arecommon,  and ease transportation underrecognized inroutine REPUTATION OF PROVIDING difficulties. Rerpesented p r a c t i c e , a n d m o s t OUTSTANDING COMPREHENSIVE s u b specialties include importantly, treatable to a HEALTHCARE TO MEET THE rheumatology, neurology, great extent. NEEDS OF THE FRAILEST dermatology, geriatricpsych- iatry, and ophthalmology. From the above description of PATIENTS . These relationships allow the challenges of geriatric care, it  patients, family members, and would behard for any individualpracticing  referring physicians peace of mind by physician to meet the needs of the frailest providing familiar settings andconsistent patients. That is why geriatricians work in  staffing who enjoy interacting with older teams and closely collaborate with nurses, adults and make a special effort to know nurse practitioners, social workers, physical  patients on an individual level. and occupational therapists, nutritionists, and other medical specialists as needed.  All of these services are available for either a one-time consultation or ongoinmg anagement Patients evaluated in one of the geriatrics of challenging clinicalproblems. In either clinics at the University of Chicago will receive  case,the consultinggeriatrician will provide a comprehensive medical, sensory, functional, a comprehensive report to the referring psychological, and social assessment. Similar physician and close follow-up care of the evaluations have been shown to decrease  patient. In general, patients referred to our mortality, increase theprobability that a  clinics are those who: (1) suffer from multiple patient will continue tolive at home,  medical problems; (2) receive care from decrease the likelihood of hospitaadlmission,  multiple subspecialists; (3h)ave undergone and enhance functional status. The University  recurrenthospitalizations; (4) havexper- of Chicago Section of Geriatrics has a national ienced functional decline; o(r5 ) present with reputation of providing outstanding comp- complaints that are notconsistent with rehensive healthcare to meet the needs of theclassic symptom or disease categories. frailest patients. FOR FURTHER READING 1. Bernabei entu Currently, we provide evaluations and geriatric ass R e , s   s V ment r : i   e w r h o  e V n , ,     T w a h rs e i r t e a ,  n h i  o P C , rwi .e t t R a e l. v     T O h n e c  c ol o  H m e pr m e a h t e ol n . s   ive longitudinal care at two sites, the Windermere 2 2. 0   0 La 0 c ;  h 3 s 3   : M 4 S 5 , -   5 F 6 e . instein AR, Cooney LM, et al. A simple procedure for Senior Health Center and the recently opened functional disability in elderly patientsA.nn Intern Med.1   990; 112:699-706.

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0 1900 1950 2000 projected 2050 Note: Data for the years 2000 to 2050 are middle-series projections of the population. Reference populatio:n These data refer to the resident population. Source: U.S. Census Bureau, Decennial Census Data and Population Projections.

3. Rueben D. Principles of geriatric assessment. In: Hazzard WR,Geriatric Medicine.4 th ed. New York, NY: Kendall/Hunt Publishing; Blass JP, Ettinger WH, et al, eds.P   rinciples of Geriatric Medicine and1999-2001. Gerontology.New York, NY: McGraw-Hill; 1999.  5. Rowe J, Kahn R. Human aging: usual and successfSucli.ence. 4. Caind R, Studenski S. Assessment. In: Cobbs E, Duthie E, Murphy 1987;237:143-149. J, et al, eds.Geriatrics Review Syllabus — A Core Curriculum in

Geriatric O n c o l o g y Geriatrics and Oncology: A New specialized care and services for elderly cancer Approach to Clinical Research and patients and cancer survivors. Two groups at Patient Care the University of Chicago are getting together to address these issues. Miriam B. Rodin, MD, PhD A S ssi t s i t o a n n   t o   f P   r G o e f r e i s a s tr o i r of Clinical Medicine  The U.S. population is aging. In 1900, a total of U e ni c versity of Chica c g s o 4.1 percent of the population was 65 years of [phone] age or older; today more than 33 million people [e-mail] are 65 years of age or older. By 2030, more than 70 million people, or 20 percent of the Two closely related revolutions are happening, population, will fall into this category (Figure one in demography and the other in oncology.1). 1 Cancer incidence increases dramatically The first revolution is the aging of the with age. The incidence of cancer in persons 65 population, the “graying of America.” What is years of age and older is tenfold higher than less well known is the graying of oncology and the incidence in people less than 65 years the impending increase in the need for  (2,164/100,000 vs. 207/100,000 people, respect- Figure 1.— Total No. of Persons Aged 65 Years or Older, by Age Group, 1900 to 2050, in Millions

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Figure 2.— Average Annual Age-Specific Cancer Incidence: All Sites by Race and Sex, 1987-1991 MALES FEMALES 4,500 4,500 4,000 4,000 3,500 BLACK 3,500 MALES 3,000 3,000 WHITE 2,500 WHITE 2,500 FEMALES 2,000 MALES 2,000 1,500 1,500 1,000 1,000 F B E L M A A C L K ES 500 500 0 0 0-4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 0-4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 Age at Diagnosis, y  Age at Diagnosis, y

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ively). Mortality from cancer among those 65 have a peak incidence and mortality rate years or older is 1,076 per 100,000, nearly 15among theelderly. times higher than the rate of 69 per 100,000 for those younger than 65 years. (Figure 2 2). Life expectancy is an important factor to Currently, about 50 percent of all malignancies consider when deciding on treatments and are diagnosed in those who are elderly. In 20 measuring their effectiveness in elderly years, a 12 percent increase in the elderly patients. Clinical trial evidence to guide population will translate into a 60 percent treatment decisions has been sparse, since 3 increase in the numbers of cancers diagnosed. elderly people have been only poorly These revolutions will challenge us to consider represented in suchresearch studies for a new approaches to screening and diagnosis, number of reasons 7 .Geriatric research has newprotocols for treating elderly patients, noted that comorbidityand functional and new systems for providing cancerstatus often are poorly correlated, but care to elderlypatients. may independently predict survival in community-dwelling, hospitalized, and other Over the last two decades, considerable clinical populations of elderl 8 y.Research also research has shown that although the elderly suggests that oncologists, patients, and are at highest overall risk for common r e f e r r i n g p h y s i c i a n s m a k e c a n c e r malignancies such as breast, colon, and treatment decisions that may be related to cervical cancer, they are less likely to be c o m o r b i d i t y a n d f u n c t i o n a lstatus. 9 screened and are therefore less likely to be However, there is a lack of research to specifi- diagnosed in early, curable stages of illness. cally address the impact of functionsatlatus The elderly more commonly present with more andcomorbidity on elderly cancer patie 1 n 0 ts. advanced disease, and even when matched for stage of disease, they are offered fewer These needs were recognized by the John A. treatment options than those who areHartford Foundation (based in New YorkN,. Y.), younger 4 .   The reasons for these findings have which has spearheaded a national effort to been extensively studied and discussed. For stimulate collaborative work between geria- example, the relationship between age and thetricians and oncologist 1 s. 1 In 1999, the biological behavior of malignancies is complex. University of Chicago was selected as one of 14 The role of early detection for survival is under centers to pilot interdisciplinary research and debate for prostate cancer, but is becomingtraining in geriatrics and oncology. Harvey clearer for breast canc 5 e , r 6 ; both diseases Golomb, MD, Chairman of the Department of

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Medicine, Todd Zimmerman, MD, of the of age and older as for womeynounger than Section of Oncology, and Deon Cox-Hayley,65 years. 12 Comorbidities increase in DO, of the Section of Geriatrics, served on the prevalence with age. However, well elderly, Hartford Foundation’s advisory board to even atadvanced ages, appearto l e r a t e develop training curricula and guidelines for a cancer treatmen 1 t. 3,14 Furthermore, advances new subspecialty in geriatric oncology. In the in the management ocf hemotherapy side following year, several projects wereeffects have raised new questions launched. Dr. Zimmerman super- about the long-term quality of life vised the fellowship research of Andrea Bial,MD, who will T HE for R   o c d a i ncer survivor   s. a 15 nd Drs. join the University of U NIVERSITY OF Fle n m   in a g n ,  d  M M D a ,  u o e f r   , the S   e G c i ti n o i n Chicago faculty in the C HICAGO WAS SELECTED of Oncology, with other Section of Geriatrics this AS ONE OF 14 CENTERS TO members of theb r e a s t s u m m e r . D r . B i a l ’ s PILOT INTERDISCIPLINARY and gastrointestinal tumor study, “The Evaluation RESEARCH AND TRAINING groups, will be investigating of Depression inElderly IN GERIATRICS AND the  t l h on er g-term effects of M e n W i t h P r o s t a t e - Cancer,” suggests ac omplex ONCOLOGY . lo c gi h c e a m l  o func a ti p o y n     o in n     e n l e d u e r rl o y relationship betweenp rostatecancer survivors.  cancer and depression, one that needs to take treatment modality into account. To facilitate the care of elderly cancer survivors, the Section of Geriatrics at the Drs. Cox-Hayley, Zimmerman, and Bial, with University of Chicago is initiating a referral Miriam Rodin, MD, PhD, of the Section of clinic devoted to the special needs of those 65 Geriatrics, Ann Mauer, MD, of the Section of years of age and older who have undergone Oncology, and Elizabeth Lamont, MD, cancer treatment. One clinical site will be at research fellow from the Robert Wood Johnson the Outpatient Senior Health Center at South Foundation (which is based in Princeton, N.J.), Shore, located 7101 S. Exchange Ave., in hosted a continuing medical education Chicago. It will be staffed by geriatricians, conference in March for primary care and geriatric nurse practitioners with oncology oncology physicians and allied professionals cross-training, and fellows in the joint entitled “Geriatric Oncology 2001: A New geriatric-oncology fellowship. The clinic will Approach to the Older Cancer Patient.” The provide geriatric primary care, periodic conference featured several internationally monitoring according to current oncology prominent authorities in this emerging field. practice guidelines, close interaction with the patients’ primary oncologists, and collaborative Several new initiatives are soon to be follow-up of clinical-trial participants. The launched. Although it is difficult to estimate clinic provides local-area transportation and numbers, it is clear that improvements in shuttle service to the University of Chicago cancer treatment arle eading to increasedHospitals for needed laboratory and radiology numbers ofcancersurvivors in the population services. In addition, joint patient conferences at large, and in the elderly population as well. including both oncology and geriatric faculty Little is known about long-term survival and are under development. its impact on general health and aging, quality of life, and functional status. Research Dr. Cox-Hayley, of the Section of Geriatrics, is sparse,b u t t h e r e s u l t s a reencour- offers an additional component of care, at the aging. Overall, the five-year survival rate of Windermere Senior Health Center, located at breast cancer is the same for women 65 years5549 S. Cornell Ave., in Chicago. She is an

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