AGING FROM THE OUTSIDE IN - pogoe.org from the outside in.pdf · Aging From the Outside In Faculty Guide 1 ... Gain familiarity with changes in vision and hearing found in older

Aging From the Outside In Faculty Guide

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AGING FROM THE OUTSIDE IN An Experiential Learning for Medical Students Rainier P. Soriano, MD and Rosanne M. Leipzig, MD, PhD Icahn School of Medicine at Mount Sinai

2016


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AGING FROM THE OUTSIDE IN

1. INTRODUCTION

Say: Welcome to today’s session. Hopefully at the end of this session, you will have an appreciation of the tremendous amount of effort health care providers do in caring for vulnerable elders and experience the joys as well as frustrations, health care providers undergo in the care of older adults. Note to Facilitator: Consider opening the session with the following:

Introduce yourself (background, interests, limitations in expertise)

Have the students introduce themselves and what they are looking forward in this session.

II. LEARNING GOALS OF THE SESSION Say: By the end of this session, you will be able to:

Understand the principles behind the discipline of geriatric medicine and relate its importance in the care of the rapidly expanding older adult population in the United States

Develop an awareness of differences between the learner’s and the older adult’s perception of themselves, their environments, and the interaction between them.

Gain familiarity with changes in vision and hearing found in older adults, and recognize that some age-associated changes are due the aging process, some to life habits, and others to disease

Apply the content of this session in your clinical encounters

III. WHAT IS GERIATRICS?

Discuss: Why do we become “old” at 65 years?

Copyright 2016-2017 Icahn School of Medicine at Mount Sinai Instructions for the Facilitators are in italics All participants should be encouraged to contribute to discussions. Ask your learners if they have other goals for this session aside from the ones you mentioned.


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Answer:

It is generally accepted in the United States today that a person is described as "old" once he or she reaches 65 years of age.

While 65 is commonly accepted, there is no intrinsic biological reason for this to be the chronological point at which one becomes categorized as "old." The reason is historic, arbitrary, and not well substantiated. (See side panel)

Ask: What is the current population of the United States and how many of them are over the age of 65 years? Answer:

The population age 65 and over numbered 44.7 million in 2013, an increase of 8.8 million or 24.7% since 2003

About one in every seven, or 14.1%, of the population is an older American.

In 2013, 21.2% of persons 65+ were members of racial or ethnic minority populations--8.6% were African-Americans (not Hispanic), 3.9% were Asian or Pacific Islander (not Hispanic), 0.5% were Native American (not Hispanic), 0.1% were Native Hawaiian/Pacific Islander, (not Hispanic), and 0.7% of persons 65+ identified themselves as being of two or more races. Persons of Hispanic origin (who may be of any race) represented 7.5% of the older population.

Ask: How about those over the age of 85 years? Answer:

The 85+ population is projected to triple from 6 million in 2013 to 14.6 million in 2040.

Those over 100 years are the fastest growing segment of the population

Transition: No matter which field of medicine one would want to focus his/her medical career on, they are bound to encounter an older adult in clinical practice. In fact, in pediatrics, grandparents now sometimes are raising their grandchildren on their own. Dealing with these older adults then comes into play in this physician-patient-caregiver relationship.

Otto von Bismarck, who was Chancellor of Germany in the 1880s, was instrumental in introducing pensions for older adults. Germany was the first country to adopt such a plan. The myth is that the United States adopted age 65 as the age for retirement benefits because this was the age used by Germany when they created their program. In fact, Germany initially set age 70 as the retirement age, and it was not until 27 years later that the age was lowered to 65. By that time, Bismarck had been dead for 18 years.


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In 2013, about 536,000 grandparents aged 65 or more had the primary responsibility for their grandchildren who lived with them. IV. AGING FROM THE OUTSIDE IN: WORKSHEET COMPLETION

Note to Facilitator: Distribute the “Aging From the Outside In” worksheet. Ask each of the students as to how an older adult patient BORN IN 1945 would answer the questions in the first column. They should place their responses on the column marked “YOUR GERIATRIC PATIENT.” They should also answer the same questions (for themselves) and write their answers in the column marked “YOU.” V. AGING FROM THE OUTSIDE IN: WORKSHEET DISCUSSION

Note to Facilitator: Ask the students for their answers to each of the questions. Try to encourage EVERYBODY to participate.

Try to play on the differences as well as occasional similarities between the students and what they think an older adult’s responses would be, again emphasizing the GAP between the younger adult and the older adult.

A. WHAT YEAR WERE YOU BORN?

B. WHAT IS YOUR LIFE EXPECTANCY AT BIRTH? YOUR “PATIENT?”

Discussion Points:

Life expectancy in 1900 at birth was only 47.3 years; by 1950 it had improved to 68.2 years.

U.S. life expectancy for children born in 2012 is now 78.8 years.

Life expectancy for men born in 2012 is 76.4 years. For women, it is 81.2 years.

A man who is 65 is expected to live another 17.9 years (to age 82.9) and 65-year-old women are expected to live another 20.5 years (to age 85.5).

C. COUNTRY WHERE BORN? Discussion Points:

The purpose of this section is to “get into the shoes” of the older adult.

Handout: Aging From the Outside In Worksheet What is the difference between life expectancy and life span? Life Expectancy: Time to death for people born in that year Life Span: Maximum survival potential under ideal conditions in absence of disease or trauma Occasional clarification point: You can make the point of “cohort effects”- those things that people who


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Most students are American-born, but not all. Many of their co-HuMed students may not be aware that they were born elsewhere.

Many older patients may be immigrants with different culture, first language (to which they may return, instead of using English, if they dement)

D. PRESIDENT OF THE UNITED STATES?

Woodrow Wilson, 1913-1921

Warren Gamaliel Harding, 1921-1923

Calvin Coolidge, 1923-1929

Herbert Clark Hoover, 1929-1933

Franklin Delano Roosevelt, 1933-1945

Harry S. Truman, 1945-1953

Dwight David Eisenhower 1953-1961

John Fitzgerald Kennedy, 1961-1963

Lyndon Baines Johnson, 1963-1969

Richard Milhous Nixon, 1969-1974

Gerald Rudolph Ford, 1974-1977

James Earl Carter, Jr., 1977-1981

Ronald Wilson Reagan, 1981-1989

George HW Bush, 1989-1993

William Jefferson Clinton, 1993-2001

E. CHANGES IN THE WORLD DURING LIFETIME? Possible responses: Young adults

Communication and electronics explosion; through the Internet, computers, and cellular phones.

The end of the “Cold War”

HIV and AIDS Older adults

Antibiotics and “modern medicine”

Airplanes, easy access to cars, telephone

The World Wars, The Depression

F. AGE AT RETIREMENT? Possible responses: Most students have never thought about this

Some expect to retire by 65 years and are unaware that Social Security age will likely be at least 67.

were born at a certain time may have in common, e.g., amount of education, nutrition.


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Some even say it’s specialty dependent and some may retire earlier than others (e.g. in surgical field)

Most older adults

Males retired around age 65

Females- many didn’t work outside of the home

Many of this generation will live about 1/3 of their lives in retirement

G. HOW TIME IS SPENT? Possible responses: Younger adults

Studying, going out with friends, watching TV, and engaging in sports activities, etc.

Older adults:

Activities span from spending time alone reading and watching TV, to engaging in communal activities with others (e.g., Bingo, travel, meals).

A significant number of older people spend time with their grandchildren. In East Harlem, at least 10% of the older population is responsible for raising at least one grandchild or youngster.

H. NUMBER OF PEOPLE SPOKEN TO OR SEEN EVERYDAY? Possible responses: Younger adults

Estimate from 25-100

Often state “too many”

Older adults

Although there is great variability in the older population, in general social network decreases with age due to:

o Death, o Disease resulting in relocation (near children, adult-living,

nursing homes)

Some elders have vigorous social networks and others see few individuals or nobody on a daily basis.

A recent survey of East Harlem elders found that in fact about many older adults participate in building, group, and church activities; may not be that high in other parts of the city.

I. WHAT CAUSES WORRY?


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Possible responses: Younger adults

Money, grades, and family

Older adults

Their health, that they will suffer or be alone in death, money, how to manage to get their physical and medical needs met

J. HAS A PERSONAL DOCTOR?

Possible responses: Younger adults

Rare after pediatrician

Older adults:

Often yes, however may have lost primary MD due to retirement, death or relocation

Newly starting MDs may therefore see many older adults looking for a new primary care MD

K. WHAT CAUSES WORRY WHEN SEEING A DOCTOR? Possible responses: Younger adults

That they’re really sick, they’re overweight

Older adults

Their health

Doctor will NOT take them seriously and listen to them, not just say it’s because they’re old

Getting ready and getting to the appointment

Breeze through their appointment

VI. VISUAL IMPAIRMENT: VISION SIMULATORS

A. Age-Related Changes In Vision Discuss: Can you describe some of the changes to the eye with aging?

Possible responses:

Corneal changes lead to more blurring of vision and decrease in

Students may say that older adults worry about dying. Research has shown that older adults worry more about the people they will leave behind if they die. Most of them believe they have lived a full life and ready to die when their “time is up.” Anecdote: 90 y/o man goes to MD complaining about left knee pain; MD states “Nothing to worry about, what do you expect, you’re 90 years old”; patient states: “So is my right knee and that’s not hurting!”


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contrast sensitivity.

Decrease in tear production results in dry uncomfortable eyes and blurred vision.

Iris and ciliary bodies become rigid causing slowing of the opening or closing of the pupil leading to increased glare, slower adaptation to changes in light.

Lens yellows (due to photo-oxidation) leading to blurred vision as well as yellow vision, making it difficult for affected older adults to see the color blue.

A decrease in lens elasticity as well as atrophy of the ciliary bodies causes adults to have difficulty focusing near objects, a condition called presbyopia.

B. Vision Simulators

Note to Small Group Preceptor: Hand out ONE set of vision simulators to each student triad. Have the student triad take turns in using the simulators.

During the discussion, for EACH simulator ask the students to:

Describe the changes in their vision caused by the simulator.

Discuss the changes the glasses show as to whether it is secondary to disease or usual aging process.

Discuss how this affects vision and function

Discuss how might patients compensate for this loss? Low Contrast

Difficulty differentiating the edges of objects

Usual aging – atrophy of the corneal epithelium

Loss of color, detail, sharpness

Wear or prefer bright colors Overall Blur

Hard to see clearly, similar to 20/200

Disease - cataract or corneal disease

Leads to decrease contrast and increased glare – cannot differentiate objects; cannot see well due to glare

Compensate by maximizing performance of route actions and minimizing new or complex tasks.

Note to Facilitator: Ask the students to wear either the LOW CONTRAST or the OVERALL BLUR.

Vision Simulators There are 6 simulators per set:

1. Low contrast 2. Overall Blur 3. Color 4. Central Loss 5. Peripheral Loss 6. Hemianopia


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Hold up the RED sheet of paper and ask the students if they could read the print clearly. Then hold up the YELLOW sheet of paper and ask the students if they could read the print. Say: As you can see, people with LOW CONTRAST or OVERALL BLUR can benefit from increasing the contrast between objects and their backgrounds. Color

Blues appear dark and hard to distinguish from greens, secondary to yellowing of the lens and yellow filters out blue

Usual aging – may also be Disease - due to a maturing cataract

The elderly lens absorbs blue light selectively leading to distortion of color vision

May prefer high contrast colors

Central Loss (12 degree scotoma)

Cannot see the center of anything looked at

Disease - Macular degeneration

Difficult to see faces, read print

Use of low-vision magnifying devices to enable them to read and do close work.

Peripheral Loss

Can only see a narrow field of vision; “tunnel vision”

Disease - Advanced glaucoma

Difficult to get around safely in unfamiliar places

CAN read but needs to move head to increase visual field

Hemianopia

Cannot see one-half of visual field; Older persons may have trouble finding the beginning of lines or seeing the ends of words; patients may constantly bump into objects on one side.

Disease - stroke or brain injury

Interferes with orientation in space, walking, communication

Discuss: How do we improve communication with the visually impaired? Possible responses:

COLORED PAPERS


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Assure adequate lighting

Check that the patient is wearing her glasses

Acknowledge that the patient may pull away in order to better focus

Write clearly

Use large print material

Consider alternatives (recordings, pictures, diagrams)

Avoid low contrast materials

They can also use LARGE TEXT books or newspapers

VII. HEARING IMPAIRMENT: THE UNFAIR HEARING TEST A. Age-Related Changes in Hearing

Discuss: What are the effects of aging on hearing?

Possible responses:

Cerumen becomes drier causing muffled sounds and can be a cause of hearing loss

Tympanic membrane becomes thicker/duller and ossicular joints undergo degeneration causing decreased hearing

Loss of hair cells in the Organ of Corti leading to loss of high frequency sounds (“s”, “sh”, “f”: hissing sounds) causing condition called presbycusis

Note to Facilitator: Distribute the “Unfair Hearing Test” worksheet to each student. Start the tape and keep the volume loud enough for everyone in the room to hear.

Say: I want you to listen to the ten words. Listen closely and try to write your answers on column A. Note to Small Group Preceptor: After the first segment, stop the tape and ask the students what they wrote down in Column A. Write their responses on the chalkboard/whiteboard and highlight the differences in their answers. Discuss: Column A

What did you observe? How difficult was it?

This is a person with moderate hearing loss (presbycusis)

NOTE: Show the students

New York Times (Large Print)

Handout: Unfair Hearing Test Worksheet

The Unfair Hearing Test Audio: Column A


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The high-pitched sounds were filtered out.

Say: I want you to listen to the same ten words again. Listen closely and this time write your answers on column B

Note to Small Group Preceptor: After this second segment, stop the tape and ask the students what they wrote down in Column B. Write their responses on the chalkboard/whiteboard and then compare/contrast their answers with their previous answers in Column A. Discuss: Column B

This is a person with normal hearing but words are said softly

The words have softer sounds

Say: I want you to listen to the same ten words again. Listen closely and this time, write your answers on column C.

Note to Small Group Preceptor: After this second segment, stop the tape and ask the students what they wrote down in Column C. Write the CORRECT answers on the chalkboard/whiteboard and then compare/contrast their answers with their previous answers in Column A & B.

Discuss: Column C

This is a person with hearing aids

The hearing aid emphasizes the high-pitched sounds

The Ten Words 1. Fill 2. Catch 3. Thumb 4. Heap 5. Wise 6. Wedge 7. Fish 8. Shows 9. Bed 10. Juice

The Unfair Hearing Test Audio: Column B

The Unfair Hearing Test Audio: Column C


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Ask: What are some ways health care professionals can improve communication with our hearing impaired patients? Possible responses:

Ask the patient if they have a known impairment

Have the patient’s attention

Speak clearly, and face the patient

Repeat by paraphrasing

Avoid shouting

Speak slowly and in low tones

Be within 2 to 3 feet

Reduce background noise

Pause at end of sentences

Do not appear frustrated

Reinforce speech through other channels (gestures, writing)

Alert patient when you change the subject

Have person repeat the important facts

VIII. CONCLUSION

A. Summary

Ask: So now that you have developed an awareness of differences between the younger physician and the older adult patient’s perception of themselves, their environments, and the interaction between them, what can we do to minimize these potential but legitimate barriers? Possible Responses:

Have more than one visit

Just talk, let the patient speak for the first 5 minutes

Make patient comfortable

Call by title: Mr., Mrs., Dr., never by first name

Form an equal relationship

Make office physically accessible

Introduce yourself clearly

Consider gentle touching

Use an unhurried pace

Ask: What are some of the barriers to the doctor/patient relationship we have


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learned this session? Answers:

Age differences – Some older adults feel that since we are younger than they are we are ill-equipped to take care of them

Life experiences – Some older adults also think that since you are much younger than they are you will have difficulty in understanding where they are coming from. You may not have or will never experience what they have experienced.

Personal concerns – Since you are younger, your concerns may not be their concerns.

B. Review of Learning Goals Say: Let’s review the learning objectives for this session and see if we have made progress towards achieving them.

By the end of our session, you will be able to:

Understand the principles behind the discipline of geriatric medicine and relate its importance in the care of the rapidly expanding older adult population in the United States

Develop an awareness of differences between the learner’s and the older adult’s perception of themselves, their environments, and the interaction between them.

Gain familiarity with changes in vision and hearing found in older adults, and recognize that some age-associated changes are due the aging process, some to life habits, and others to disease

Apply the content of this session in your clinical encounters


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AGING FROM THE OUTSIDE IN WORKSHEET

YOUR GERIATRIC PATIENT

YOU

What year were you born?

What was your life expectancy at birth?

What country where you born?

Who was the President of the United States when you were born?

What major changes in the world have you encountered during lifetime?

What age did you retire or expect to retire?

How do you spend your time?

How many people do you speak to or see every day?

What worries you?

Do you have a personal doctor?

What worries you when seeing a doctor?


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THE UNFAIR HEARING TEST WORKSHEET

Column A Column B Column C

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

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AGING FROM THE OUTSIDE IN - pogoe.org from the outside in.pdf · Aging From the Outside In Faculty Guide 1 ... Gain familiarity with changes in vision and hearing found in older