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U.S. POPULATION AGE 65 AND OVER · – Dietary supplements such as used in the Aged-Related Eye...
Transcript of U.S. POPULATION AGE 65 AND OVER · – Dietary supplements such as used in the Aged-Related Eye...
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U.S. POPULATION AGE 65 AND OVER
010203040506070
Population (millions)
1900 1990 Est. 2010 Est 2030
Year
Special Considerations in Geriatric Care
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WHAT’S POTENTIALLY DIFFERENT ABOUT PEOPLE
AS THEY AGE?
• Multiple chronic illnesses • Multiple medications • Physiologic changes lead to adverse drug
effects, altered illness presentations • Cognitive/functional limitations • Increased importance of social/familial
support
Special Considerations in Geriatric Care
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GOALS OF GERIATRIC CARE
• Maintain or improve functional abilities • Prevent disease • Avoid iatrogenic illness • Cooperate with multidisciplinary team • Incorporate family into care
Special Considerations in Geriatric Care
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OLDER PATIENT ASSESSMENT
• Medical • Cognitive • Affective • Environmental • Economic • Social • Functional
Special Considerations in Geriatric Care
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FUNCTIONAL STATUS
• Complete functional tasks and fulfill social roles
• Activities of daily living (ADLs) – Personal care tasks
• Instrumental activities of daily living (IADLs) – Home management tasks
Special Considerations in Geriatric Care
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PRESCRIBING FOR OLDER PATIENTS
• Consider nonpharmacologic measures • Ask about all medication use, including
over-the-counter products • Use lowest effective dose • Increase dose slowly • Consider functional status
Special Considerations in Geriatric Care
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SUMMARY
• Goal of care: maintain or improve function, quality of life
• Assess patient’s status thoroughly • Consider status in therapeutic regimen • Work with other MDs as needed • Involve family caregivers
Special Considerations in Geriatric Care
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VISUAL LOSS ASSOCIATED WITH AGING
• 1 in 3 may face some visual loss by age 65 • Potential consequences
– Daily activities curtailed – Social isolation, depression – Less mobility, falls and fractures – Loss of independent living
Principal Problems of the Aging Eye
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POTENTIAL EFFECTS OF AGING
ON VISION • Decline in visual acuity • Increase in visual impairment • Legal blindness
Principal Problems of the Aging Eye
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AGING AND THE CRYSTALLINE LENS
• Lens – Yellows: May affect color discrimination – Opacifies: Cataract – Hardens: Nuclear sclerosis
• Ciliary body/lens – Loses accommodative ability: presbyopia
Principal Problems of the Aging Eye
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SYSTEMIC DISEASES AND THE
AGING EYE
• Hypertension: retinal vein occlusion • Arthritis: dry eye • Diabetes: glaucoma, cataracts, diabetic
retinopathy
Principal Problems of the Aging Eye
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VISION LOSS IN THE AGING EYE:
LEADING CAUSES • Age-related macular degeneration • Glaucoma • Cataract • Diabetic retinopathy
Principal Problems of the Aging Eye
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VISUAL IMPAIRMENT OFTEN UNTREATED
• Leading causes of blindness in the aging eye (Baltimore Study): – Unoperated cataract – Primary open-angle glaucoma – Age-related macular degeneration
• 1/3 of new blindness is avoidable
Principal Problems of the Aging Eye
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EVALUATION: HISTORY
• Problems with vision? • Was vision decrease sudden or gradual? • Any pain with vision loss? • Any eye operations? • Using any eyedrops?
Principal Problems of the Aging Eye
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EVALUATION: EXAMINATION
• Visual acuity • Lids and orbits • Pupils • Visual fields • Motility • Anterior segment • Intraocular pressures • Posterior segment
Principal Problems of the Aging Eye
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EVALUATION: FREQUENCY
• Asymptomatic patients 65+: Every 1–2 years
• Symptomatic patients: Evaluate and refer on presentation
• Decreased visual acuity: Routinely refer • Treatment goal: Optimize visual function
Principal Problems of the Aging Eye
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Principal Problems of the Aging Eye
Blepharitis
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Principal Problems of the Aging Eye
Entropion of left lower lid
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Principal Problems of the Aging Eye
Ectropion
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Principal Problems of the Aging Eye
Ptosis
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Principal Problems of the Aging Eye
Basal cell carcinoma
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Principal Problems of the Aging Eye
Corneal damage: severe dry eye
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Principal Problems of the Aging Eye
Herpes zoster ophthalmicus
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AGE-RELATED MACULAR DEGENERATION (AMD)
• Most common cause of irreversible visual loss in the aging eye
• Loss of central vision • Risk factors
– Advanced age – Family history of AMD – Smoking, CV disease
Principal Problems of the Aging Eye
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Medium-size drusen
Principal Problems of the Aging Eye
Large drusen inferonasal to macular center
Large drusen (125 + µm)
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AMD: RISK OF PROGRESSION
• Early AMD – May not have any increased risk of advanced AMD
compared to people without drusen
• 1 eye intermediate AMD, 1 eye without AMD – 5% risk of progression to advanced AMD within 5 years
• Both eyes intermediate AMD – 25% risk of progression to advanced AMD within 5 years
• 1 eye advanced AMD – 50% risk of advanced AMD in second eye within 5 years
Principal Problems of the Aging Eye
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AMD: CENTRAL VISION LOSS IN ADVANCED STAGES
• “Dry” AMD – Atrophy of photoreceptors and choriocapillaris – Gradual vision loss
• “Wet” AMD – Neovascularization between retina and choroid – Disc edema, disciform scar – More sudden visual loss
Principal Problems of the Aging Eye
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AMD: SYMPTOMS
• Intermediate stage – No symptoms or slight
difficulty with reading, driving, etc, due to atrophy not yet involving center of macula
– Straight lines may appear crooked
• Advanced stage – Central blind spot – Peripheral vision usually
remains intact
Principal Problems of the Aging Eye
Central blind spot
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Principal Problems of the Aging Eye
Fluorescein angiogram: neovascular AMD
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TREATMENTS FOR AMD
• Aim to reduce risk of progression in intermediate to advanced stage – Dietary supplements such as used in the Aged-Related Eye
Disease Study (vitamin C 500 mg, vitamin E 400 IU, beta carotene 15 mg, and zinc oxide 80 mg)
• Reducing risk of vision loss in selected cases of neovascular AMD – Laser photocoagulation – Photodynamic therapy with verteporfin – Intraocular injection therapy with anti-VEGF drugs (some may
increase chance of improving vision)
Principal Problems of the Aging Eye
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AMD: MINIMIZING VISION LOSS
Patients with intermediate stage of AMD: • Consider dietary
supplement such as that used in AREDS
• Periodic monitoring at home and office for progression to CNV
• Prompt notification of vision changes suggesting CNV
• Periodic educational update
Principal Problems of the Aging Eye
Normal appearance
Abnormal distortion
Home Monitoring with Amsler Grid
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AMD: DEALING WITH VISION LOSS
• Low vision aids • Treatment of depression
and anxiety when indicated
Principal Problems of the Aging Eye
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GLAUCOMA
• Second most common cause of visual loss in older people
• Affects – 10% African-Americans ≥ 70 – 2% Caucasians ≥ 70
• Early detection and treatment can prevent blindness
Principal Problems of the Aging Eye
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GLAUCOMA: RISK FACTORS
• IOP may be high • African racial heritage • Advanced age • Family history of glaucoma • Hypertension, diabetes, myopia
Principal Problems of the Aging Eye
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Glaucomatous optic nerve Normal optic nerve
Principal Problems of the Aging Eye
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TYPES OF GLAUCOMA
• Primary open-angle glaucoma (POAG) – Most common type in people over age 50
• Angle-closure glaucoma
Principal Problems of the Aging Eye
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Primary open-angle glaucoma
Principal Problems of the Aging Eye
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Principal Problems of the Aging Eye
Visual field testing
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POAG: MANAGEMENT
• Halt visual field loss • Prevent further optic nerve damage • Use medications to lower IOP • Consider laser surgery, glaucoma filtration
surgery, other interventions where warranted
Principal Problems of the Aging Eye
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ANGLE-CLOSURE GLAUCOMA
• Approximately 10% of glaucoma cases in U.S.
• More common in ages 50+ • More common in some Asian groups • Risk factors: female with hyperopia
Principal Problems of the Aging Eye
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Angle-closure glaucoma
Principal Problems of the Aging Eye
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Principal Problems of the Aging Eye
Acute angle-closure glaucoma
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Laser iridotomy
Principal Problems of the Aging Eye
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AGE-RELATED CATARACT
• Third most common cause of visual loss in older people
• Decreased vision (Framingham Eye Study) – 65–74 years = 18% – 75–85 years = 46%
Principal Problems of the Aging Eye
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Dense cataract causing pupil to appear gray rather than black
Principal Problems of the Aging Eye
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CATARACT: SYMPTOMS
• Disturbance of near or distance vision at first
• Progresses to diminution of vision • Cataract severity and location determine
impairment • Glare is bothersome
Principal Problems of the Aging Eye
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CATARACT: TREATMENT
• Surgery indicated if – Significant visual impairment – Daily activities curtailed (eg, problems driving, reading, etc.)
• No current medical treatment
Principal Problems of the Aging Eye
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CATARACT: PRE-OP EVALUATION
• Often done in consultation with PCP • Factors to consider
– Local (retrobulbar, peribulbar, or topical) anesthesia – May use IV sedation – Requires lying supine–optimize pulmonary function
Principal Problems of the Aging Eye
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Principal Problems of the Aging Eye
Implantation of an artificial intraocular lens within the capsular bag
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CATARACT: PROGNOSIS & FOLLOW-UP
• 90% achieve 20/40 vision or better • Infrequent complications
– Infection – Glaucoma – Retinal swelling or detachment
• Capsular bag opacifies, requiring Nd:YAG laser capsulotomy in 15%
Principal Problems of the Aging Eye
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DIABETIC RETINOPATHY (DR)
• Fourth most common cause of visual loss in people over age 55
• Type II diabetes more likely in people over age 55
• Macular edema more common with type II
Principal Problems of the Aging Eye
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Principal Problems of the Aging Eye
Hard exudates and macular edema
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Neovascularization of the disc (NVD)
Principal Problems of the Aging Eye
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DR: MINIMIZING EFFECTS
• PCP and ophthalmologist work together – Type I: Annual eye exam beginning 5 years after diagnosis – Type II: Eye exam at time of diagnosis, and then annually
• Good glycemic control – Type I: Insulin – Type II: Diet, exercise, weight loss
Principal Problems of the Aging Eye
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RETINAL VASCULAR OCCLUSIONS
• Cause sudden visual loss • Transient or permanent • Refer to ophthalmologist, and possibly
neurologist or vascular surgeon
Principal Problems of the Aging Eye
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Principal Problems of the Aging Eye
Central retinal artery occlusion
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Principal Problems of the Aging Eye
Branch retinal artery occlusion
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Principal Problems of the Aging Eye
Central retinal vein occlusion
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Principal Problems of the Aging Eye
Branch retinal vein occlusion
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Principal Problems of the Aging Eye
Posterior vitreous detachment
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Principal Problems of the Aging Eye
Retinal detachment
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Principal Problems of the Aging Eye
Retinal detachment
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CRANIAL NERVE PALSIES
• Systemic ischemic disease can lead to palsies
• Cranial nerves III, IV and VI control extraocular movements
• PCP and ophthalmologist manage together
Principal Problems of the Aging Eye
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Principal Problems of the Aging Eye
Third-nerve palsy of right eye: patient attempting to look up
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Principal Problems of the Aging Eye
Sixth-nerve palsy of right eye: patient attempting to look to the right
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Principal Problems of the Aging Eye
Ischemic optic neuropathy
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TEMPORAL ARTERITIS
• Vasculitis affecting medium-sized vessels • May cause
– Ischemic optic neuropathy – Cranial nerve palsies – Retinal vascular occlusions
Principal Problems of the Aging Eye
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TEMPORAL ARTERITIS: SYMPTOMS
• Headaches • Malaise • Night sweats • Weight loss • Jaw claudication • Polymyalgia rheumatica
Principal Problems of the Aging Eye
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TEMPORAL ARTERITIS: DIAGNOSIS
• A diagnosis based on history and clinical findings
• Sedimentation rate often elevated, but test has low sensitivity and specificity
• C-reactive protein level may also be elevated. • Temporal artery biopsy usually confirms giant
cell infiltration • If untreated, may progress to vision loss
Principal Problems of the Aging Eye
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TEMPORAL ARTERITIS: TREATMENT
• Oral corticosteroids • Start treatment on diagnosis • Biopsy not affected if performed within 1
week of beginning treatment
Principal Problems of the Aging Eye
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MODERATE LOW VISION (~ 20/70 to 20/160)
• Refractive devices – Special spectacles – Contact lenses – Telescopes – Electronic magnification
• Increased lighting – General for ambulation – Intense for near vision tasks
Principal Problems of the Aging Eye
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SEVERE LOW VISION (20/200 to 20/400 or worse)
• Magnifiers for near vision tasks • Electronic magnification • Special household appliances
– “Talking” clocks – Computers with voice-recognition capability
Principal Problems of the Aging Eye
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CARE OF THE AGING EYE
• Decreased vision with age • Common eye conditions affect people over
the age of 50 • Many conditions are preventable or
treatable • Improve or maintain visual function • Coordination between PCPs and
ophthalmologists ensures best care
Conclusion