Module 0: Introduction

0.2: Course Topics

Topics covered include:

• Demography of our aging population
• Epidemiology of health and functional problems experienced by older adults
• Theories of aging
• Biology and physiology of aging
• Principles of drug therapy
• Psychosocial, cultural, policy, and financial factors influencing the aging process and health care
• Approaches to addressing the range of common to complex problems experienced by older adults.

Data are made clinically relevant through the use of case exemplars, problem-solving activities, and introduction to research activities that are advancing our knowledge of aging and approaches to care.

0.3: Overall Course Goals

This course will provide participants with:

• A foundation in the demography, pharmacology, biology, and physiology of aging;
• The ability to distinguish age-related changes from pathology;
• A working knowledge of psychosocial, economic, cultural, and health policy issues influencing aging and health care for older adults in the United States;
• The components of a comprehensive and multidisciplinary assessment of older adults and their families;
• A working knowledge of common health problems experienced by older adults and an understanding of the potential for atypical presentations;
• An understanding of the continuum of clinical settings and services offering care to older adults;
• An understanding of how to access these services, including factors that facilitate or constrain utilization of particular types of care;
• The ability to integrate knowledge gained into the development of a comprehensive plan of care for elders across a spectrum of care settings.

0.4: Philosophy

This course recognizes a multidisciplinary team approach as fundamental to the provision of quality care to older adults. Knowledgeable, thorough and careful examination, backed by appropriate consultation with and inclusion of other clinicians and experts, is essential. It is acknowledged, however, that teams will vary in their membership, structure, and function depending on patient need and the site of care. Team members may include physicians, dentists, pharmacists, nurses, physical and occupational therapists, dietitians, social workers, and psychologists. On occasion, teams will also consult speech therapists, recreational therapists, legal experts, housing authorities, and financial managers.

0.5: Faculty

This program was developed collaboratively by faculty at the University of California, San Francisco under the auspices of the Academic Geriatric Resource Center.

	Judith C. Barker, PhD, Anthropology, History, and Social Medicine
	Susan Hyde, DDS, MPH, PhD, Restorative Dentistry
	Kirby Lee, PharmD, MA, Clinical Pharmacy
	Margaret Wallhagen, PhD, RN, CS, GNP, Physiological Nursing

Contributing Faculty

Mark Kirkland, DDS, Dentistry
R. Ron Finley, BS Pharm, RPh, Clinical Pharmacy
Bree Johnston, MD, MPH, Geriatrics, Medicine
Charlene Harrington, RN, PhD, Social and Behavioral Sciences
Joan B. Wood, PhD, Social and Behavioral Sciences and Medicine (Geriatrics); Past Campus Planner, Academic Geriatric Resource Center
 

(Circa 2003- Original AGRC Online Curriculum Faculty, from left to right (front) M. Kirkland (Dentistry), Ron Finley (Pharmacy), (back) B. Johnston (Medicine), J. Barker (Anthropology), M. Wallhagen (Nursing), Joan Wood (Geriatrics))

0.6: Why Take This Course?

Good question—why should we care? Over the past century in the United States, while the numbers of individuals under the age of 65 has tripled, the numbers of those aged 65 and older has increased by a factor of 11 (US Bureau of the Census, 1996). The oldest-old, those over 85, are the fastest growing segment of the population. And the Baby Boomers are moving into middle age. By the year 2050, it is estimated that the population of older adults in the United States will double, reaching at least 80 million persons.

These elders are having a major impact on our health care system; in 1995, when older adults represented only 12.8% of the population, they utilized over a third of the total personal health care dollars. They are hospitalized more frequently, stay longer, consume approximately one third of prescription medications, and suffer more adverse drug reactions than younger adults. While these statistics paint a potentially negative picture, many of the frequently noted problems related to aging can be minimized or avoided. We now realize that some of the problems commonly associated with aging are in fact mutable. Thus one of the reasons for developing this course is to disseminate this growing understanding of aging. To illustrate, we’ll look at three brief cases.

0.7: The Multifaceted Face of Aging: 3 Cases

Older adults comprise the most heterogeneous age group within the human lifespan. To understand aging, one must consider a vast array of individual differences.

The heterogeneity of aging is exemplified in the following brief cases:

Case 1: A Well-Elder Couple

Mr. Edward Smith and his wife, Helen, a Caucasian couple in their late 70s, are retired and enjoy activities in their church, traveling, and visiting with their 3 children and 7 grandchildren. Neither Mr. or Mrs. Smith has significant physical problems; they take no prescription medications; and they remain sexually active. Mr. Smith occasionally complains of what he describes as “arthritis” of his right knee and Mrs. Smith was recently told she had “some” macular degeneration.

Case 2: An Older Man with Chronic Medical Problems

Mr. Wujing Xian is a 78-year-old Chinese-American man with type 2 diabetes mellitus, hypertension, and vision impairment. He lives in a board and care setting. He needs assistance with several activities of daily living (bathing and dressing), uses a walker to ambulate, and depends on his son’s family to assist him get to appointments with his health care provider. He takes medication for his diabetes, hypertension, and atrial fibrillation.

Case 3: A “Frail” Elder Requiring Nursing Home Care

Mrs. Olivia Ramos is a 76-year-old Latina widow with moderately severe Alzheimer’s disease who resides in an urban nursing home. Her 55-year-old daughter visits daily. She took Mrs. Ramos home for an occasional weekend visit until Mrs. Ramos became increasingly more confused during these visits. Mrs. Ramos takes donepezil for her dementia and occasionally is given medication for constipation and for ‘pain’ when she looks uncomfortable, although Mrs. Ramos has difficulty expressing how she feels. While Mrs. Ramos needs assistance with all activities of daily living, she can eat slowly but independently if coached.

0.8: Discussion of the Three Preceding Cases

When people think about aging, many think about Mrs. Ramos, assuming that most older individuals are cognitively impaired and functionally dependent and live in a nursing home. When health practitioners in training encounter the Smiths, they are likely to describe them as “remarkable”. But in reality, 90% of older adults are living at home in the community with few functional problems; they are socially well-connected and enjoy many activities. In addition, as we learn more about the aging process, we are realizing that many changes that we used to think were ‘normal’ are the result of disease or disuse, and not the result of aging per se.

Understanding the difference between normal aging and age-associated pathology is part of the essential knowledge base for health professionals who want to improve the lives of older adults. With this course, we hope to provide a sound foundation in geriatrics and gerontology, beginning with the demography of our aging population and an understanding of “normal” aging.

0.9: How To Use This Course

This program is:

1. Developmental—beginning with basic foundational information and building into complex care;
2.   Case-based—using real situations as exemplars that allow integration of the materials into clinical practice; and
3.   Flexible—allowing you to move among content areas to focus on those topics or issues that are of most interest or relevance to your needs.
Outlines and specific objectives are provided with each content area to focus your study. Each section includes hotlinks to other sections with explanatory, in-depth, or related materials; these will facilitate ease of movement to alternative content sections. You can always by-pass any section because each is designed to stand alone, although we suggest that the first module on demographics provides a base that will facilitate an understanding of the issues that our current health care system and we, as practitioners, are facing.

0.10: Where To Start?




Because the majority of older adults have only mild impairments and are living in the community, we focus first on WELL ELDERS to demonstrate key principles of geriatric care. Through intensive consideration of several cases as you participate in this course, you will learn to integrate knowledge from various disciplines into your understanding of the present circumstances and future prospects for these individuals. These cases also provide background to an exploration of changes that occur with age with an emphasis on differentiating these changes from pathology. How these changes influence the response to medications and other treatment modalities are also emphasized. Finally, the cases provide a basis for emphasizing the importance of health promotion and disease prevention.

0.11: Then What?




Building on these foundational materials, the course moves on to consider a variety of problems or conditions that are more commonly experienced by older adults than by younger adults; for example, falls and instability, arthritis, dementia, and hypertension.

The next level focuses on common diseases that have potential multi-system complications and often require multiple drugs, such as diabetes, heart disease, and stroke.

The course ends with complex cases requiring the consideration of therapy in light of multiple, competing conditions, functional impairments, and psychosocial issues. Learning at each level is case-based, includes examples across a range of settings, and focuses on integration of knowledge from a variety of disciplines. Throughout, questions and exercises are designed to facilitate problem-solving and critical thinking.

0.12: How to Start--Case 1




The Smiths: A Closer Look

Mr. Edward Smith is a 79-year-old Caucasian man who currently lives with his 75-year-old wife, Helen, in a small house located in the rural community where he and his wife grew up. They have been married for 55 years. Mr. Smith owned and operated a hardware store for much of his adult life, retiring at the age of 74 when he decided the work was becoming too heavy and he and Helen wanted to spend some time traveling. The Smiths enjoy square dancing and are active in their local church. They enjoy occasional visits with their three children and seven grandchildren. Two sons live in an urban area nearby, while their 52-year-old daughter lives in another state.

Mr. Smith has no significant physical problems, although he is a bit overweight, has a cholesterol level and blood pressure “higher than my doctor would like”. He has been diagnosed with osteoarthritis in his right knee, for which he takes a nonprescription medication containing ibuprofen each day, which he purchases in the one drugstore in town. He continues to smoke one-half pack of cigarettes a day, in spite of the warnings of his grandchildren. Both Mr. and Mrs. Smith rarely drink alcohol and, when they do, prefer a glass of red wine. Mr. and Mrs. Smith are sexually active and enjoy at least one extended romantic holiday each year, usually as a part of a group bus tour. Mr. Smith prefers to leave the long distance driving to others since his night vision has declined in recent years. Mrs. Smith continues to do most of the cooking and house cleaning; she also spends time in volunteer activity with her local church guild. Mr. Smith enjoys fishing when he is not spending his days helping at the chamber of commerce office. On sunny days he sometimes rides his bicycle the three miles to the commerce office. The Smiths have a small retirement fund, receive social security payments and Medicare, have a small life insurance policy, but do not have long term care insurance. The Smiths have a family physician, whom they visit once a year or as necessary for ” the flu”. Mr. Smith reports having no problems with his teeth or his 20-year-old partial dentures. “I do eat less steak these days”. Visits to the dental clinic, which is 47 miles away, are infrequent.

0.13: How to Start--Case 2




Meet Another Well Elder, Mrs. Wright

Mrs. Sylvia Wright is an 80-year-old, widowed, African American, retired high school teacher who shares her suburban home with her 58-year-old daughter and two adult grandchildren. Mrs. Wright and her husband moved to this area when they were first married because her husband, a skilled electrician, got a government job here. He died 30 years ago after suffering a stroke. Because her daughter works long hours in her job as an accountant, Mrs. Wright is the primary person responsible for cleaning the house and cooking. She is active in her church and enjoys attending programs at her local senior center. Her son, who is a physician and lives six hours away, calls his mother weekly. He has been concerned that his mother may be developing some memory impairment as she recently set off the smoke alarm by leaving a pan unattended on the stove. Mrs. Wright’s daughter and grandchildren are also concerned about her. While Mrs. Wright denies any health problems, she is prescribed 60 mg of long-acting nifedipine once daily for hypertension. She reports that she sometimes “stretches” the prescription out, “because it is expensive and I pay for my medications.” She purchases various nonprescription medications for the “arthritis” pain she sometimes experiences in her knees and hands and to treat constipation. She says her feet sometime “swell” when she stands for long periods of time. Mrs. Wright visits her doctor who works in an HMO once every three months. She can afford these visits because her modest retirement pension includes health benefits that pay for doctor visits but not for medications. Her assets otherwise are her Social Security benefits and Medicare. A small nest-egg of savings inherited from her husband was used to help the grandchildren who live with her through college. She says, “My teeth are in pretty good shape. I notice a little bleeding sometimes when I brush my teeth and, of course, I have had bad breath for years”. For religious reasons, Mrs. Wright is a nonsmoker and does not drink alcoholic beverages.

0.14: Reflection on Two Cases




Consider the two preceding cases: identify the issues that might be of concern to you as a practitioner seeing these individuals for the first time.

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After you finish reflecting on these cases, move on the course content. Use the links in the “Main Menu” on your left to choose an appropriate module.