1. The Aging Canadian Population
3. The "Geriatric Giants"
4. Care Settings:
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The demographics of Canada are changing – seniors make up an increasing percentage of the population.
At present 16% of the population is aged over 65; this will rise to 20% by 2025, and to 25% by 2041. (Statistics Canada). 2015 was the first year that the number of seniors aged 65 and over exceeded the population aged 14 and under.
This graph shows the rising median age over the past 40 years.
Population pyramids (diagrams showing the age structure of the population) illustrate this shift in age.
Note the change from a triangular shape (black line, 1956) to a more rectangular structure of population:
The aging of our population reflects several factors: greater longevity, falling birth rates, the bulge due to baby boomers born following the Second World War, immigration patterns. Physicians will see increasing numbers of very elderly patients, and especially women. In the population 80 years of age and older, there were an estimated 62.8 males per 100 females in 2015.
Total Population of Canada (2015) 35,851,800
Age Structure (2015): 0-14 years: 16.0%; 15-64 years: 67.9%; 65 years and over: 16.1% or 5.8 million people.
The median age of Canada’s population was 40 years in 2011, an increase of 10.2 years in the last 30 years.
Birth, Fertility and Death (2011 National Household Survey):
Ethnic and Religious Composition
Statistics Canada animated population pyramids show how the age structure of the population has changed over time.
For more information on child and perinatal health, click here to go to the Child Health Theme
For more information on definition of common mortality rates, click here to go to the Epidemiology Theme
Gerontology: The scientific study of individual and population aging
Geriatrics: The branch of medicine addressing the health and medical care of elderly people
Core principles of care of the elderly include:
Comprehensive Geriatric Assessment: When the clinical goal is to enable an elderly person to live as independently as possible given their condition, several groups must collaborate to assess and form a treatment plan. The assessment reviews the patient’s medical, psychosocial, and functional limitations, while the treatment plan sets goals and identifies ways to adapt to these limitations. Geriatric assessment is initiated through an inpatient (i.e. already in hospital) or outpatient referral to geriatrics (e.g. by a family doctor).
Geriatric Assessment Outreach Teams provide multidimensional assessment for people aged 65+ in their homes, to identify appropriate treatment and support for seniors with complex health problems. The goal is to keep seniors independent, living in their homes, and to optimize their quality of life.
Each team consists of a geriatrician, nurses, occupational therapists, physiotherapists, social workers and a secretary or intake worker.
When should you consider a referral to the program?
In hospital, geriatric teams can help assess and support elderly patients. These teams include:
Geriatric Medicine Consult Team: Assessment & management of high-risk older adults in hospital. This team identifies risks to the patient’s independence and collaborates with other providers to achieve a sustainable discharge. A core assessment follows the M4 format: Mind issues, Mobility issues, Medications (de-prescribing), Multi-morbidity.
Geriatric Psychiatry Behaviour Support Team: Provides support/consultation for behavioural and psychological symptoms of dementia. Focus on clinical assessment, developing a personalized plan of care, monitoring in hospital and liaison post-discharge.
Geriatric Emergency Medicine: A program that identifies high-risk older adults due to be discharged home from the ED, in order to initiate early referral to specialized geriatric services & targeted community supports.
The principal chronic disabilities of old age that impact on physical, mental and social domains of older adults have been termed the Geriatric Giants. They include:
“Failure to Thrive” or ”Failure to Cope” (often secondary to issues above) is often cited as a Geriatric Giant. However, this does not represent a diagnosis, but rather a failure by clinicians to identify the interacting factors (polypharmacy, cognitive impairment, multiple co-morbidities, psychosocial factors) that cause frail seniors to present to emergency rooms.
Note: Core material on depression is covered under the Mental Health theme. The present section covers how depression may differ in geriatric patients.
Geriatric patients are at risk for depression; up to 3% of geriatric patients in the community and 15% in long-term care facilities have Major Depressive Disorder.
However, the clinical picture for geriatric patients is often different than the “typical” picture painted for depression.
Geriatric patients are more likely to present with physiological symptoms of depression (impacted sleep, appetite, weight, concentration, less energy) and less likely to describe hopelessness, guilt or active suicidal ideation. Geriatric patients with depression are also more likely to present with anxiety or agitation in association with the depression and more likely to experience psychotic symptoms.
In addition, it is always important to keep in mind the “3 Ds” of cognitive impairment in geriatrics that often occur together: Depression, Delirium and Dementia. Never assume that a patient has depression or dementia when they may have an easily reversible delirium.
It is also important to differentiate between grief and depression, which may result in similar psychological and physiological symptoms as depression. One way to determine this is to follow the time-course of the symptoms; a grieving person will have episodes of grief, between which they function well. (Grief comes in bursts, triggered and lessening; depression is enduring, autonomous and persistent). Grief generally doesn’t lead to motor slowing or suicidal ideation.
Pseudodementia: Individuals with depression may lose points in their MMSE or MOCA test due to issues with concentration and lack of interest; this is not a true dementia
All anti-depressants work on elderly patients (TCA, SSRIs, SNRIs). However, evidence doesn’t support long term use in depressed patients who also have dementia – depression usually doesn’t last long in dementia and so consider tapering after 3-5 months.
Dementia is a neurocognitive disorder characterized by deterioration of a person’s memory, followed by other aspects of intellectual, emotional and cognitive functioning in an otherwise intact consciousness (meaning that the symptoms are not due to depression or delirium, etc.).
Dementias are relentlessly progressive, and eventually lead to the point where patients become incapable of caring for themselves. Severe dementia is fatal.
Alzheimer’s Disease: Characterised by insoluble beta-amyloid plaques and tau neurofibrillary tangles in the brain. Insidious onset, gradually progressive linear deterioration of memory and cognition. Alzheimer's disease accounts for roughly two-thirds of all cases of dementia; vascular dementia accounts for a quarter.
Vascular Dementia: Dementia related to vascular events (stroke, ischemia); “Step-wise” decline in cognition if pure vascular etiology. Prominent decline in complex attention and frontal-executive function. Evidence of cerebrovascular disease from history, physical exam, neuroimaging.
Lewy Body Dementia: Alpha-synucleionopathy, presents with Lewy bodies in brain cells. Individual presents with fluctuations in attention and alertness, recurrent visual hallucinations and spontaneous Parkinsonism. Insidious onset but usually more rapid than AD.
Other common causes of dementia include Frontotemporal dementia, normal pressure hydrocephalus and a range of other conditions such as Pick's disease, Creutzfeld Jacob disease and others.
“Conversation is difficult with someone who cannot remember the question she is trying to answer, or the beginning of the sentence she is struggling to complete.” [Patrick Brown, Butterfly Mind. House of Anansi Press, Toronto, 2008, p178 ]
Frailty: This is defined in differing ways, but refers the combined effects of aging, disease, and factors such as nutritional status and functional ability that make some persons susceptible to adverse health outcomes. It is a prognostic concept, referring to people at risk of decline in health; it is the opposite of successful aging.
Frail seniors typically suffer from a loss of skeletal muscle (sarcopenia), increased expression of inflammatory and neuroendocrine markers rendering them incapable of maintaining homeostasis under stress (‘homeostenosis’). Frailty develops slowly, often in a stepwise fashion and may be reversible in its early stages.
Falls are a very common cause of morbidity among elderly people.
It is important to consider ALL of the reasons an elderly person might fall. Often with geriatric patients, numerous factors lead to their presenting complaint.
Some factors that may increase the risk of falls in a geriatric patient:
A fall (like any of the geriatric giants) is a good reason to refer a geriatric patient for a Comprehensive Geriatric Assessment.
Elder abuse generally means "the physical, psychosocial or financial mistreatment of a senior." Neglect is a common form of abuse.
The WHO defines elder abuse as “a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person.”
While reliable figures on elder abuse are hard to find, it is common, especially so in people who are frail, or disabled, or with dementia. Doctors should be alert to potential signs.
Risk factors for abuse include: family financial problems; family stress and frustration as the elderly person becomes more dependent; migration of young couples to urban centres; social isolation due to mental or physical frailties; erosion of cultural bonds between the generations.
In addition to physical abuse, elder abuse may take the forms of financial abuse (using an older patient’s money, not allowing the patient access to their money), chronic verbal abuse, psychological abuse, and neglect, among others.
Polypharmacy: The simultaneous use of multiple drugs by a single patient to treat one or more conditions.
Elderly patients are more likely to experience polypharmacy: they often have multiple illnesses and see several physicians. Physicians may feel hesitant to stop a drug prescribed by a colleague and may also feel pressured by the time it takes to completely assess the impact of all the medications that an elderly patient is taking. In theory, the family physician should keep track of the overall picture and be alert to potential polypharmacy.
From a physiological perspective, the pharmacodynamics or pharmacokinetics of a drug may be different in an elderly patient (e.g. hepatic metabolism changes) and this leads to increased risk of unexpected consequences of prescription drug use.
Prescribing cascade: Where the side effects of a drug are interpreted as a new disease → 2nd medication added → new side effects → 3rd medication, etc.
The simplest predictor for Adverse Drug Reactions (a drug interaction that leads to an undesirable event) is the number of drugs a patient is taking.
Common presentations of ADRs in the elderly: falls, cognitive decline (confusion, memory loss), GI symptoms + bladder symptoms, postural hypotension, electrolyte disturbance, etc.
Hospitals in particular can be dangerous for geriatric patients from a polypharmacy perspective. Medications are often stopped on admission and new drugs started on release. Oftentimes, patients are given repeats of medications they have at home. Again, the family physician must remain vigilant.
Steps to avoid ADRs from polypharmacy:
For many years, Canada admitted a higher proportion of its elderly population to institutional care than other countries. However, this has been changing as a result of funding cuts to health care and a growing preference on the part of seniors to remain at home.
At the same time there has been a significant change in the types of institutional care available. There are now many more categories of institutional settings, many privately owned. These often provide a range of levels of supervision, from those that resemble apartments (including cooking facilities, etc.) to those with full-time nursing staff. It therefore becomes difficult to define precisely what "institutional care" means. It should be emphasized that retirement homes are not regulated heath care facilities. Increasingly, family and patients are expected to fund long term care in these facilities.
The 2011 Census found that 7.2% of seniors aged 65 and over lived in “collective dwellings”, which included residences for senior citizens, health care settings and related facilities. By contrast, 92.1% lived in private households.
The percentage of seniors who live in collective dwellings increases with age, from 1.6% at ages 65 to 69 to 43.5% of seniors in their nineties.
In the context of reduced institutional care, home care becomes more important. Many (88%) of seniors relied on help from family and friends and half of these individuals also received professional home care services. Only 12% relied on professional services alone.
Statistics Canada Report: Receiving care at home
Note that 92.1% lived in private households and may require home care to remain in their home. The development of urinary incontinence seems to be a common tipping-point that leads to the delivery of home care services. Note that types of home care (and of long term care) vary from province to province.
In theory, home care services in Ontario are made available to people of all ages who meet the following criteria:
Home care services are divided into “professional services” and “personal support and homemaking services”.
Personal Support and Homemaking Services:
Undertaking a Complete Geriatric Assessment may help the patient, family and friends better identify what services the patient requires and what are available.
Home care can include:
Acute (short-term treatment, with the goal of rehabilitation and discharge from the program). Acute home care is typically used for cancer patients following discharge, for ex-surgical patients or post partum mothers. Acute care includes services such as nursing, physiotherapy, occupational therapy, social work, nutrition services or homemaking. Transportation can be provided to and from medical appointments.
Long-term. This seeks to prevent or slow further decline, or to delay institutional admission. It includes palliative care, and generally refers to people who require assistance in managing personal care needs. The services available are similar to those in acute programs, but are intended mainly for patients requiring functional support, or for patients with cognitive impairments, or for palliative care.
Placement services are involved in referring a patient to a long term care facility.
The provision of services keeps changing, reflecting financial pressures and political decisions, so details of what services are available and the costs involved will no doubt change before you enter practice.
Is the Supply of Home Care Meeting the Demand?
Statistics Canada reported that in 2012, 8% of Canadians (2.2 million people) received home care because of a long-term health condition, disability or problems related to aging. Of these, 15% reported that they did not receive all the help needed; an additional half a million people reported that they had needed help or care in the last year for a chronic health condition and did not receive any: “unmet” home care needs.
Because hospital stays are becoming shorter, home nursing care has risen among those who had been hospitalized. This came at the expense of regular assistance with household chores: home care is becoming more specialized. Only about 35% of those reporting a dependency in activities of daily living were receiving subsidized care, down from 46% in 1994.
Some of the comments made by politicians on the topic are worthy of being framed. On May 21, 2002, CBC radio reported a plan to save money by reducing the number of baths that home care workers assist elderly people with from two to one per week. The unfortunate home care spokesperson being interviewed argued that, as "home care is intended to keep people independent, it would not be appropriate to create a dependency on it." Apparently, washing twice per week constitutes an addiction.
Physicians typically refer a patient to a home care agency, which assigns a case manager who visits to assess the client's need and link them to the appropriate program, such as meals on wheels, adult day programs, etc.
At least until 2016, the main route for a physician in Ontario to arrange community care for a patient is through the local Community Care Access Centre (CCAC). The Ottawa Champlain region CCAC is at 613-745-5525. Services are coordinated by a case manager, who typically schedules visits by a nurse, occupational therapist or social worker to the patient`s home. The Ottawa CCAC now falls under the Champlain Local Health Integration Network (LHIN).
Alternatively, you can arrange care through private home health care agencies. An example in Ottawa is the We Care Home Health Services. This offers a range of clinics (click on link for examples).
A huge information resource is the Community Information Centre of Ottawa, listing thousands of resources in its ‘Blue Book’. This provides a directory of available community care agencies that may help you care for your patients. They have a searchable web-based list of resources (click on the "e-Blue Book" link on their web page).
A related clearinghouse is 211Ontario. This is a phone number and website that provides information and referral to community and social services in Ontario.
For mental health services, your one-stop shopping is at ementalhealth.ca. The website allows you to search anywhere in Canada, and it lists huge numbers of resources. Bookmark this site!
There is a list of support agencies on the Ottawa Seniors Directory web site. These include retirement living, home support, seniors' centres, home cleaning services and lots more.
Meals on Wheels is a long-established program that supplies hot meals to elderly or disabled people. The aim is to help people live independently in their own homes. There is a charge, but kept low in this not-for profit agency.
My memory's not as sharp as it used to be.
Also, my memory's not as sharp as it used to be.
Barry's rule: If you stop to think, remember to start again. The nice thing about being senile is you can hide your own Easter eggs. The Holstein Mini-Mental Status Exam tests for mad cow disease and includes items such as:
Orientation to Place:
Where are we? Country, Farm, Pasture, Barn, Stall
Person: Herd, Breed, Bull
Attention and Concentration:
Cereal sevens: Name seven cereals that go well with 2% milk
Alternatively, spell UDDER backwards
Follow this command: "Chew cud; Use tail to swat fly; Moo."
Updated August 2, 2017