the grey tsunami - regulating aging professionals

College of Physicians and Surgeons of OntarioQUALITY PROFESSIONALS | HEALTHY SYSTEM | PUBLIC TRUST

The Grey Tsunami: The Regulation of Aging

Professionals

Angela BatesManager, Committee Support

Compliance & Monitoring (CPSO)

“I have reached an age when, if someone tells me to wear socks, I don’t have to.”- Albert Einstein

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and Surgeons of Ontario

Key Themes Our Aging Population“Normal” Aging, “Successful” AgingThe Cognitive ContinuumRegulatory Approaches

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and Surgeons of Ontario

Our Aging PopulationStatistics Canada:

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Our Aging Population

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and Surgeons of Ontario

Our Aging PopulationAs the general

population ages, so does the professional population.

Should this worry regulators?

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and Surgeons of Ontario

“Normal” AgingEffects of normal aging on the body:

Sensory organsReflexes SkinBonesMetabolism and hormone production

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and Surgeons of Ontario

“Normal” AgingEffects of aging on the mind (cognition):

“Fluid” intelligence declinesDecline in recent memory/new memory formationAttention changesProcessing speed slows

*Effects vary considerably among individuals

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“Normal” AgingSome aspects of cognition tend to remain stable or improve with age:

Language, conversation skills“Crystallized” intelligence is stableRemote memory is preservedNew brain cells can still be formed

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Successful AgingRowe & Kahn, 1998

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The Cognitive Continuum

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Mild Cognitive Impairment (MCI)

More serious cognitive declineSubjective and objective indicatorsHigher risk of developing dementiaAble to function with adaptations

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and Surgeons of Ontario

Mild Cognitive Impairment (MCI)

Amnestic vs. non-amnesticThorough assessments necessary to determine underlying causeCan be compensated for (e.g., reminder lists) and does not necessarily interfere with daily living MCI may be early stage of Alzheimer’s

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and Surgeons of Ontario

Mild Cognitive Impairment (MCI)

Can an individual with MCI safely practise as a professional?

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DementiaMost common causes of age-related dementia:

Alzheimer’s DiseaseVascular (Blood Vessel) DementiaParkinson’s Disease

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and Surgeons of Ontario

Alzheimer’s DiseaseAccounts for 60-70% of all cases of dementiaMore prevalent at age 65 and older, but can begin in 40s and 50s.Slow onset: makes it difficult at first to distinguish normal “forgetfulness” from pathological condition.

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Alzheimer’s Disease

Progressive illness: worsens over time, to point where patient may not be able to respond to environment or remember loved ones.Treatment aimed at symptom

stabilization; no cure.

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Alzheimer’s Disease: Assessment & Diagnosis

Preferably conducted by neurologist and/or geriatricianNo definitive diagnostic test; e.g., no x-ray or scan or blood test but brain imaging may be used:

Single Photon Emission Computerized Tomography (SPECT) ScanPositron Emission Tomography (PET) Scan

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Vascular (Blood Vessel) Dementia

Second most common cause of dementiaNot a single disease, but a group of syndromes relating to different vascular mechanisms.May be caused by:

Stroke (CVA, or cerebrovascular accident): but all strokes do not necessarily cause dementiaNarrow or damaged blood vessels in the brain

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and Surgeons of Ontario

Vascular Dementia: Assessment & Diagnosis

Neurological examinationBrain imagingCarotid ultrasoundNeuropsychological testing

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and Surgeons of Ontario

Parkinson’s DiseaseProgressive disorder of the nervous system marked by impaired movement, coordination, cognition and affectCaused by impaired dopamine-producing cells in the substantia nigra portion of the brainDopamine is a neurotransmitter involved in regulation of movement and pleasure

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Parkinson’s Disease:Assessment & Diagnosis

Clinical history and observation:Tremor, slow movement, muscle rigidityOnset on one side of bodyResting tremorResponsiveness to dopamine

Neurological examination

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and Surgeons of Ontario

Capacity (Health) AssessmentsThreshold for triggering assessment?

Assessments are invasiveCannot be directed by regulator capriciously; must meet statutory threshold (if governing legislation articulates one); and take into account considerations of procedural fairness and privacy

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and Surgeons of Ontario

Capacity (Health) AssessmentsNeuropsychological

Assessment of functional capacityNeurological

Brain imaging (CT, MRI)GeriatricOccupational

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AdaptationMost professionals will adapt their practices as they age; e.g., limit tasks, hours of workIssues:

Professionals with financial issuesProfessionals who lack insight into health issues and potential impact of same

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Regulatory Approaches to MCI

The grey area: What options are there for addressing health assessments which indicate MCI, but which do not contain a clear statement of risk to public?

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and Surgeons of Ontario

Regulatory Approaches to MCIAvoid solo practiceClose practice supervision, with regular reportsRegular follow-up with

Family physicianGeriatricianNeuropsychological testing (repeat)Neurological examination (repeat)

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Regulatory Assessments

Competence (Quality Assurance)

Random?Age-targeted?

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and Surgeons of Ontario

ReferencesAging and Cognitive Decline:

Adler, R., Constantinou, C. (2008). “Knowing – or not knowing – when to stop: cognitive decline in doctors”. The Medical Journal of Australia 189 (11/12): 622-624.

Salthouse, T., Atkinson, T., Berish, D. (2003). “Executive functioning as a potential mediator of age-related cognitive decline in normal adults”. Journal of Experimental Psychology: General 132 (4): 566-594.

Salthouse, T. (2009). “When does age-related cognitive decline begin?”. Neurobiological Aging 30(4): 507-514.

Singer, T., Verhaegehn, P., Ghisletta, P., Baltes, P. (2003) “The fate of cognition in very old age: six-year longitudinal findings in the Berlin Aging Study”. Psychology and Aging 18 (2): 318-331.

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and Surgeons of Ontario

ReferencesSuccessful Aging:•Baltes, Paul B.; Baltes, Margret M. (1990). "Psychological perspectives on successful aging: The model of selective optimization with compensation". In Baltes, Paul B.; Baltes, Margret M. Successful Aging. pp. 1–3

•Depp, Colin A.; Jeste, Dilip V. (2009). “Definitions and predictors of successful aging: a comprehensive review of larger quantitative studies”. FOCUS 7 (1): 137–50.

•Jeste, D. V.; Harris, J. C. (2010). "Wisdom--A Neuroscience Perspective". JAMA: the Journal of the American Medical Association 304 (14): 1602

Rowe, J. W.; Kahn, R. L. (1997). "Successful Aging". The Gerontologist 37 (4): 433–40.

College of Physicians

and Surgeons of Ontario

ReferencesMild Cognitive Impairment:•Troyer, A., Murphy, K., Anderson, M., Moscovitch, M., Craik, F. (2008) “Changing everyday memory behaviour in amnestic mild cognitive impairment: A randomised controlled trial”. Neuropsychological Rehabilitation: An International Journal (8) 1: 65-68.

•Anderson, N., Murphy, K., Troyer, A. (2012). Living with MCI Oxford University Press: Toronto.

•Whitwell JL, Shiung MM, Przybelski SA, et al. (2008). “MRI patterns of atrophy associated with progression to AD in amnestic mild cognitive impairment”. Neurology 70 (7): 512–20

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and Surgeons of Ontario

Contact

Angela BatesManager, Committee SupportCompliance Monitoring & SupervisionCollege of Physicians and Surgeons of Ontarioabates@cpso.on.ca

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