Dealing with the Elderly

Rojim J Sorrosa, M.D., DFMFamily Medicine

Palliative Medicine

Lecture : Dealing With the Elderly

Primary Objective

Discuss the general principles of illnesses affecting the elderly population using the BIOPSYHOSOCIAL APPROACH

a. Biomedical - Osteoporosis- Falls- Pain

b. Psychosocial - Individual- Family Life Cycle- Illness Trajectory

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Biopsychosocial Approach/Model

1.Physiological factors, cultural, social differences within the individual.

2.It is a scientific model that takes into account the mising dimensions of the biomedical model.

- Person Centered- Family Focused- Community Oriented

3. Systems Theory- Every unit is a whole and a part. - Large units interact to the less complex

smaller units.- Its a chain reaction!

4. The physician can be compassionate, caring and attuned to the needs of the patients and their families.

Disease IllnessExamining clinical and laboratory evidences of biologic and psychological dysfunction

Exploring the meaning of illness to the patient and the patient’s family

OSTEOPOROSIS

General Considerations:

1.Increased porosity of the bone resulting in decreased bone mass.

2.Individuals are prone to fractures

3.Factors affecting the pathogenesis of osteporosisa. Age-related changes: Osteoblasts and Osteoclastsb. Reduced physical activity: increase rate of bone lossc. Genetic factorsd. Nutritional status: Calciume. Hormonal Influences: Estrogen deficiency

Goals of Care

1.Treatment of low bone mineral density2.Prevention of fragility fractures and their negative consequences

2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada: Summary

Burden and Care Gaps

Fragility fractures: Mortality, morbidity, chronic pain, admission to institutions, economic costs

FALLS

General Considerations

1.Falls are one of the most common geriatric syndromes threatening the independence of older persons.

2.The risk of familling increases with age.a. Morbidityb. Mortalityc. Quality of Life: functioning, long term facilities

3. Risk of fall increased in patients with dementia.a. Impairment in judgementb. Attentionc. Executive Function ( walking + mental arrithmetic)

Goals of Care

Reducing fall risk in older individuals is an important public health objective.

Multifactorial Risk Assessment (Gait ,Balance, Cognition, Vision , ADL)

Summary of Updated American Geriatrics Society/British Geriatric Society Clinical Practice Guidelines for the Prevention of Falls in Older Persons.

ARTHRITIS

General Considerations:

1.Inflammation of the Joints (Arthralgia).

2.Cardinal signs of inflammation

3.Infectious and non-infectious causes

4.Basic pathophysiologya. Loss of articular cartilageb. Tissues are affected (cartilage, subchondral bone,

synovium, menisci, etc)c. Biomolecular events

- Loss of proteoglycancs- Matrix degradation- Loss of collagen fibers

Burden and Care Gaps

1.Health burden: Morbidity, mortality, quality of life2.Pain

Goals of Care1.Improve quality of life and daily functioning2.Symptom management

EULAR Recommendations for the Management of Early Arthritis

PAINGeneral Considerations:

1.Definition

“Unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”

2.Acute vs Chronic Pain

3.Types of Paina. Somatic Painb. Visceral Painc. Neuropathic Pain

Burden and Care Gaps

1.TOTAL PAINP: Physical problemsA: Anxiety, Anger DepressionI: Interpersonal relationshipsN: Non-acceptance of approaching death and a desperate

search for the meaning of life.

2. Barriers to pain managementa. Health care professionalsb. Patientsc. Health system

Goals of Care:

1.Aggressive symptoms control2.Analgesic Ladder: Stepwise approach in the use of analgesic drugs

WHO Analgesic Ladder

Barriers to health care in the elderly

1.Optimal health outcomes for geriatric patients depend on medical self-management

a. Self management process Improved health outcomes

b. Barriers Affect specific outcomes (mortality, morbidity, QOL)

2. Goal is to maintain a good functional status with multiple co-morbidities

3. Assessment of factors that affect optimal health outcomes and implementation of strategies to address them.

How barriers may affect health outcomes

Elderly Patient with multiple Comorbidities

Patient resources and Barriers

Self-management process

HEALTH OUTCOMES

General Biomedical Approach

1.Medical Historya. Precipitating eventsb. Review of medicationsc. Acute and chronic medical problemsd. Mobility/ADL’se. Cognitive Status

2. Physical Examinationa. Focused and targeted physical

examinationsb. Mental Status Examination

3. Assessment: Multidimensional

a. Different Approaches: - Possibilistic Approach- Pragmatic Approach- Prognostic Approach- Probabilistic Approach

b. Risk Assessment- Hazard- Uncertainty of occurrence and outcomes- Possible adverse health outcomes- Target- Time frame- The importance of risk for people affected

by it.

Issue Identification

Hazard Assessment

Exposure Assessment

Risk Characterization

RISK MANAGEMENT

Review and Reality Check

Review and Reality Check

4. Management: Intent of Treatment

a. Diagnostic Tests b. Pharmacologic Intervention: Pharmacokinetics and dynamics c. Non-pharmacologic Intervention d. Follow-up/Planning/Evaluation: STRATEGIZE!

Biomedical Interventions

a. Active or disease modifying interventions: aggressive/Curative

b. Conservative comfort interventions: relieve symptoms

c. Urgent palliative interventions: rapid and urgent relief of pain and suffering

The Psychosocial Domain

The Concept Of Suffering

CDHB Hospital Palliative Care Service July 2008

Comprehensive Multidimensional Approach

Quality of Life

Dignity

Relief of suffering

and distress

Physical

Psychological

Spiritual

Social

Consider these factors:

1.The Family Illness Trajectory

a. Normal course of the psychosocial aspects of the disease

b. Predict, anticipate and deal with the patient and family’s response to illness.

c. Normal vs Pathologic reactions

d. STAGES IN FAMILY ILLNESS TRAJECTORY Stage I: Onset of Illness to Diagnosis Stage II: Impact Phase- Reaction to Diagnosis Stage III: Major Therapeutic Efforts Stage IV: Recovery Phase (Full Health Stage V: Adjustment to the Permanency of the

Outcome (crisis)

2. Family Life Cycle

a. Composite of individual developmental changes of all family members

- Medical- Emotional/Social Changes

b. Cyclic development of the evolving family unitc. Why?

- predictable, chronologically oriented sequence of events- Stressful changes that requires compensating and

readjustmentd. STAGES OF FAMILY LIFE CYCLE

- Attached Young Adult- The Newly Married Couple- The Family With Young Children- The Family with Adolescents- Launching Family- Family in Later Years

Family in Later Years: Empty Nest

1.Shifting of generational roles

2.Maintaining couple functioning in the face of physiologic decline

3.Support the younger generation

4.Dealing with loss of spouse, siblings and other peers

5.Preparation for own death, life review and integration

Functions of the Physician

• Guiding• Coordinating • Advocating• Consulting • Collaborating• Supporting

Psychosocial Interventions

a. Patients source of distress and suffering

1. Psychosocial: anxiety, depression2. Family Problems: conflict3. Spiritual and existential problems

b. The FAMILY IN CRISIS

1.. Family as a SYSTEM2. Tools to explore FAMILY DYNAMICS3. Identify Pathologies

When cure is not possible, the RELIEF of suffering is the CARDINAL goal of medicine.

The alleviation of suffering is universally acknowledged as a cardinal goal of medical care.

To cure sometimes, to relieve often, to comfort always

Edward Livingston Trudeau

“Death must simply become the discreet but dignified exit of a peaceful person from a helpful society. A death without pain or suffering and ultimately without fear.

Philip Aries

Thank You.Have a nice

day.