geriatrics and gerontology - amazon s3 · 2014-04-01 · • definitions of geriatrics and...

Geriatrics and Gerontology

Bruce H. Robinson, MD, FACS, MSOM (Hon)

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List of topics to be discussed

• Definitions of geriatrics and gerontology

• The sociology of aging and the status of the elderly in society.

• Physical aspects of aging that be forestalled or benefitted by the right lifestyle.

• Biological aging that is inevitable: changes that occur in each body organ.

• Theories of why and how we age.

• Hot medical issues in geriatric medicine.

• Special medical problems and challenges of the elderly.

• Medical and ethical considerations surround the end of life.

• The care of those who are in the last stages of life.

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Introduction to the Course

Definitions:

Geriatrics:

• The branch of medicine that treats all medical problems associated with aging and the aged.

• This field is a subspecialty of internal medicine, as elderly people have different medical problems, different manifestations of illness, and different reactions to medications than younger people, with a narrower “therapeutic window” for beneficial responses to treatment versus adverse effects.


Gerontology: The broad study of aging from multiple standpoints, including:

• Biology

• Genetics

• Medical care

• Psychology

• Sociology

• Anthropology

• Philosophy

• History

• Religion


• Other words from this prefix:

• Gerodontics: the practice of dentistry for the elderly

• Gerontophilia: those who are especially attracted to older people and enjoy working with them

• Gerontophobia: a dislike or aversion to elderly people


What is the age when someone is considered elderly?

• This is extremely difficult to say in any given individual: some who are 50 seem elderly, and others seem vibrant and youthful when in their 70’s, or even older.

• To arrive at an average, it is rather mutually agreed that we should take age 65 as the dividing line.

• Note: in terms of the actual potential for human longevity, 65 is rather closer to the middle than to the far end, but most of us when we turn 65 realize we are getting “older”…and we may feel it as well!

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Getting Old: Social and Physical Implications


Sociological implications of the aging process:

Centenarian: one who is at least 100 years old

• 1980: 15,000 centenarians in the U.S.

• 2012: 71,000 centenarians in the U.S.; 3,700 in Australia*

• 2050: 1 million predicted in the U.S.

• Good question: how healthy will all these old folks be?

*United Nations Population Study

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Murial Duckworth, Canada, on her 100th birthday


We are an aging population:

• Percentage of all patients seen in U.S. medical clinics that are over 65:

• 2005: 33%

• 2012: 50% (dramatic increase due to surge of baby boomers born during WW II)

• Need for nursing homes (ECF’s, SNFs) will increase rapidly as these baby boomers become elderly over the next few years.


How are the elderly treated?

• Increasing age brings increasing respect in Asian, Hispanic, African cultures.

• My experiences in China during three extensive trips when in my mid to late 60’s: I was treated with profound respect.

• Such increased respect is not quite so pronounced in the U.S., Canada, Australia and New Zealand. Why?

• A generation gap is always present, although shifting around from one generation to the next [cartoons]

Berger p 9


As we live longer, our society is being flooded with the elderly:

• At ski resorts in the US. free skiing for super-seniors over age 70 has been around for years, but is now becoming a thing of the past (there are too many of us, now, and ski resorts are losing too much money).

• The cost of medical care for the elderly will become staggering in the years to come.


Clinical Implications of the aging process:

• Natural aging processes make the patient more susceptible to diseases and less tolerant of stress that when younger.

• We should think in terms of thresholds: what threshold of a certain stress will lead to disease?

• Old age does not imply the presence of disease, just it’s increased likelihood due to the narrowed threshold for environmental toxins, infections, recovery from accidents, and stress.


Clinical Implications of the Aging Process:

• Many old people (over 70) are very healthy.

• Old people are not victims: they are the survivors!

• Practitioner’s role is to enhance the coping abilities and the coping repertoire of his/her older patients.

• Those involved in work or volunteer activities live longer and stay healthier than those who don’t.

• Studies reveal that older people in long-term nurturing relationships feel even closer in old age and continue to live longer as a result.

Berger p 683

Man in his early 80’s volunteering in a 4th grade class

Berger p 671

Retired executive in his 90’s working

in an arboretum

Berger p 692 Happy couple on their 60th wedding anniversary


• Studies of cultures where people live the longest and healthiest have four things in common:

• A moderate diet of mostly fruits and vegetables with relatively little fat and meat.

• Work continues throughout life.

• Family and community are important, with integration of all the generations.

• Exercise and relaxation are a part of the daily routine, with time for rest, usually lots of walking, and interaction with others in the community.

Four generations at a picnic

Ogula Lodara, age 102, and two younger friends, Republic of Georgia

Maryusha (103) and Selekh (113) Butka, Republic of Georgia: out for a walk

Photo of Fuki Kushida (100) speaking at a peace rally in Japan

President Gordon B. Hinckley: he presided over the entire

Mormon Church throughout his 90’s, dying at just shy of 98

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Centenarian field worker in Okinawa

Elderly women watching male jazzercise teacher in Florida, USA

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Me (age 77) and my daughter Kristen (age 47) earlier this year


Physical implications of aging:

• Recovery from surgery or trauma is delayed in the elderly, who are also at risk for more complications.

• Studies have suggested most organ systems lose function starting at age 35 at rate of about 1% per year (from cross-sectional comparisons of groups at different ages)

• Physical conditioning reduces or delays many changes that otherwise occur in the lungs, muscles, brain, and heart.


• Avoiding the chronic use of certain medications, such as NSAID’s, can protect the liver and the kidneys.

• Those who live to be old can attribute about 35% to their genes and 65% to their lifestyle, relationships, environment, and good luck.

• Maybe good luck is less important than one’s Karma: the effects of all of one’s deeds in the past actively create present and future experiences that are either negative or positive, depending on what the person has built up over the years.


Biological Aging:

• The processes that go on in the body not caused by disease, but simply with time

• These changes tend to occur in all older people.

• The rate of these degenerative changes depends on genetics, nutrition, and physical fitness, but they do take place no matter what!


What happens:

Overall:

• decreased height (vertebral compression and increased kyphosis)

• decreased weight, over age 80

• increased fat to lean-body ratio

• decreased water content in body


What happens in specific organ systems as a result of the aging process:

Skin:

• increased wrinkling, gradual atrophy of skin

• atrophy of sweat glands, affecting thermo-regulation

Kidneys:

• interstitial fibrosis

• decreased renal blood flow

• decreased glomerular filtration rate

• decreased maximum urine osmolarity during body dehydration (decreased concentration of urine)


Cardiovascular system:

• elongation and increased tortuosity of arteries and veins

• intimal thickening of arteries

• fibrosis of media of arteries

• sclerosis of heart valves (esp. aortic valve)

• decreased cardiac output with exercise

• decreased heart rate response to stress and exercise

• decreased elasticity and compliance of all arteries and veins


Lungs:

• decreased elasticity of lungs

• decreased activity of mucociliary escalator in bronchial passages

Gastrointestinal Tract:

• slower intestinal motility

• decreased hydrochloric acid secretion

• decreased number of taste buds

Skeleton:

• Osteoarthritis

• Osteoporosis


Eyes:

• Decreased widening of pupils

• Arcus senilis (grey line around the limbus of the eye; of uncertain significance)

• Growth and thickening of lens, with less accommodation

• Development of cataracts in the lens

• Hyperopia (decreased ability to see things that are close)

• Decreased visual acuity, depth perception, color perception


Ears:

• Hardening of ear ossicles with less joint flexibility and less magnification of incoming sound waves

• Enlargement of ears but atrophy of external auditory meatus

• Decreased perception of high frequencies (starts at age 17)

• Reduced pitch discrimination


Nervous system: • Decreased brain weight, cortical cell count • Increased motor response time • Decreased fluid intelligence activity (deterioration starts at age 17) • Stable or increased crystalline intelligence (judgment, wisdom) • Decreased short-term memory • No change in long-term memory • No change in implicit memory (as in tying your shoes; riding a bike) • No change in sustained attention • Decreased selective attention and divided attention (affects driving

skills) • Decreased sleep time per night • Decreased hours of REM during sleep and decreased stage 4 sleep


Immune system:

• Decreased T cell activity

• Decreased activity of natural killer cells

• Decreased destruction of mutated cells that can become cancer

Endocrine system:

• Decreased T3 (triiodothyronine)

• Decreased testosterone and more DHT

• Increased insulin

• Increased norephinephrine, parathormone, vasopressin


Theories of Aging: these have condensed into two master theories. Both seem to be operative.

1. Sociobiological theory

• We have selected out the gene pool over thousands of years that enables us to mature, chose the best mates we can have, and raise our children.

• We then die, to allow for the upcoming generation to have enough living space and resources (we die to get out of the way!)


Sociobiological theory:

• Regulation of specific genes causes genetically programmed senescence (it’s not understood how this happens)

• Thus we all have an inborn genetic clock that determines how long we can live (based on our genes and our lifestyle!)

• Length of a long human life has not changed over historical time (it was the same in biblical days as now; it’s just that fewer people in the past survived the rigors of life to live into their 80’s or 90’s)


Maximum genetic life-spans in mammals (not often achieved by individual animals):

• Hamsters – 3 years

• Mice and rats– 4 years

• Rabbits – 13 years

• Dogs – 20 years

• House cats – 30 years

• Tigers – 26 years

• Brown bears – 37 years

• Chimpanzees – 55 years

• Elephants – 86 years

• Humans – 125 years (this is our potential!)

• Humpback whales – 150 years or more ( a bowhead whale was 211)

• Giant tortoises – 190 years, or longer (maybe over 200)


• Some researchers have correlated longevity with heart rate: the concept that all advanced organisms, even when fully healthy, have only so many heart beats in them and then they die.

• Thus hamsters have a heart rate of 450/min and live 2 or rarely 3 years

• Humans have a heart rate of 70/min

• Elephants have a heart rate of 30/min

• Large whales have a resting heart rate of 7/min*

*http://www.sjsu.edu/faculty/watkins/longevity.htm

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Humpback whale

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Herman the hamster

Jeanne Calmet, Arles, France, when she was 122; she met

Vincent Van Gogh there when she was 13, in 1889

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Vincent Van Gogh, self portrait, 1889


• There is a long list of super-centenarians that are documented to be over 110.

• The oldest living human in March, 2012 that we are certain about: Besse Cooper, United States: born 26 August, 1896.

• This August Besse will be 116.

• But there must be older people scattered around the world that we don’t know about or who can’t prove it.

• Sarkahn Desova, Kazakhastan, is said to be 130 (she has a passport, ID card, and other records to support this).

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Sarkahn Desova, Kazakhastan, is said to be 130

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Progeria:

• A genetic defect in humans

• Their genetic aging clock is set too fast

• Leads to premature, rapid aging

• Person is elderly at 12-16

• Death due to old age, often before age 20

Grandmother (in her 80’s) and grandson (age 16): New Guinea


Second theory of aging:

• Accumulation of damage to informational molecules

• Spontaneous mutagenesis over time as cells age and mitosis becomes less efficient

• Failure of DNA repair systems – loss of telomere length (cancer cells have telomerases and do not age)

• Fibroblasts in vitro have 50-60 doublings in young patients, less in older patients, then finally stop doubling and die (Hayflick, 1994).

• Superoxide radicals build up in cells that can react with DNA, RNA, proteins, lipids and cause cellular damage; opposed by Vit C, E, lycopenes, flavinoids, selenium.


Research on this theory: damage to informational molecules in cells because of excess oxidation:

• Caloric restriction lowers oxidative stress in cells of rodents, with less cellular damage and extended lifespan.

• Increasing expression of antioxidative enzymes extends life of fruit flies (Finkle and Holbrook, 2000; Masoro, 2000).

• A growth-factor gene in mice has been shown to cause aging. Mice selected without this gene are smaller but lived longer: The “Mousesuzela Project” is ongoing: to raise a mouse that lives for 10 years.

Hot Medical Topics for the Elderly (and all of us)

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Hot Medical Issues in Geriatrics There are two topics of special concern for elderly people I’d like

to start off with this discussion; both based on multiple recent studies. Topic #1:

• Inflammation and Chronic Diseases:

• Inflammation is a natural process the body uses to ward off infection, on a temporary basis. Chronic inflammation damages body tissues.

• Modern diets high in sugars and saturated fats, accompanied by inadequate exercise, promote chronic inflammation in tissues where there is no actual infection, such as blood vessels, the brain, the pancreas, etc.

Hot Medical Issues in Geriatrics Effects of inflammation in the body:

• Inflammation destabilizes cholesterol deposits in coronary and cerebral arteries

• Inflammation and oxidation of LDL-cholesterol in the sub-endothelium of blood vessels causes monocyte activity, fibrin deposition, followed by scar tissue and calcification.

Hot Medical Issues in Geriatrics

• Study by Dr. Paul Ridker, Harvard Medical School Study, beginning in 1997: healthy middle age men with CRP levels above 3.0 mg/L are three times more likely to have heart attacks. Those with CRP levels below 0 .5 mg/L are very unlikely to have heart attacks.

• CRP (c-reactive protein) is a non-specific marker in the bloodstream for inflammation in the body.

• “Now the whole field of inflammation research is about to explode”-Dr. Ridker, commenting about his and other researcher’s studies.


Effects of inflammation in the brain:

• Inflammation damages brain cells in Alzheimer patients, leading to amyloid plaque deposits and brain cell deterioration with neurofibril tangles.

• This happens in those with this dementia, and may also occur in those who do not have dementia but are genetically predisposed to it: those with the E4 allele of the ApoE protein gene.

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One of the genes associated with Alzheimer's disease, Apolipoprotein E or ApoE, is a good example of how genes affect disease development. There are three possible alleles* for this gene: E2, E3, and E4. Each allele differs by one DNA base, and the protein product of each gene differs by one amino acid.

*an allele is one form of a gene. If both chromosomes have the identical gene they have the same allele and they are therefore homozygous. If they have different alleles of the gene they are heterozygous (for example the gene for eye color: BB homozygous, Bb heterozygous)

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• Each individual inherits one maternal copy of ApoE and one paternal copy of ApoE.

• Research has shown that a person who inherits at least one E4 allele will have a greater chance of developing Alzheimer's disease.

• Apparently, the change of one amino acid in the E4 protein alters its structure and function enough to make disease development more likely.

• Inheriting the E2 allele, on the other hand, seems to indicate that a person is less likely to develop Alzheimer's.

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• A healthy diet and overall lifestyle is therefore very important to prevent Alzheimer’s disease, especially in those who are genetically predisposed to it.

• However, as we age, we are all at risk for it:

– 80% of all dementia in the U.S. is Alzheimer’s disease

– Affects 10% of those age 65

– Affects 35% by age 85

– Estimated chance of getting Alzheimer’s after a person turns 85 is 42%

– Similar prevalence rates in Australia

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• There were 52,000 Australians newly diagnosed with dementia in 2005.

• By 2050, there are projected to be over 385,000 new cases diagnosed every year, more than the total number of people with dementia in Australia in 2009.

• This is almost an eight-fold increase

• Incidence is far higher in urban areas* *http://www.alzheimers.com.au/alzheimers/incidence.php; retrieved

3/12/12

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http://www.alzheimers.com.au/alzheimers/incidence.php

http://www.alzheimers.com.au/alzheimers/incidence.php


Inflammation can foster the proliferation of abnormal cells that can lead to cancer

• Study in 2000: Patients taking Celebrex (an anti-inflammatory drug for arthritis) had fewer colon tumors: now dozens of studies are ongoing.

• Aspirin may fight colon and breast cancer and Alzheimer’s disease as well as heart attacks. Higher doses are recommended (325 mg rather than the 81 mg dose recommended as a blood thinner)


• Dr. Steve Shoelson, another professor of medicine at Harvard Medical School has also focused his research on inflammation. He and his team have determined that inflammation plays a key role in a set of disorders that include type II diabetes, obesity, and heart disease.

• His team determined that patients with type 2 diabetes and cardiovascular disease have elevated levels of inflammatory markers such as CRP in their bloodstream, suggesting the possibility that inflammation might be associated with the development of these diseases.

• These researchers have shown that pro-inflammatory cytokines released by white cells, such as TNF-a and IL-6 promote insulin resistance, leading to diabetes.

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Role of free-radicals, produced by inflammation, causing genetic mutations leading to cancer:

• Inflammation produces cyclo-oxygenase 2 (cox-2), which is related to the development of polyps and colon cancer (ASA blocks cox-2!)

• Inflammatory cytokines, linked to Alzheimer’s disease, are blocked by ASA, fish oil

• Krill oil is especially good for it’s omega 3’s and astaxanthin (a caroteinoid that is a powerful antioxidant)

• Benefits far outweigh the negative aspects in most people (not those on anticoagulants or who are allergic to it)

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Antarctic krill, about 1 cm long

Hot Medical Issues in Geriatrics Other helpful remedies to reduce inflammation:

• ASA, other anti-inflammatory agents.

• Cholestatin drugs drive down CRP and other inflammatory proteins (but watch for the many side effects of statin drugs)

• Phytosterols, bioflavonoids from grapes, help reduce LDL-cholesterol inflammation.

• Magnesium supplements have been found to reduce inflammation; often dispensed with calcium.

• Vitamin D3 supplements are anti-inflammatory (many people, especially older patients, are magnesium and Vitamin D deficient)


More helpful remedies to reduce inflammation:

• Exercise: helps reduce chronic inflammation.

• Weight loss if overweight: large active fat cells elaborate inflammation enhancers.

• Diet: avoid saturated fats when possible, use vegetable/olive oils; especially avoid hydrogenated fats with their trans-fatty acids; try to lower your omega 6 to omega-3 ratio: eat less meat; more veggies, fruit, whole grains, fish.

• Oral hygiene: flossing and vigorous brushing reduces chronic gum inflammation (one of 10 factors leading to increased longevity)

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Topic #2: Breast cancer linked to overuse of antibiotics:

• Study of 10,000 women in Seattle area (2004): women 20 and older who took antibiotics for more than 500 days over an average of 17 years or had a life history of more than 25 antibiotic prescriptions had twice the rate of breast cancer.

• This is more likely in older women with such a life history of many treatments with antibiotics

• This link between cancer and overuse of antibiotics was first reported in Lancet, 1981:one study with rats and one with men and colon cancer


Breast cancer and overuse of antibiotics:

• Finnish Study (2000): increased breast cancer in premenopausal women who took long-term antibiotics for UTI’s.

• Some antibiotics fight infection but raise levels of inflammation in body if taken for prolonged periods of time

• Antibiotics destroy beneficial bacteria in the gut that metabolize cancer-fighting phytochemicals in broccoli, lentils, nuts, cruciferous vegetables.

• Many studies show the benefits of taking probiotic strains: lactobacillus acidophilus, bifidobacterium lactis, plus green tea extracts, fructooligosaccharides (nondigestible fiber in fruits and vegetables), calcium phosphate

The Special Challenges of the Medical Treatment of the Elderly

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How Geriatric Medical Practice is Different

The 14 I’s of Geriatric Medical Practice*:

• Instability (when walking or standing)

• Immobility

• Intellectual impairment

• Impairment of vision, hearing

• Incontinence

* Kane, R.L., Ouslander, J.G., & Abrass, I.B. Essentials of Clinical Geriatrics,

Fifth Edition. 2004. McGraw Hill. New York, NY


The 14 I’s of Geriatric Medical Practice:

• Irritable bowel syndrome

• Isolation – with possible depression

• Inanition (malnutrition due to improper eating)

• Impecunity (lack of financial resources)

• Iatrogenesis (mistakes by treating professionals such as doctors and nurses are more common with the elderly, with greater negative consequences)


The 14 I’s of Geriatric Medical Practice:

• Insomnia

• Immune deficiency

• Impotence

• Improper labeling of an older person: disoriented older person in the hospital or ECF who is not demented: can become a self-fulfilling prophecy

• The scale tips easily, and an older patient can go from alert to confused to demented in a short period of time if isolated from peers and loved ones

Evaluation of the Geriatric Patient


• One of most challenging aspects of geriatrics:

• Requires a different perspective than with younger patients

• Requires patience!

• Leads to interactions with many other health professionals (you can’t do it alone)

• Requires careful evaluation of physical, psychological and socioeconomic factors


Potential difficulties in taking geriatric histories:

Poor communication: due to:

• decreased vision and hearing

• decreased ability to concentrate on questions you are asking

• decreased recent memory

Conditions must be ideal for good results:

• well lit room

• speak slowly, facing patient

• quiet environment

• write instructions in large print


Potential difficulties, continued: • Pt may under-report his/her symptoms, due to:

• fear • stoical depression • cognitive impairment. If so, you need to:

• ask specific questions • follow a printed guideline to stay on track • use other relatives, friends for more info

• Pt may give vague, non-specific symptoms: • he has altered physiological responses • we should evaluate him/her for treatable diseases even

when symptoms are non-specific


Important aspects of the history:

• living arrangements

• relationships with family, friends

• expectations of family and caregivers

• economic status

• abilities to perform activities of daily living

• social activities and hobbies

• mode of transportation

• advance directives


• Challenges in history assessment:

• watch out for over emphasis: symptoms may be exaggerated due to emotional distress with anxiety

• watch out for under emphasis: depression/hopelessness may cause patients to understate their symptoms

• inactivity may mask underlying symptoms, so always assess activity levels: “How far do you walk in a typical day? How often do you climb stairs? How many?”

Then:

• Perform a regular history and physical exam as you would with any other patient


Arriving at a good functional assessment:

• Establish correct medical diagnoses

• Estimate physical capabilities (see below)

• Determine management requirements

• Assess motivation (can you improve this, or not?)

• Take into account the patient’s environment:

• Social: level of support, friends, family

• Physical, with elder-proof home

• Psychological: depression, anxiety, helpless/hopeless

• Careful monitoring over specific time period allows scientifically-based clinical interventions when necessary


ADL: Activities of Daily Living:

• Feeding

• Dressing

• Ambulation

• Climbing stairs

• Toileting

• Bathing

• Transfer: from bed to wheelchair to toilet and back again

• Continence

• Grooming

• Communication


IADL: Instrumental Activities of Daily Living: • Writing • Reading • Cooking • Cleaning • Shopping • Doing laundry • Using telephone • Managing medications • Managing money • Gardening, yard work • Ability to travel: drive a car, ride a bus, fly in a plane • Ability to perform paid employment activities


Assessment for Pain: • Characteristics of any pain (acute vs. chronic, nature of

pain, intermittent or constant) • Rating on a pain intensity scale • Relation of pain to impairments of physical function • History of methods to achieve pain relief: present,

previous, prescribed, over-the-counter, TCM treatments, alcohol

• Attitudes and belief about pain and management • Effectiveness of treatments for pain in the past • Social support and health care accessibility

Evaluation of the Geriatric Patient A good final summary format for geriatric screening: 1. Name, address, referring physician 2. Reason for consultation 3. Problems -list of medical problems -list of psychosocial problems 4. Standard documentation of workup: a. complete history b. social and environmental information c. functional assessment d. advance directives status e. physical exam f. laboratory and other study data 5. Recommendations


Final thoughts about your evaluation:

• The risk versus benefit ratio is narrower in older patients. This is the therapeutic window versus a toxic response.

• Not such an issue in Chinese medicine, but huge in Western medicine: 100,000 people die each year in the United States due to drug reactions, many of them the elderly…a major cause of death.

• Watch out for your loved ones when they are in the grips of the Western medicine healthcare system: they may need it but it is dangerous for them as well!

• For more than any other group, TCM treatments for the elderly are very important and extremely beneficial.

Medical, Ethical and Social Issues Surrounding the End of Life


Ethical dilemmas are many:

Life and death examples:

• When (if ever), should practitioners withdraw or withhold treatment?

• Do you always try to resuscitate? If not, when do you not?

• What about tube feeding? Recent cases in the media.


More common everyday dilemmas:

• When should the elderly patient be admitted to a hospital?

• Should terminal patients remain at home?

• When ready to discharge? (complex!)

• Admit to a nursing home?

• Should we treat cancer with dangerous therapies in elderly patients?


Some definitions: (these are broad guidelines for ethical living):

• Autonomy: one’s inherent right to control one’s destiny, exercise one’s will.

• Benificience: our inherent obligation to do good to others, offer help when needed

• Nonmaleficience: the obligation to avoid harming others

• Justice: nondiscrimination; duty to treat all individuals fairly, and to distribute resources fairly

• Fidelity: our duty to keep promises, to follow through with what we can do and should do

• Competence: the patient’s ability to act reasonably after understanding the situation faced.


• Issues concerning autonomy:

• We need to support and respect it whenever safe to do so (NOT whenever ‘beneficial’ to do so)

• Questions:

• Is the pt. capable of understanding the issues involved?

• Has the pt. received adequate information regarding all available options?

• Are there clear options?

• What if the pt.’s preferences are contrary to the practitioner or the family? Who should prevail?

• How do we deal with the demented pt.?


Competence and informed consent:

• Pt. must have cognitive ability (includes memory capacity) to understand all alternatives with their risks and benefits

• Yet reviewing “all alternatives” may be too encyclopedic for a reasonable pt. to process. If so, the practitioner must decide which to present! (example of Fenphen and cardiac damage)

• With full reasonable disclosure, practitioner’s liability is protected

• With a nursing home or ECF admission, what are the trade-offs between safety, privacy, and autonomy (less critical in a problem-oriented hospital admission than in a maintenance- oriented long-term nursing facility.


Advance Directives: these address how someone would wished to be cared for in a hypothetical situation. There are two kinds:

• 1. Living will: what a person wants done under certain circumstances:

• DNR: do not resuscitate (story of hospital pt. with DNR sign who choked to death in front of the nurses while eating)

• Do not hospitalize

• Do not give tube feedings, place on a respirator, intravenous infusions, antibiotics…THUS: forego heroic measures. Does this mean abrogating all interest in surviving when very sick?


• 2. Durable Power of Attorney: a person is chosen to act as a proxy in the event the patient is unable to communicate due to illness.

• Who would be the best proxy or agent?

• It is important to know the patient’s preferences

• It may or may not be the next of kin! (may be a minister, friend, or even the practitioner)


• The court can have the final say in a disputed care situation regarding a proxy for an elderly incompetent person.

• May appoint an ombudsman to represent the presumed wishes of the elderly person.

• In prolonged, lingering end-of-life situations this can be a real challenge.

Medical ethics at the end of life

• Tube feeding dramas in the media: the Terri Schiavo case in Florida, US a few years ago illustrates graphically the medical-ethical issues involved at the end of life.

• In this case it was a young woman involved, but these issues often come up with the elderly, namely whether or not to prolong life in a person that is in a vegetative state, or nearly so.

• This story captivated America and the English-speaking world in 2004 and 2005.

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Medical Ethics

Terri Schiavo (Dec 3, 1963 – March 31, 2005) St. Petersburg, and Pinellas Park, Florida.

• At age 26 (Feb 20th 1990) she collapsed in her home and experienced cardiac and respiratory arrest.

• Intubation was delayed, causing hypoxic brain damage.

• The actual cause of her collapse was never ascertained – it might have been severe nutritional imbalance from fasting and drinking 10-12 glasses of ice tea a day (her serum K+ when admitted to hospital was 2.0 mEq/L).

• She entered a profoundly demented state; was intubated, put on respirator, fed through a gastrostomy.

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Terri Schiavo before her collapse

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Terri and husband after her collapse

Medical Ethics • Her husband Michael brought her home in September ; then

realized he couldn’t adequately care for her, returned her to a Rehab Center in nearby Bradenton, Florida.

• He became trained as a nurse and a respiratory therapist so he could assist with her care.

• Terri was no longer on a respirator; was able to breathe on her own.

• Michael took her to parks in a wheelchair for stimulation.

• He realized she was not responding to the environment; he gradually became convinced there was no hope for her recovery.

• In 1992 Michael won a million dollar lawsuit on behalf of Terri because her physician had failed to recognize she had an eating disorder that contributed to her collapse and coma. The remaining 750 K (after attorney fees) was in Terri’s name but he was her guardian.

Medical Ethics

• In 1993 Michael filed a DNR order; he stated she had asked him in earlier times that if she ever became seriously ill he should never take any extraordinary measures to prolong her life.

• He then filed several petitions to have her feeding tube removed.

• Terri’s parents the Schindlers opposed him. They wanted her life to continue, with all extraordinary measures possible.

Medical Ethics • 1998 – 2002 Michael and the Schindlers fought this out in the

courts

• Terri had never filed a living will, thus her actual proven wishes could not be legally ascertained. Michael was her legal guardian. The Schindlers attacked Michael’s credibility and questioned his motives.

• The Schindlers particularly did not wish Terri to die by dehydration (although for terminally ill patients who chose to die by dehydration this method of death is generally peaceful).

• The Schindlers petitioned the court to remove Michael as legal guardian so they could protect the continuance of her life.

• There was a large trial with seven neurologists and a radiologist, arguing that Terri was either in a “persistently vegetative state” or, on the other side, in a “minimally conscious state”.

Medical Ethics • Large amounts of money were spent on both sides

• The court judge ruled in favor of Michael that Terri was terminally vegetative, with severe brain atrophy on CT scans

• This ruling was upheld by the Florida Second District Court of Appeals, stating, “we have carefully reviewed all the evidence and we agree with the lower court…if we had reviewed this decision de novo, based on all the evidence, we would still affirm it’s ruling.”

• On October 15, 2003, Terri’s feeding tube was removed.

• By then it had become a national right to life versus death with dignity issue.

• The tube stayed out for a week. However Terri stayed alive.

• Florida Governor Jeb Bush then overruled the Court of Appeals, based on a hastily-passed “Terri’s Law” by the Florida legislature, and he had the feeding tube re-inserted.

Medical Ethics

• The Florida Supreme Court then found “Terri’s law” unconstitutional, negating the right of the Governor to intervene, giving Terri’s guardian the right to have her feeding tube pulled out again.

• Because of court challenges by Terri’s parents the Schindlers, the tube remained in during these challenges.

• Publicity grew and the case dominated the national news in February and March 2005.

• The court of appeals again denied the Schindler’s attempts to prevent removal of the tube, after MRI scans, failed swallowing tests, and more neurological evaluations were unable to show she had any capacity to recover consciousness.

Medical Ethics

• President George Bush then asked the U.S. congress to become involved.

• Chief right to live advocates: In the Senate, Bill Frist, a physician; and in the House, Majority Leader Tom Delay.

• The congress jointly passed a bill that Terri’s feeding tube should remain in place.

• President Bush interrupted his vacation to return to Washington DC to sign the bill into law.

• The US Supreme Court refused to allow this law to stand. The court stated such a law could not reverse all the previous rulings of the Florida Courts in favor of the feeding tube removal.

• Thus, ignoring the U.S. Congress, Terri’s husband saw to it that his wife’s feeding tube was removed again, on March 18, 2005.

Medical Ethics • The tube remained out during those last two weeks in March,

2005. Terri lived on.

• Right to life activism around the US reached a fever pitch.

• Responding to these sentiments, the Florida Department of Law Enforcement under Governor Jeb Bush (the President’s brother) threatened to forcibly take control of Terri and transfer her to a hospital where the tube could be re-inserted and she could be guarded around the clock, with the tube in place.

• All the Pinellas County Police Departments in Central Florida, following their court orders, prepared to oppose these state officers if they actually tried to take possession of Terri, but they did not. Civil war in Florida was somehow avoided.

Medical Ethics

• Terri died on March 31st, 2005.

• The chief medical examiner noted that her autopsy revealed massive brain atrophy (less than one-half normal weight) with no possibility she could have ever regained any brain function at all.

• Following this saga, medical ethicists have mostly concurred that in the absence of a living will of the comatose patient, decisions to withhold life support should be based on expert assessment that there is irreversible coma, thus rendering all further life support care as futile.

• However such expert assessment remains challenging.

• Functional MRI’s may help in the future (intriguing!)

Medical Ethics Functional magnetic resonance imaging or functional MRI

(fMRI):

• This is an MRI procedure that measures brain activity by detecting associated changes in blood flow.

• The most widely used form of fMRI uses the blood-oxygen-level-dependent (BOLD) contrast technique.

• This is used to map neural activity in the brain by imaging the change in blood flow related to energy use by brain cells.

• If brain cells are active, they attract blood flow and utilize oxygen.

• A fMRI can measure that. It be used to determine the level of a patient’s coma.

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Medical Ethics

• The resulting brain activation can be presented graphically, by color-coding the strength of activation across the brain or the specific region studied.

• Oxygen use changes the magnetization of the images which is given a color in the resulting images.

• The technique can localize brain activity to within millimeters and within a time frame of a few seconds.

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The cortex and its dedicated areas for brain function

Talking to a brain injured patient (yellow areas) who cannot respond,

yet he hears you and is trying to talk with you. Green is mostly sensory,

orange is mostly speech center activation.


End of Life Care:

• A great challenge and trial for the patient, the family, friends, the treating practitioners

• It should also be considered an opportunity to do for someone else what we would want done for ourselves when we die

• Areas of general agreement among patients, family members, and caregivers:

– Name someone who will be the decision maker: avoid all disagreements, squabbling between family members


• Keep the pt. groomed and clean

• Listen to the pt. and the family, too.

• Have a nurse with whom the pt. feels comfortable

• Control pain – be pain free if possible

• Control shortness of breath

• Preserve pt.’s natural dignity

• Touch and talk to the pt. often

• Have financial affairs in order

• Have a practitioner/physician pt. trusts and family trusts


• Keep the patient as anxiety-free as possible

• Maintain a sense of humor

• Let them say goodbye to important people

• Have presence of family and close friends (difficult in ICU settings!)

• Have caregivers who are comfortable talking about death and dying

• Remember personal accomplishments of pt. – a useful and meaningful life

• Prepare family in advance

• Prepare patient for death: it is like going to sleep

• Do not let any patient die alone

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When the sun sets on life, the heavens open up

geriatrics and gerontology - amazon s3 · 2014-04-01 · • definitions of geriatrics and...

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