Presentation on theme: "Dealing with the Elderly"— Presentation transcript:
1Dealing with the Elderly Rojim J Sorrosa, M.D., DFMFamily MedicinePalliative Medicine
2Lecture : Dealing With the Elderly Primary ObjectiveDiscuss the general principles of illnesses affecting the elderly population using the BIOPSYHOSOCIAL APPROACHBiomedicalOsteoporosisFallsPainPsychosocialIndividualFamily Life CycleIllness Trajectory
3The Five-Star Filipino Physician Health Care ProviderTeacherResearcherHealth Care provider: Applies highest standard of clinical care, long lasting relationship, preventive careResearcher: EBMEducator: Health promotionSocial Mobilizer: Reconcile individual and communit health needsManager: work harmoniously with individuals and organizationsHealth ManagerSocial Mobilizer
4Biopsychosocial Approach/Model Physiological factors, cultural, social differences within the individual.It is a scientific model that takes into account the mising dimensions of the biomedical model.Person CenteredFamily FocusedCommunity Oriented3. 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.A change in one level reverberates upward and downwards simultaneously.
5DiseaseIllnessExamining clinical and laboratory evidences of biologic and psychological dysfunctionExploring the meaning of illness to the patient and the patient’s family
6OSTEOPOROSIS General Considerations: Increased porosity of the bone resulting in decreased bone mass.Individuals are prone to fracturesFactors affecting the pathogenesis of osteporosisAge-related changes: Osteoblasts and OsteoclastsReduced physical activity: increase rate of bone lossGenetic factorsNutritional status: CalciumHormonal Influences: Estrogen deficiency
7Treatment of low bone mineral density Burden and Care GapsFragility fractures: Mortality, morbidity, chronic pain, admission to institutions, economic costsGoals of CareTreatment of low bone mineral densityPrevention of fragility fractures and their negative consequences2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada: Summary
8FALLS General Considerations Falls are one of the most common geriatric syndromes threatening the independence of older persons.The risk of familling increases with age.MorbidityMortalityQuality of Life: functioning, long term facilitiesRisk of fall increased in patients with dementia.Impairment in judgementAttentionExecutive Function ( walking + mental arrithmetic)
9Goals of CareReducing 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.
10ARTHRITIS General Considerations: Inflammation of the Joints (Arthralgia).Cardinal signs of inflammationInfectious and non-infectious causesBasic pathophysiologyLoss of articular cartilageTissues are affected (cartilage, subchondral bone, synovium, menisci, etc)Biomolecular eventsLoss of proteoglycancsMatrix degradationLoss of collagen fibers
11Health burden: Morbidity, mortality, quality of life Pain Burden and Care GapsHealth burden: Morbidity, mortality, quality of lifePainGoals of CareImprove quality of life and daily functioningSymptom managementEULAR Recommendations for the Management of Early Arthritis
12PAIN General Considerations: Definition “Unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”Acute vs Chronic PainTypes of PainSomatic PainVisceral PainNeuropathic Pain
13Burden and Care GapsTOTAL PAINP: Physical problemsA: Anxiety, Anger DepressionI: Interpersonal relationshipsN: Non-acceptance of approaching death and a desperate search for the meaning of life.Barriers to pain managementa. Health care professionalsb. Patientsc. Health systemGoals of Care:Aggressive symptoms controlAnalgesic Ladder: Stepwise approach in the use of analgesic drugs
15Barriers to health care in the elderly Optimal health outcomes for geriatric patients depend on medical self-managementSelf management process Improved health outcomesBarriers Affect specific outcomes (mortality, morbidity, QOL)Goal is to maintain a good functional status with multiple co-morbiditiesAssessment of factors that affect optimal health outcomes and implementation of strategies to address them.
16How barriers may affect health outcomes Elderly Patient with multiple ComorbiditiesSelf-management processResources and Barriers: Social Support, Financial Resources, Establish routine, Self-efficacy, Depressive Symptoms, Functional Literacy, Knowledge BaseSelf management process: phsyical and psychological health, interactions with healthcare clinicians, adherence, monitoring of health status, decisionsPatient resources and BarriersHEALTH OUTCOMES
17General Biomedical Approach Medical HistoryPrecipitating eventsReview of medicationsAcute and chronic medical problemsMobility/ADL’sCognitive Status2. Physical Examinationa. Focused and targeted physical examinationsb. Mental Status Examination
18Assessment: Multidimensional a. Different Approaches:- Possibilistic Approach- Pragmatic Approach- Prognostic Approach- Probabilistic Approachb. Risk Assessment- Hazard- Uncertainty of occurrence and outcomes- Possible adverse health outcomes- Target- Time frame- The importance of risk for people affected by it.
19Risk Characterization Issue IdentificationHazard AssessmentExposure AssessmentReview and Reality CheckReview and Reality CheckRisk CharacterizationRISK MANAGEMENT
204. Management: Intent of Treatment a. Diagnostic Testsb. Pharmacologic Intervention: Pharmacokinetics and dynamicsc. Non-pharmacologic Interventiond. Follow-up/Planning/Evaluation: STRATEGIZE!
21Biomedical Interventions a. Active or disease modifying interventions: aggressive/Curativeb. Conservative comfort interventions: relieve symptomsc. Urgent palliative interventions: rapid and urgent relief of pain and suffering
23The Concept Of Suffering CDHB Hospital Palliative Care Service July 2008
24Relief of suffering and distress Comprehensive Multidimensional ApproachQuality of LifeDignityRelief of suffering and distressPhysicalPsychologicalSpiritualSocial
25Consider these factors: The Family Illness Trajectory Normal course of the psychosocial aspects of the diseasePredict, anticipate and deal with the patient and family’s response to illness.Normal vs Pathologic reactionsSTAGES IN FAMILY ILLNESS TRAJECTORYStage I: Onset of Illness to DiagnosisStage II: Impact Phase- Reaction to DiagnosisStage III: Major Therapeutic EffortsStage IV: Recovery Phase (Full HealthStage V: Adjustment to the Permanency of the Outcome (crisis)Stage 1: Acute Rapid, clear onset, provide little time to adjust, deal with immediate decisions vs Chronic: more debilitating = apprehension, denial, anxiety
26Composite of individual developmental changes of all family members Family Life CycleComposite of individual developmental changes of all family membersMedicalEmotional/Social ChangesCyclic development of the evolving family unitWhy?predictable, chronologically oriented sequence of eventsStressful changes that requires compensating and readjustmentSTAGES 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 YearsAttached young adult: Accepting parent offspring separationNewly married Couple: commitment to the new systemYoung Children: Accepting marital system to make space for childrenAdolescents: Increasing flexbility to accept children independenceLaunching Family: mutlitude of entries and exits in the family
27Family in Later Years: Empty Nest Shifting of generational rolesMaintaining couple functioning in the face of physiologic declineSupport the younger generationDealing with loss of spouse, siblings and other peersPreparation for own death, life review and integration
28Functions of the Physician GuidingCoordinatingAdvocatingConsultingCollaboratingSupporting
29Psychosocial Interventions Patients source of distress and suffering1. Psychosocial: anxiety, depression2. Family Problems: conflict3. Spiritual and existential problemsThe FAMILY IN CRISIS1.. Family as a SYSTEM2. Tools to explore FAMILY DYNAMICS3. Identify Pathologies
30The alleviation of suffering is universally acknowledged as a cardinal goal of medical care. When cure is not possible, the RELIEF of suffering is the CARDINAL goal of medicine.
31To cure sometimes, to relieve often, to comfort always Edward Livingston Trudeau
32“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