2Psychological Issues in Advanced and Terminal Illness Average life expectancy in North America is 76 years.Leading causes of death in adults are chronic illnessWhat are the leading causes of death across the life span?
3Mortality Rates Leading causes of death < 1 yearcongenital abnormalities;sudden infant death syndrome (SIDS)Children > 1 year oldAccidents (40% of all deaths)Cancer (especially leukemia)AdolescenceUnintentional injuryHomicideAIDSSIDS is higher in lower class urban environments, when mother smoked during pregnancy, and when baby is put to sleep lying on his/her stomach or side.Accidents due to accidental poisoning, injuries, or falls. Later the main cause of death dues to accidents is automobile accidents.Remember that leukemia strikes the bone marrow producing an excessive amount of white blood cells, resulting in severe anemia and other complications.
4Mortality Rates Leading causes of death Middle ageSudden death due to heart attack or strokeCancerElderlyHeart diseaseStrokeWhen asked how they would like to die, most say sudden death. By the way, in women under the age of menopause, breast cancer remains the number one cause of premature deaths.
5Why do women live longer than men? More fit – more males are conceived but more female fetuses are born. This trend persist in infancy so that more male babies are likely to die. Thus, females may be more hardy.
6Potential Reasons for Gender Differences in Mortality Females are more hardyMales engage in riskier behaviours (factor after birth and infancy)Men engage in riskier sportsMales tend to hold high stress or higher risk jobsMen tend to have poorer health habits (e.g., drink more alcohol)Social support may be more protective in womenMore fit – more males are conceived but more female fetuses are born. This trend persist in infancy so that more male babies are likely to die. Thus, females may be more hardy. Essentially, no one really knows why there is the female advantage.Conflicting reports on social support since marriage appears to benefit men more than women.All of these factors may operate to increase the mortality rates in men.
7Risk Factors Family history Marital status (adds 10 yrs in men; 4 yrs in women)Economic statusBody weightExerciseAlcohol (add 2 years if drink 1-3 drinks/day)
8Risk Factors - continued SmokingDisposition (add 2 yrs if reasoned, practical)EducationEnvironment (add 4 yrs if rural)Sleep (more than 9 hours subtract 5 years)Temperature (add 2 yrs if thermostat is < 68)Health care – regular check ups add 3 yrs
10Adapting Under Good Circumstances First concern upon hearing diagnosis is fears about mortality.Optimistic but tentative about plansMay try to normalize activitiesRisk is they may over-extendMay have feelings of helplessnessRisk is to become overly dependent
11Three Themes of Adaptation Find meaning: why illness happened or rethink prioritiesGain sense of controlcontrol symptoms and treatmentRestore self-esteemOften by comparison with worse off others
12Adapting Under Bad Circumstances Relapse seen as a bad sign with poor prognosisRe-focuses one on the illnessNeed to undergo the coping process again but likely less hopeful than before.30%-40% of stroke victims have another stroke within five years.
13Heart Disease Due to narrowing or blocking of the coronary arteries. Angina pectorispainful cramp in chest, arm, neck, or back due to brief blockage of oxygenated blood to the heart.More often during exercise, stress, cold temperature, digesting large fat meal.Little or no permanent damage
14Heart Disease Myocardium Myocardium infarction (heart attack) Muscle tissue around the heartMyocardium infarction (heart attack)Prolonged blockage of blood to an area of the heart resulting in muscle tissue damage.Symptoms of a heart attackPressure in chest, fullness, squeezing pain.Pain spreading to shoulders, neck, or armsLightheadedness, fainting, sweating, nausea
15Who Is At Risk of Heart Disease? Prevalence increases with age, particularly after 45 years of agePrior to 50s, 60s, men at greater risk than women but increases in women after menopause.More women than men are likely to die from a heart attackBlacks at higher risk, Asians at lower risk
16Heart Disease Risk Factors High blood pressureFamily historyCigarette smokingHigh LDL and total cholesterol levelsPhysical inactivityDiabetesObesityStress
17Why high blood pressure a risk factor? Heart has to work harder.Since heart muscle is working harder, it can become enlarged.Wear and tear on the arterial wall can increase the likelihood of lipid and calcium deposits adhering to the arterial wall. This leads to hardening of the arteries.
18Type A Behaviours Hostile, cynical Judgmental (opinionated) CompetitiveTime urgentUses gestures while talkingNodding of head while others are talkingIntense
19Physiological Reactivity Physiological and cardiovascular reactivity to acute stress (“hot reactors”).Exaggerated increases in blood pressure, heart rate, catecholamines, corticosteroidsHigh levels of these hormones can damage heart and blood vesselsPresence of epinephrine (a catecholamine) increases the formation of clots.
21Psychosocial Predictors of Sudden Cardiac Death (BDI>10) 1.000.950.900.85ProportionSurvivingHigh scores on the Beck Depression Inventory in the placebo group was associated with a 2-times greater risk of mortality over 2 –years follow-up.Irvine J, Basinski A, Baker B, Jandciu S, Paquette M, Cairns J, Connolly S, Gent M, Roberts R, Dorian P. Depression and risk of sudden cardiac death after acute myocardial infarction: Testing for the confounding effects of fatigue. Psychosomatic Medicine, 1999; 61:Placebo, BDI <10Placebo, BDI >10AMIO, BDI <10AMIO, BDI >10Survival in days
22When do heart attacks occur? Less likely during sleep.Among the employed, more often on a Monday between 6 and 11 am.In part due to waking and becoming active shortly after dreaming which increases BP.In part because of circadian rhythm effects, increases in arousal hormones and blood pressure.
23Medical TreatmentInitial treatment may involve clot-dissolving medication and close monitoringBalloon angioplastyTiny balloon is inserted into blocked vessel and inflated to open blood vesselBypass surgeryUse grafted vessel (e.g., piece from leg) to bypass blockage in artery to the heart
24Medical TreatmentMedications (e.g., beta blockers, calcium channel blockers) to protect heart and improve function.Risk managementControl of high blood pressureControl of lipid abnormalities
25Rehabilitation Promote recovery and reduce risk of another attack Heart disease is chronic condition requiring ongoing management.
26Rehabilitation Includes: ExercisePhysiological and psychological benefitsWeight managementSmoking cessationLipid and BP management include dietary changes to control lipidsReduce excessive alcohol intakeStress management
27Rehabilitation Exercise is the key component but: 50% drop-out rate within first 6 monthsFor those who continue benefits include:Improved self concept, perceived health, sexual activity, involvement in social activities.Those who stop are more likely to:Smoke, have poorer cardiac function, have higher body weight, be more sedentary, experience greater anxiety and depression.
28Symptoms of a Stroke Sudden weakness or numbness of the face, arm, or leg (usually on one side of the body)dimness or loss of vision (usually one eye)Loss of speech or trouble talking or understanding speechUnexplained, severe headacheDizziness, unsteadiness, or sudden fall
29What is a stroke?Tissue damage to area of the brain due to disruption in blood supply, depriving that area of the brain of oxygen.
30Causes of StrokesInfarction – blockage in cerebral artery that cuts off or reduces blood supplyThrombosis – blood clotEmbolus – piece of plaque becomes lodged in the artery.Hemorrhage – happens suddenly. Less frequent than infarction but more damaging and more likely to cause death.
31Stroke Risk FactorsRare up to age 55, than risk increases sharply with age (doubling with each decade).More common in men but women more likely to die from them.Rates highest among blacks and lowest among Asians.Family history
32Stroke Risk Factors High blood pressure Cigarette smoking Heart disease, diabetes, and their risk factors such as obesity and physical inactivity.High red blood cell count (making the blood thicker and likelier to clot).Mini-strokes – transient ischemic attacks (TIA)TIAs may occur one or more times before a stroke.
33Effects of a StrokeSome motor, sensory, cognitive, or speech impairment usually occursLimitations may be permanent but lessen in severity over time.Younger patients recover betterImpairments caused by hemorrhages more easily overcome than those caused by infarctions.
34Effects of StrokeMotor impairments often due to paralysis on one side of the body (side opposite to brain damage).After about 6 weeks of rehab about 50% of patients can perform independently (many with cane or walker).Language, learning, memory, and perception problems depend on location of the injury.
35Effects of StrokeLeft-hemisphere damage more commonly associated with language problems called aphasia.Receptive aphasia – difficulty understanding verbal information.Expressive aphasia – difficulty producing and using language.Damage to right side of brain often associated with difficulties in visual processing and emotions.The difficulty with emotions can be either managing their own emotions or understanding those of others.
36Psychosocial Aspects of Stroke Denial is commonUnclear whether psychological or physiological basis.This ambiguity also applies to depression when it occurs after a stroke.Less than ½ of the patients return to work following a stroke.