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Izben C. Williams, MD, MPH Instructor

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1 Izben C. Williams, MD, MPH Instructor
BEHAVIORAL SCIENCE Izben C. Williams, MD, MPH Instructor


3 WHO or WHAT IS OLD In contemporary urban societies, chronological boundaries for life phases (youth, middle age, and old age) are continuously being revised upwards as medical and social advances extend the vitality and productivity of older adults

4 WHO or WHAT IS OLD Truth is that aging proceeds at different rates in different individuals and at different rates with specific organ systems. Many persons seem old in body or spirit at age 50 and others scarcely so at age 65 or 70

5 Whence 65+ The common practice of designating people over age 65 as “old” began in Germany in the 1880s when Otto von Bismarck selected 65 as the starting age for certain social welfare benefits The question is: “Should this continue to be the qualifying standard?" Gerontologists as well as politicians continue to struggle with this question Otto von Bismarck was was a conservative Prussian statesman who dominated German and European affairs from the 1860s until He created the first welfare state in the modern world, with the goal of gaining working class support that might otherwise go to his Socialist enemies.

6 Life Expectancy USA 150 years

7 Life expectancy USA 100 yrs
So much for the political shininagans of von Bismarck ……….and all political likes

8 Aging Epidemiology In the USA the fastest growing segment of the population is over age 85 The 65+ population now comprises about 12% of the US population Projections suggest that by 2020 more than 15% of the US population would be more than 65 years old Contrast this with US census 1900

9 Age – Just a number To avoid undue emphasis on chronological age, it may be useful to think of each person as having several different ages, eg: biological, psychological and social (bio-psycho-social paradigm) And to recognize that individuals may be “aged” in one continuum and “youthful” in another

10 Biology of Aging -1 Aging is not a disease, though often a dis-ease
But irreversible changes including some disease changes often accompany aging Distinguishing between changes due to normal aging and those due to disease processes is not always straightforward

11 Biology of Aging -2 Distinguishing between normal senescence and senility (by way of example): Senescence involves slowing, varying from scarcely noticeable to moderate changes. Relationships not impaired Senility is a serious illness with progressive cognitive compromise and often death within a few years (incidence 10% over 65; 20% over 85)

12 Biology of Aging -3 Some changes in aging process
Nervous system: The nervous system demonstrates, possibly more clearly than any other system, the poorly defined borderline between normal, expected and tolerable changes due to aging and the pathologic changes due to disease Skin and Hair Muscles

13 Biology of Aging -4 Some changes in aging process
Special Senses Cardiovascular System Respiratory System Gastrointestinal Tract Urinary Tract


1. A child’s response to death is based on his level of awareness. An awareness of the meaning of death becomes more concrete (7-11 reversibility and irreversibility) with developing comprehension abilities a. Children younger than 5 years tend to view death as abandonment They fail to appreciate the finality and irreversibility. Hence don’t mourn fully these important individuals

1b. By middle childhood, a more realistic view of death begins to emerge, with children understanding the finality of the event. (1) The anxiety at this point about death concerns not only the loss of (separation from) loved ones but also fears of mutilation (castration anxiety) and suffering and pain

1b (2) Because of the egocentric thinking of children they tend to feel guilty and to view themselves as responsible for their own or other’s illness and death. Frequently the illness or death is viewed as a punishment for having been bad.

1c. By adolescence comes an adult cognitive view of death, and with it a clear understanding of its irreversibility. In addition, there is a capacity to mourn, especially by mid-adolescence. (1) Adolescents with chronic physical illnesses, eg cystic fibrosis, precociously develop a sense of finiteness to life, often living while waiting for the final stage

1c. (2). With a decrease in egocentricity of their thinking and a diminished tendency to see their illness or death as justified or deserved, adolescents experience alterations of resentment and despair as they struggle to accept their own death

2. Parental response to child’s death. A child’s death is certainly one of the most devastating experiences that could befall any parent. If the death is not a sudden one, there is a tendency for the parents unconsciously to undergo anticipatory mourning, resulting in the gradual relinquishment of strong emotional ties to the child. This can be hurtful to the child and parent alike

2a. The parent may be physically in attendance but emotionally disengaged and the child experiences the dreaded sense of abandonment The relationship becomes bland and lacks intensity as the parents try not to let the child see them “upset” An emotional barrier is erected, the talk is superficial, and the subject most on the child’s and the parents minds becomes taboo

2b. When the child dies, the parents may feel guilty that they are not more upset by the child’s death or that they may be relieved to have the ordeal over Unless properly counseled they may think of themselves as collous or non-loving when in fact they have already grieved, albeit unconsciously in advance

1. Adults tend to be anxious about their own death because of: The dread of being separated from loved ones Concern about pain and suffering, and Because of the narcissistic injury associated with the end of existence There is often also a sense of not having left an indelible mark on the world that will assure “perpetual existence” thereby avoiding a sense of nothingness.

24 The Process of Dying People die as they lived (cum defenses and all)
Mortal man can’t imagine his mortality Some investigators, particularly Elizabeth Kubler-Ross have proposed a series of five psychological stages through which the dying patient progresses These stages should be viewed only as representative of emotional reactions experienced by the terminally ill

2. Elizabeth Kubler-Ross: Describes five stages that the dying patient experiences before demise: a. The Stage of denial and isolation– can’t be, not true b. The Stage of anger with rage, bitterness, why me, etc The Stage of bargaining including miracles and magic The Stage of depression preparatory grief (emotional detachment, withdrawal) final grief (existential reflections) The Stage of acceptance with calm and even euphoria

C. There are several common responses observed in physicians who care for the dying. 1. Sense of failure. In spite of rationally knowing otherwise, many physicians harbor a belief that if they had tried harder perhaps the outcome would have been different 2. When the patient reminds the physician of someone significant then the additional emotional strain may be impactful.


28 BEREAVEMENT Terminal illness exacts a heavy toll on all those involve with the dying person Physician’s role should be to assist the family in achieving adequate adjustment to loss, recognizing that: Family members are an integral part of the experience of terminal illness and death Terminal illness may result in major changes in family structure and dynamics

29 BEREAVEMENT -2 Patient’s problems have ended and the family problems escalate. Some probable emergent issues: Implications if patient was family provider. Loneliness, resentment, guilt and fear must be faced Survivors need to reassess the meaning and direction of their own lives

30 BEREAVEMENT -3 The essential task of mourning or grieving is the withdrawal of emotional concern and attachment from a lost object (person) and preparation for relationships with new objects.

31 BEREAVEMENT -4 Five stages of bereavement recognized
These share similar characteristics with: Reactions of the dying patient, and with Characteristics of the stress syndrome (qv) These stages and phenomena vary in sequence, duration, intensity and even occurrence in any given individual

32 BEREAVEMENT -5 Five stages of bereavement: Alarm Numbness
Pining and searching for the lost object (hallucinations and pseudohallucinations) Depression and disorganization Recovery and reorganization

33 BEREAVEMENT -6 The major mourning period lasts 6-18 months , with most people able to resume usual functioning in less than 6 months In truth, however, the time course of the mourning process is lifelong, but with time memories become less painful and less intrusive

34 BEREAVEMENT -7 The role of the physician:
Work with the family starts well before the ill person’s death Offer realistic appraisal of the situation but at the same time allow for hope The concept of anticipatory grief encourages family members to verbalize their thoughts and feelings


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