Dealing with the Elderly Rojim J Sorrosa, M.D., DFM Family Medicine Palliative Medicine

Lecture : Dealing With the Elderly Primary Objective Discuss the general principles of illnesses affecting the elderly population using the BIOPSYHOSOCIAL APPROACH Biomedical Osteoporosis Falls Pain Psychosocial Individual Family Life Cycle Illness Trajectory

The Five-Star Filipino Physician Health Care Provider Teacher Researcher Health Care provider: Applies highest standard of clinical care, long lasting relationship, preventive care Researcher: EBM Educator: Health promotion Social Mobilizer: Reconcile individual and communit health needs Manager: work harmoniously with individuals and organizations Health Manager Social Mobilizer

Biopsychosocial 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 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. A change in one level reverberates upward and downwards simultaneously.

Disease Illness Examining 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: Increased porosity of the bone resulting in decreased bone mass. Individuals are prone to fractures Factors affecting the pathogenesis of osteporosis Age-related changes: Osteoblasts and Osteoclasts Reduced physical activity: increase rate of bone loss Genetic factors Nutritional status: Calcium Hormonal Influences: Estrogen deficiency

Treatment of low bone mineral density Burden and Care Gaps Fragility fractures: Mortality, morbidity, chronic pain, admission to institutions, economic costs Goals of Care Treatment of low bone mineral density Prevention of fragility fractures and their negative consequences 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada: Summary

FALLS General Considerations Falls are one of the most common geriatric syndromes threatening the independence of older persons. The risk of familling increases with age. Morbidity Mortality Quality of Life: functioning, long term facilities Risk of fall increased in patients with dementia. Impairment in judgement Attention 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: Inflammation of the Joints (Arthralgia). Cardinal signs of inflammation Infectious and non-infectious causes Basic pathophysiology Loss of articular cartilage Tissues are affected (cartilage, subchondral bone, synovium, menisci, etc) Biomolecular events Loss of proteoglycancs Matrix degradation Loss of collagen fibers

Health burden: Morbidity, mortality, quality of life Pain Burden and Care Gaps Health burden: Morbidity, mortality, quality of life Pain Goals of Care Improve quality of life and daily functioning Symptom management EULAR Recommendations for the Management of Early Arthritis

PAIN 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 Pain Types of Pain Somatic Pain Visceral Pain Neuropathic Pain

Burden and Care Gaps TOTAL PAIN P: Physical problems A: Anxiety, Anger Depression I: Interpersonal relationships N: Non-acceptance of approaching death and a desperate search for the meaning of life. Barriers to pain management a. Health care professionals b. Patients c. Health system Goals of Care: Aggressive symptoms control Analgesic Ladder: Stepwise approach in the use of analgesic drugs

WHO Analgesic Ladder

Barriers to health care in the elderly Optimal health outcomes for geriatric patients depend on medical self-management Self management process  Improved health outcomes Barriers  Affect specific outcomes (mortality, morbidity, QOL) Goal is to maintain a good functional status with multiple co-morbidities 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 Self-management process Resources and Barriers: Social Support, Financial Resources, Establish routine, Self-efficacy, Depressive Symptoms, Functional Literacy, Knowledge Base Self management process: phsyical and psychological health, interactions with healthcare clinicians, adherence, monitoring of health status, decisions Patient resources and Barriers HEALTH OUTCOMES

General Biomedical Approach Medical History Precipitating events Review of medications Acute and chronic medical problems Mobility/ADL’s Cognitive Status 2. Physical Examination a. Focused and targeted physical examinations b. Mental Status Examination

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.

Risk Characterization Issue Identification Hazard Assessment Exposure Assessment Review and Reality Check Review and Reality Check Risk Characterization RISK MANAGEMENT

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

Relief of suffering and distress Comprehensive Multidimensional Approach Quality of Life Dignity Relief of suffering and distress Physical Psychological Spiritual Social

Consider these factors: The Family Illness Trajectory Normal course of the psychosocial aspects of the disease Predict, anticipate and deal with the patient and family’s response to illness. Normal vs Pathologic reactions 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) Stage 1: Acute Rapid, clear onset, provide little time to adjust, deal with immediate decisions vs Chronic: more debilitating = apprehension, denial, anxiety

Composite of individual developmental changes of all family members Family Life Cycle Composite of individual developmental changes of all family members Medical Emotional/Social Changes Cyclic development of the evolving family unit Why? predictable, chronologically oriented sequence of events Stressful changes that requires compensating and readjustment 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 Attached young adult: Accepting parent offspring separation Newly married Couple: commitment to the new system Young Children: Accepting marital system to make space for children Adolescents: Increasing flexbility to accept children independence Launching Family: mutlitude of entries and exits in the family

Family in Later Years: Empty Nest Shifting of generational roles Maintaining couple functioning in the face of physiologic decline Support the younger generation Dealing with loss of spouse, siblings and other peers Preparation for own death, life review and integration

Functions of the Physician Guiding Coordinating Advocating Consulting Collaborating Supporting

Psychosocial Interventions Patients source of distress and suffering 1. Psychosocial: anxiety, depression 2. Family Problems: conflict 3. Spiritual and existential problems The FAMILY IN CRISIS 1.. Family as a SYSTEM 2. Tools to explore FAMILY DYNAMICS 3. Identify Pathologies

The 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.

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.