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

2. 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

3. 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

4. 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.

5. 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

6. 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

7. 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

8. 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)

9. 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.

10. 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

11. 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

12. 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

13. 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

14. WHO Analgesic Ladder

15. 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.

16. 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

17. 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

18. 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.

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

20. 4. Management: Intent of Treatment
a. Diagnostic Tests
b. Pharmacologic Intervention: Pharmacokinetics and dynamics
c. Non-pharmacologic Intervention
d. Follow-up/Planning/Evaluation: STRATEGIZE!

21. 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

22. The Psychosocial Domain

23. The Concept Of Suffering
CDHB Hospital Palliative Care Service July 2008

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

25. 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

26. 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

27. 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

28. Functions of the Physician
Guiding
Coordinating
Advocating
Consulting
Collaborating
Supporting

29. 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

30. 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.

31. To 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

33. Thank You.
Have a nice day.