Dealing with the Elderly

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 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.

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

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)

26. 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

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.