Dealing with the Elderly Rojim J Sorrosa, M.D., DFM Family Medicine Palliative Medicine
Apr 01, 2015
Dealing with the Elderly
Rojim J Sorrosa, M.D., DFMFamily Medicine
Palliative Medicine
Lecture : Dealing With the Elderly
Primary Objective
Discuss the general principles of illnesses affecting the elderly population using the BIOPSYHOSOCIAL APPROACH
a. Biomedical - Osteoporosis- Falls- Pain
b. Psychosocial - Individual- Family Life Cycle- Illness Trajectory
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Biopsychosocial Approach/Model
1.Physiological factors, cultural, social differences within the individual.
2.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.
Disease IllnessExamining 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:
1.Increased porosity of the bone resulting in decreased bone mass.
2.Individuals are prone to fractures
3.Factors affecting the pathogenesis of osteporosisa. Age-related changes: Osteoblasts and Osteoclastsb. Reduced physical activity: increase rate of bone lossc. Genetic factorsd. Nutritional status: Calciume. Hormonal Influences: Estrogen deficiency
Goals of Care
1.Treatment of low bone mineral density2.Prevention of fragility fractures and their negative consequences
2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada: Summary
Burden and Care Gaps
Fragility fractures: Mortality, morbidity, chronic pain, admission to institutions, economic costs
FALLS
General Considerations
1.Falls are one of the most common geriatric syndromes threatening the independence of older persons.
2.The risk of familling increases with age.a. Morbidityb. Mortalityc. Quality of Life: functioning, long term facilities
3. Risk of fall increased in patients with dementia.a. Impairment in judgementb. Attentionc. 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:
1.Inflammation of the Joints (Arthralgia).
2.Cardinal signs of inflammation
3.Infectious and non-infectious causes
4.Basic pathophysiologya. Loss of articular cartilageb. Tissues are affected (cartilage, subchondral bone,
synovium, menisci, etc)c. Biomolecular events
- Loss of proteoglycancs- Matrix degradation- Loss of collagen fibers
Burden and Care Gaps
1.Health burden: Morbidity, mortality, quality of life2.Pain
Goals of Care1.Improve quality of life and daily functioning2.Symptom management
EULAR Recommendations for the Management of Early Arthritis
PAINGeneral Considerations:
1.Definition
“Unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”
2.Acute vs Chronic Pain
3.Types of Paina. Somatic Painb. Visceral Painc. Neuropathic Pain
Burden and Care Gaps
1.TOTAL PAINP: Physical problemsA: Anxiety, Anger DepressionI: Interpersonal relationshipsN: Non-acceptance of approaching death and a desperate
search for the meaning of life.
2. Barriers to pain managementa. Health care professionalsb. Patientsc. Health system
Goals of Care:
1.Aggressive symptoms control2.Analgesic Ladder: Stepwise approach in the use of analgesic drugs
WHO Analgesic Ladder
Barriers to health care in the elderly
1.Optimal health outcomes for geriatric patients depend on medical self-management
a. Self management process Improved health outcomes
b. Barriers Affect specific outcomes (mortality, morbidity, QOL)
2. Goal is to maintain a good functional status with multiple co-morbidities
3. 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
Patient resources and Barriers
Self-management process
HEALTH OUTCOMES
General Biomedical Approach
1.Medical Historya. Precipitating eventsb. Review of medicationsc. Acute and chronic medical problemsd. Mobility/ADL’se. Cognitive Status
2. Physical Examinationa. Focused and targeted physical
examinationsb. Mental Status Examination
3. 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.
Issue Identification
Hazard Assessment
Exposure Assessment
Risk Characterization
RISK MANAGEMENT
Review and Reality Check
Review and Reality Check
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
Comprehensive Multidimensional Approach
Quality of Life
Dignity
Relief of suffering
and distress
Physical
Psychological
Spiritual
Social
Consider these factors:
1.The Family Illness Trajectory
a. Normal course of the psychosocial aspects of the disease
b. Predict, anticipate and deal with the patient and family’s response to illness.
c. Normal vs Pathologic reactions
d. 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)
2. Family Life Cycle
a. Composite of individual developmental changes of all family members
- Medical- Emotional/Social Changes
b. Cyclic development of the evolving family unitc. Why?
- predictable, chronologically oriented sequence of events- Stressful changes that requires compensating and
readjustmentd. 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
Family in Later Years: Empty Nest
1.Shifting of generational roles
2.Maintaining couple functioning in the face of physiologic decline
3.Support the younger generation
4.Dealing with loss of spouse, siblings and other peers
5.Preparation for own death, life review and integration
Functions of the Physician
• Guiding• Coordinating • Advocating• Consulting • Collaborating• Supporting
Psychosocial Interventions
a. Patients source of distress and suffering
1. Psychosocial: anxiety, depression2. Family Problems: conflict3. Spiritual and existential problems
b. The FAMILY IN CRISIS
1.. Family as a SYSTEM2. Tools to explore FAMILY DYNAMICS3. Identify Pathologies
When cure is not possible, the RELIEF of suffering is the CARDINAL goal of medicine.
The alleviation of suffering is universally acknowledged as a cardinal goal of medical care.
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.