7.1. elderly and diasbility
DESCRIPTION
Elderly and DisabilityTRANSCRIPT
ELDERLY and DISABILITY
Sharon Gondodiputro dr., MARS.,MHDept. Of Public Health Faculty of
MedicineUnpad
Fact Sheets !!!! About Elderly
The world population is rapidly ageing
Between 2000 and 2050, the proportion of the world's population over 60 years will double from about 11% to 22%. The number of people aged 60 years and over is expected to increase from 605 million to 2 billion over the same period.
By 2050 the world will have almost 400 million people aged 80 years or older. Never before have the majority of middle-aged adults had living parents.
By 2050, 80% of older people will live in low- and middle-income countries
The main health burdens for older people are from noncommunicable diseases
Already, even in the poorest countries the biggest killers are heart disease, stroke and chronic lung disease, while the greatest causes of disability are visual impairment, dementia, hearing loss and osteoarthritis.
Many of these problems can be easily and cheaply prevented.
The need for long-term care is rising The number of older people who are no
longer able to look after themselves in developing countries is forecast to quadruple by 2050.
Many require long-term care, including home-based nursing, community, residential and hospital-based care.
Effective, community-level primary health care for older people is crucial
Good care is important for promoting older people's health, preventing disease and managing chronic illnesses.
Supportive, “age-friendly” environments allow older people to live fuller lives and maximize the contribution they make
Creating “age-friendly” physical and social environments can have a big impact on improving the active participation and independence of older people
Healthy ageing starts with healthy behaviours in earlier stages of life
These include what we eat, how physically active we are and our levels of exposure to health risks such as those caused by smoking, harmful consumption of alcohol, or exposure to toxic substances.
We need to reinvent our assumptions of old age
Society needs to break stereotypes and develop new models of ageing for the 21st century. Everyone benefits from communities, workplaces and societies that encourage active and visible participation of older people.
Caring for older family members is a normal, but often a stressful situation, may be manifest through illness in the caregivers
Human biologic aging is characterized by the progressive constriction of each organ system’s homeostatic reserve (homeostenosis)
Begins in the third decade, progressive, but varies in speed for each individual
Pra lansia = 49 -59 tahun Lansia > 60 tahun
Is influenced by :– genetic factor, – diet, – environment and – personal habits
Several principles from this concept: Individuals become more dissimilar as they age, rejecting any stereotype of aging
Abrupt decline in any system/function …..> almost certain due to disease, not to normal (or usual) aging
“ Normal aging” can be attenuated to some extent by modification of risk factors.
In the absence of disease, homeostenosis should not cause symptoms or impose restrictions on activities of daily living.
THE AGED RELATED CHANGES AND THEIR CONSEQUENCES
ORGAN OR SYSTEM
AGE RELATED PHYSIOLOGIC CHANGE
CONSEQUENCES OF AGE RELATED PHYSIOLOGIC CHANGE
CONSEQUENCES OF DISEASE, NOT AGE
General ⇑ Body fat Total body water
⇑ vol of fat soluble drugs Vol of water soluble drugs
ObesityAnorexia
Eyes and ears
PresbyopiaLens opacification High frequency acuity
ß Accomodation⇑Suspectibility to glareDifficulty discriminating words if background noise is present
BlindnessDeafness
Respiratory
ß Lung elasticity⇑Chest wall stiffness
Ventilation perfusion mismatch & O2 saturation
Dyspnea, hypoxia
ORGAN OR SYSTEM
AGE RELATED PHYSIOLOGIC CHANGE
CONSEQUENCES OF AGE RELATED PHYSIOLOGIC CHANGE
CONSEQUENCES OF DISEASE, NOT AGE
Endocrine Impaired glucose homeostatisß Thyroxine clearance, Renin .aldosterone, testosterone, Vit D absorption & activation,estrogen⇑ ADH
⇑ Glucose level in response to acute illness
T4 dose required in hypothyroidism
D.M.
Throid dysfunctionßSerum Na, ⇑ Serum KImpotenceOsteomalacia,fractures
Cardiovascular
ß Arterial compliance and ⇑Systolic BP (LVH)
ß Beta adrenegic responsiveness, baroreceptor sensitivity and SA node automaticity
Hypotensive response to ⇑ HR, volume depletion or loss of a trial contractionßCardiac output and HR response to stressImpaired blood pressure to standing, volume depletion
Syncope
Heart failure
Heart block
ORGAN OR SYSTEM
AGE RELATED PHYSIOLOGIC CHANGE
CONSEQUENCES OF AGE RELATED PHYSIOLOGIC CHANGE
CONSEQUENCES OF DISEASE, NOT AGE
Haematologic and immune system
bone marrow reserve T cell function⇑ autoanti bodies
AnemiaFalse negative PPD responseFalse positive rheumatoid factor, antinuclear antibody
Auto immune disease
Renal ßGFR urine concentration-dilution
Impaired excretion of some drugsDelayed response to salt or fluid restriction or overload, nocturia
⇑ Serum creatinine, renal failure Or ⇑ serum Na
Genitourinary
Vaginal or urethral mucosal atrophyß Bladder contractilityProstate enlargement
Dyspareunia, Bacteriuria ⇑ Residual urine volume
BPH
Symptomatic UTIUrinary incontinence, urinary retention, Prostate cancer
Musculoscletal
Lean body mass and muscle , bone density
ß StrengthOsteopenia
Functional impairmentHip,vertebral fractures
ORGAN OR SYSTEM
AGE RELATED PHYSIOLOGIC CHANGE
CONSEQUENCES OF AGE RELATED PHYSIOLOGIC CHANGE
CONSEQUENCES OF DISEASE, NOT AGE
Gastrointestinal
Hepatic function, gastric acidity , colonic motility,anorectal function
Delayed metabolism of some drugs Ca Absorption on empty stomachConstipation, Fecal incontinence
CirrhosisOsteoporosisB12 defFecal impaction
Nervous system
Brain atrophy Brain carechol synthesis , brain dopaminergic synthesis, righting reflexes, stage 4 sleep.
Benign senescent forgetfulnessStiffer gait⇑Body swayEarly awakening, insomnia
DementiaDeliriumDepressionParkinson’s diseaseFallsSleep apnea
THE FRAIL ELDERLY
Syndrome that results from a multisystem reduction in reserve capacity
Increased risk of disability and death from minor external stresses …..> extraordinarily thin tightrope in an attempt to balance physiologic function
THE FRAIL ELDERLY
FALLS DEMENTIA DEPRESSION URINARY CONTINENCE IRRATIONAL DRUG THERAPY
(POLYPHARMACY)
FIVE CLASSIC GERIATRIC PROBLEMS
Priorities : in elderly are likely to differ from those of younger people ……> Quality of life
Caregiver issues : requires attention as well as the patient, since the health and well being of the two are closely linked.
APPROACH TO THE PATIENT
1. Physical assessment2. Mental status assessment3. Functional assessment4. Social assessment5. Home environment assessment
COMPREHENSIVE GERIATRIC ASSESSMENT
History taking : 1. Auto/Allo anamnesis2. visual impairment3. hearing loss4. Falls5. Incontinence6. drug ingestion7. dietary patterns8. sexual dysfunction9. depression and anxiety
Physical Assessment
1. Be prepared to spend more time with older patients and more slowly
2. Always address the patient first3. Involve caregivers and family members
early in the patient’s care4. Recognize the emotional concerns
underlying any explicit requests5. Do not make significant changes in a
treatment plan based solely on the family’s report without evaluating the elderly patient directly
Interviewing older patients and their family members
Physical examination: Very private, do not mention anything, with respect and kindness.– General examination: vital signs– Special senses : eyes and ears– Mouth and denture– Neck– Breasts– Cardiovascular system– Abdomen and urinary tract – Gait and balance : “The get up and go”– Neurological system
Mental status assessment– Geriatric Depression scale – Cognitive testing : dementia (intelectual
impairment)Conversational probing: for patients
who follow the news or reading, television
Draw a clock test: ask the patient to draw a clock with the hands at a set time ex 15 min before 03:00
Folstein’s Mini Mental Status Examination (MMSE)
Elderly Cognitive Assessment Questionnaire (ECAQ)
Geriatric Depression scale
A score > 5 points is suggestive of depression.
A score > 10 points is almost always indicative
of depression.A score > 5 points should
warrant a follow-up comprehensive
assessment.
Elderly Cognitive Assessment Questionnaire (ECAQ)
Items Score
Memory
1 I want you to remember this number. Can you repeat after me (4517). I shall test you again in 15 min.
1
2 How old are you? 1
3 When is your birthday? OR in what year were you born?
1
Orientation and information
4 What is the year? 1
5 date? 1
6 day? 1
7 month? 1
8 What is this place called? Hospital/Clinic 1
9 What is his/her job? 1
Memory Recall
10 Can you recall the number again? 1
Total
Score (correct answer)
>7 Normal
5-6 borderline
0-4 Probable case of cognitive inpairment
– Assessment of Decision Making Capacity :Capacity to make decision for medical intervention : four components:
Ability to express a choice Ability to understand relevant information
about the risks and benefits of planned therapy and the alternatives including no treatment
Ability to understand the situation and its possible consequences
Ability to reason
Functional assessment
Information about function can be used in a number of ways:
1. As baseline information2. As a measure of the patients’s need
for support services or placement3. As an indicator of possible caregiver
stress4. As a potential marker of spesific
disease activity5. To determine the need for the
therapeutic interventions
Measurement: Activities of daily living (Katz):
Social and economic assessmentEvaluates the patient’s perception of
his own health status, his environment, his family situation, financial status and leisure activities
Home environment assessment The main objectives :
– To understand the home environment of the elderly and home hazards
– To see the interaction between the elderly’s functional abilities and the home environment
– To see how care can be optimized taking into considerations the home situation
– To detect any potential hazards that may predisposed the elderly to falls
Areas of assessment Housing : accesibility, social services,
transportation, medical services, amenities
The house/flat: type and location, number of rooms, lift, stairs and walkway, lighting, hazards, entry and exit
Room: flooring, ventilation, telephone location, furniture arrangement, lighting, hazards, bed
Living room: Furniture arrangement, wiring, hazards, chairs and table
Bedroom: bed, lighting,flooring,hazards Toilet/bathroom: grips,bars, railings, toilet
type, flooring, drainage, non slip measures, hazards
Kitchen: storage space and accesibility, sharps, hot water, oven, flooring and hazards.
TEN STEPS TO REDUCE POLYPHARMACY
1 Keep an accurate record of all medications the patient is on, including over the counter medications
2 Get into the habit of identifying all drugs by generic name and drug class
3 Make certain that each drug being prescribed has a clinical indication
4 Know the side-effect profile of the drugs being prescribed
5 Understand how pharmacokinetics and pharmacodynamics of aging increase the risk of adverse drug events
Polypharmacy