Illness Behavior in the ElderlyIllness Behavior in the Elderly

C. Eberle, M.DC. Eberle, M.D..University of Nebraska Medical CenterUniversity of Nebraska Medical Center

Healthy AgingHealthy Aging

Paul Tatum, 76 y/oPaul Tatum, 76 y/o

Competing in cross Competing in cross country cycling event.country cycling event.

Illness Behavior in the ElderlyIllness Behavior in the ElderlyObjectivesObjectives

Describe ways a person may respond to illness.Describe ways a person may respond to illness.

Identify reasons an older person may not report Identify reasons an older person may not report symptoms.symptoms.

Explain how a person’s response to his/her illness Explain how a person’s response to his/her illness impacts his/her health.impacts his/her health.

Discuss the role of disability in elders’ illness.Discuss the role of disability in elders’ illness.

Illness Behavior in the ElderlyIllness Behavior in the Elderly

What is the impact of this behavior?What is the impact of this behavior?

Is it really any different than yours or mine?Is it really any different than yours or mine?

How does this affect my interaction?How does this affect my interaction?

Illness Behavior in the ElderlyIllness Behavior in the Elderly

Any behavior that occurs due to the illness:Any behavior that occurs due to the illness:– Symptom reporting Symptom reporting – Compliance/ AdherenceCompliance/ Adherence

– MedicationsMedications

– Lifestyle (diet, exercise, habits, etc)Lifestyle (diet, exercise, habits, etc)

Response to illness Response to illness

This frequently occurs without conscious This frequently occurs without conscious thought.thought.

If done reflexively, how is it learned/ taught ? If done reflexively, how is it learned/ taught ? – Trial & errorTrial & error– FeedbackFeedback– RepetitionRepetition

Responses to IllnessResponses to Illness

MinimizeMinimize .. .. ..‘Just a cold.’‘Just a cold.’

DenyDeny .. .. . . Don’t come in.Don’t come in.

WithdrawalWithdrawal .. .. . . Isolates self.Isolates self.

FightFight .. .. . . ‘…beat it.’‘…beat it.’

Over-reactOver-react .. .. . . Lose control.Lose control.

Embrace the sick roleEmbrace the sick role .. DependentDependent

Matter of factMatter of fact .. . . . . Deal/Cope w it.Deal/Cope w it.

Different Patterns of IllnessDifferent Patterns of IllnessJAMA 262(7):907-913, 1989JAMA 262(7):907-913, 1989

-35

-25

-15

-5

5

Physical Life Role Social MentalHealth

Perceptions Pain

Hypertension Arthritis GI MI

Healthy AgingHealthy Aging

Lenny Aikins, 83 y/o

Parachutes 6 times / week

Age / AgingAge / Aging

AGE Distance from birthAGE Distance from birth– Chronologic measureChronologic measure

AGING Encompasses whole personAGING Encompasses whole person– Ubiquitous processUbiquitous process– Not a disease !Not a disease !– Timeline Timeline v v PuddlePuddle

AgingAging

PuddlePuddle TimelineTimeline

BirthBirth

SchoolSchool

CollegeCollegeWorkWork

RetireRetireMarried ?

Children ?

Illness Behavior in the ElderlyIllness Behavior in the ElderlyTruth Truth v v MythMyth

Old people are somatic or hypochondriacal.Old people are somatic or hypochondriacal.

Old people are noncompliant.Old people are noncompliant.

Old people are set in their ways.Old people are set in their ways.- “Can’t teach an old dog new tricks.”- “Can’t teach an old dog new tricks.”

Illness Behavior in the ElderlyIllness Behavior in the ElderlyHypochondriacal ?Hypochondriacal ?

Self Rated HealthSelf Rated Health

0 10 20 30 40

Excellent

Very good

Good

Fair

Poor

Illness Behavior in the ElderlyIllness Behavior in the ElderlyHypochondriacal ?Hypochondriacal ?

SymptomSymptomShortness of BreathShortness of Breath

Chest PainChest Pain

““Feeling Blue”Feeling Blue”

Coughing a lotCoughing a lot

Difficulty with urineDifficulty with urine

Reported : Not ReportedReported : Not Reported

5757 43 43 %%

6969 3131

4242 5858

6262 3838

6060 4040

Illness Behavior in the ElderlyIllness Behavior in the ElderlyHypochondriacal ?Hypochondriacal ?

1.1. ““Normal” agingNormal” aging

2.2. Ignored or minimized previouslyIgnored or minimized previously

3.3. Physician already knowsPhysician already knows

4.4. Fear of consequencesFear of consequences

Why Symptoms Aren’t Reported

Kaplan, ...Jl Gerontol 43(4):s114-120,1988Kaplan, ...Jl Gerontol 43(4):s114-120,1988

50

75

100

0 1 3 4 5

Years

% s

urv

ival Healthy

Fairly HSickVery sick

Illness Behavior in the ElderlyIllness Behavior in the ElderlyHypochondriacal ?Hypochondriacal ?

Illness Behavior in the ElderlyIllness Behavior in the ElderlyTruth Truth v v MythMyth

Old people are somatic or hypochondriacal.Old people are somatic or hypochondriacal.

• Old people are noncompliant.Old people are noncompliant.EVERYONEEVERYONE is non-adherent is non-adherent..

Learned early in our experience with antibiotic Learned early in our experience with antibiotic therapytherapy

• Old people are set in their ways.Old people are set in their ways.

- “Can’t teach an old dog new tricks- “Can’t teach an old dog new tricks.”.”

Medication AdherenceMedication Adherence

• Daily.Daily. .. .. .. .. 95%95%• Twice daily.Twice daily. .. .. .. 76%76%• Three times daily.Three times daily. .. .. 75%75%• Four times daily.Four times daily. .. .. 58%58%

Cockburn, BMJ, 1987Cockburn, BMJ, 1987

Illness Behavior in the ElderlyIllness Behavior in the Elderly“Set in their ways”“Set in their ways”

Sleep (< 6 h) 22 20Meals 24 8Smoker (d) 39 31Smoker (curr) 30 16Sedentary 16 14EtOH 38 12Obese (30%>) 13 13

U.S. NCHS, NHIS, 1985, unpublished

Habit 18 y/o + 65 y/o +

Illness Behavior in the ElderlyIllness Behavior in the ElderlyTruth Truth v v MythMyth

• Old people are somatic or hypochondriacal.Old people are somatic or hypochondriacal.

• Old people are noncompliant.Old people are noncompliant.

Old people are set in their ways.Old people are set in their ways.““Can’t teach an old dog new tricksCan’t teach an old dog new tricks.”.”

Illness Behavior in the ElderlyIllness Behavior in the Elderly Is it Different ? Is it Different ?

NONO• DenialDenial• NonadherenceNonadherence

YESYES• Attribute signs/symptoms to ageAttribute signs/symptoms to age• FearFear

Illness Behavior in the ElderlyIllness Behavior in the ElderlyReason for DifferencesReason for Differences

• Different types of illnessesDifferent types of illnessesAcute Acute vv Chronic Chronic

• Atypical presentation of illnessAtypical presentation of illness• Aging: Decreased reserveAging: Decreased reserve• Age: Variable loss of reserveAge: Variable loss of reserve

Illness in the ElderlyIllness in the Elderly

• Main health problem is:Main health problem is:• CHRONIC DISEASECHRONIC DISEASE

• Frequently results in:Frequently results in:• Physical impairmentPhysical impairment and and • Functional disabilityFunctional disability• PerhapsPerhaps dependence dependence on otherson others..

Acute Acute vsvs Chronic Illness Chronic Illness

ACUTEACUTE– SuddenSudden

– Short, limitedShort, limited

– Return to Return to normalnormal

– limited sick limited sick rolerole

– Identify & cure.Identify & cure.

CHRONICCHRONIC

– Sudden-GradualSudden-Gradual

– Long-unknownLong-unknown

– ? If able to return to ? If able to return to NormalNormal

– sick role, dependentsick role, dependent

– Can’t cure … Can’t cure … – Why me?, what did I do?Why me?, what did I do?

ONSET

DURATION

EXPECTED OUTCOME

ROLES

ETIOLOGY

Prevalence of Disability in Prevalence of Disability in Older PersonsOlder Persons

0

20

40

60

80

100

65 + 65-74 75-84 85 +

Need helpReceive help

IADLS

ADL

Prevalence of Disability in Prevalence of Disability in Older PersonsOlder Persons

0

20

40

60

80

100

65 + 65-74 75-84 85 +

DifficultyReceives help

U.S. Dept. of Health & Human Services, 1986.

Prevalence of Disability in Prevalence of Disability in Older Persons Older Persons (Hospital)(Hospital)

Rosin, 1966 18-28 --- 6

Warshaw, 1982 50 65 21

Pinholt, 1987 32 29 29

Bonar, 1990 35 74 34

Study Cognition Mobility Continence

Health and DisabiltyHealth and Disabilty

Hoenig H. JAGS, 1997 & GRS.

Cascade to Disability and HandicapsCascade to Disability and Handicaps

Patient Care NeedsPatient Care NeedsRule of ThumbRule of Thumb

Bathing 3 visits per weekMedication admin DailyMeal preparation Daily, 2-4 hoursDressing Daily, 2-4 hoursFeeding Daily, 8 hoursContinence 24 hoursAmbulation, Tfr 24 hours

Based on ADL and IADL abilities:

Illness Behavior in the ElderlyIllness Behavior in the ElderlySummarySummary

Response to illness is very similar between Response to illness is very similar between young and oldyoung and old– Denial, Fear, Isolation, Fight, Sick RoleDenial, Fear, Isolation, Fight, Sick Role

There are differencesThere are differences– Older individuals frequently fail to report Older individuals frequently fail to report

symptoms, attributing them to ‘normal’ aging symptoms, attributing them to ‘normal’ aging and may be more fearful of illness.and may be more fearful of illness.

Illness Behavior in the ElderlyIllness Behavior in the ElderlySummarySummary

Failure to recognize and report symptoms Failure to recognize and report symptoms leads to delay in diagnosis and treatment, leads to delay in diagnosis and treatment, and poorer outcomes.and poorer outcomes.

Disability is an important element of Disability is an important element of chronic disease/illness that requires chronic disease/illness that requires intervention in our management.intervention in our management.

Healthy AgingHealthy Aging

Earl Shaffer, 79 y/oEarl Shaffer, 79 y/o

Through-walked the Appalachian Trail, 98Through-walked the Appalachian Trail, 98(The 3rd time)(The 3rd time)