psychiatry and aging - a powerpoint presentation

8/13/2019 Psychiatry and Aging - a Powerpoint presentation

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MENTAL HEALTH AND OLDER ADULTS

WORLD MENTAL HEALTH DAY 2013

Ward One Grand RoundsFriday November 1st, 2013

DR. SHIVAN A.C. MAHABIRPsychiatry Department, SWRHA



Case History

P. S.

78 yr old female

Pensioner

Widowed. Lives with her son in Point Fortin

Roman Catholic

Housewife

Attended Primary School only.



Case History

P/C:Thinking her daughter wanted to poison herEating mudWandering away from homeThrowing away household items

HxP/C:Memory problems starting within last 5 yrsParanoia for 1 yearTravelled to USA 6/12 ago. May have gotten ill and been admitted

to a psychiatric hospital there.Returned to Trinidad 3/52 ago.Since the behaviour as above along with c/o talking to herself,talking about the past and occasional aggressive behaviour.



Case History

Past Psychiatric Hx:

Known psychiatric patient

Attended Point Fortin POPC many years ago but defaulted

Diagnosis – unknown

Past Psychiatric Medication – Stelazine

? Past Psychiatric Hospital Admissions

? Pre-morbid level of functioning

Past Medical Hx: + HTN



Case History

MSE:

Clean

Cooperative

Oriented to person and place ONLY

Mood – even Affect – Congruent

Speech – relevant

Denied Hallucinations

+ Paranoid Delusions

Insight and Judgement were intact

MMSE: 18/30 (Moderate Impairment)



Case History

Physical Examination:

Lump in Left Axillary Region

Referred to Surgical Unit

Blood Ix:

Eosinophilia - ? Intestinal Parasites ? Allergies

Creatinine 1.2

CK 1338 . Rpt on following day 165

HbA1C: 5.3%



Case History

Differential Diagnoses:

? Dementia ? Type

? Schizophrenia

Hypertension

Renal Impairment

Lump in Axilla for Evaluation



Psychiatric illnesses in older people include:

Pre-existing psychiatric disorders in the aging patient

New disorders related to the specific stresses andcircumstances of old age (e.g. bereavement, infirmity,

dependence, sensory deficits, isolation).

Disorders due to the changing physiology of the aging brain,as well as psychiatric complications of neurological andsystemic illnesses.

The elderly are more likely to manifest physical symptoms ofpsychiatric disorder than younger adults



Prevalence of Psychiatric Illness in the Elderly

5% of people older than 65 yrs suffer from moderate to severe dementiaand the prevalence increases to over 30% of those over 85 yrs2.

In people >65 yrs approximately:

1.1% for schizophrenia;

1.4% for bipolar disorder;

12.5% for neurosis and personality disorder3.

~30% in old age homes have cognitive impairment

30-50% patients >65 yrs in general hospital wards have psychiatricdisorder)



Psychogeriatrics

Psychiatric problems often coexist with physical problems,

Cognitive assessment and physical examination are alwaysessential parts of psychiatric management of the older person.

Dementia is generally the main focus of interest inpsychogeriatrics, but the discipline also concerns itself withdepressive illness, paranoid states, and other late-onset

problems.



Psychogeriatrics

Since older people are often dependent on others, consideration ofthe role and the needs of carers are important aspects ofholistic care.

Psychiatric care of the elderly interfaces with multiple services,both state and independent (e.g. social services, housing andwelfare services, the legal system, charity organisations, andreligious institutions).



Neuro-Physiological Aspects of Aging

· The weight and volume of the brain decreases by 5% betweenages 30 and 70 yrs, by 10% by the age of 80, and by 20% by theage of 90.

· MRI shows decreased cortical grey matter with little change towhite matter.

· CBF in frontal and temporal lobes and thalamus decreases withage.

· There is some nerve cell loss in the cortex, hippocampus,substantia nigra, and purkinje cells of the cerebellum. Theremay also be reduction in dendritic processes. The cytoplasm ofnerve cells accumulates a pigment, (lipofuscin), while there arealso changes in the components of the cytoskeleton.

· Tau protein (NFT)/ Senile plaques/ Lewy bodies



Psychological Aspects of Aging

Cognitive assessment is often complicated by physical illness orsensory deficits.

IQ peaks at 25 yrs, plateaus until 60-70, and then declines.

Problem solving deteriorates due to declining abstract ability and

increasing difficulty applying information to another situation.Short-term memory (STM) does not alter with age. However,

working memory (WM) shows a gradual decrease in capacityand this is worse with increased complexity of task andincreased memory load.

Long-term memory (LTM) declines, except for remote events ofpersonal significance which may be recalled with great clarity.



Psychological Aspects of Aging

There is a characteristic pattern of psychomotor slowing andimpairment in the manipulation of new information.

Tests of well-rehearsed skills such as verbal comprehension show

little or no decline.

Performance IQ drops faster than verbal IQ, which may be due toreduced processing speed or to the fact that verbal IQ dependslargely on familiar “crystallised” information while performance

IQ involves novel, fluid information.



Social Issues of Aging

Increasing numbers of elderly live alone or in homes for the aged.

Losses include: loss of status, loss of independence, and loss ofspouse/partner.

Most elderly have limited income and are unemployed.

Increase in medical problems compounds the dependency andcare needs.

The elderly face variable degrees of isolation, marginalisation, andstigmatisation.



Multi-disciplinary Assessment

Elderly people suffering from mental health problems often have a range

of psychological, physical, and social needs. This implies thatindividual assessment, management, and follow-up requirescollaboration between health, social, and voluntary organisations andfamily carers.

Assessment of the older patient with mental illness includes thefollowing:

· Full history from the patient, family, and carers

· Full physical and neurological examination

· MSE, including full cognitive assessment

· Functional assessment (evaluation of ability to perform functions of

everyday living).

· Social assessment (accommodation; need for care; financial and legalissues; social activities)

· Assessment of carers' needs



Multi-disciplinary Assessment

The best place for performing an assessment is in the patient's home.

A domiciliary visit has the advantage of being more convenient andrelaxing for the patient and it provides the health carer with anopportunity to assess living conditions, social activities, and

medications kept in the house.

In addition, family members, neighbours, and carers may be available forinterviewing.

MSE needs to include an assessment of sight and hearing.



MMSE



Key questions for carers include:

· Relationship to the patient

· Amount of care provided

· Degree of stress they are under

· What help they would accept

· Understanding and knowledge of the patient's illness

· What expectations they have from services

· Their awareness of support or voluntary organisations



Dementia

Dementia is a syndrome – usually of a chronic or progressive nature – in which there is deterioration in cognitive function (i.e. the ability toprocess thought) beyond what might be expected from normalageing.

It affects memory, thinking, orientation, comprehension, calculation,

learning capacity, language, and judgement.

Consciousness is not affected.

The impairment in cognitive function is commonly accompanied, andoccasionally preceded, by deterioration in emotional control, socialbehaviour, or motivation.

Dementia is caused by a variety of diseases and injuries that primarilyor secondarily affect the brain, such as Alzheimer's disease or stroke.



Dementia

Early stage: the early stage of dementia is often overlooked, because theonset is gradual. Common symptoms include:

forgetfulness

losing track of the time

becoming lost in familiar places.

Middle stage: as dementia progresses to the middle stage, the signsand symptoms become clearer and more restricting. These include:

becoming forgetful of recent events and people's names

becoming lost at home having increasing difficulty with communication

needing help with personal care

experiencing behaviour changes, including wandering and repeated

questioning.



Dementia

Late stage: the late stage of dementia is one of near total dependence andinactivity. Memory disturbances are serious and the physical signs andsymptoms become more obvious. Symptoms include:

becoming unaware of the time and place

having difficulty recognizing relatives and friends

having an increasing need for assisted self-care

having difficulty walking

experiencing behaviour changes that may escalate and include aggression.

Positive features include wandering, aggression, flight of ideas, and logorrhoea:



Dementing Disorders

Epidemiology - Rare below 55yrs of age. 5-10% prevalence above 65yrs.20% prevalence above 80yrs, and 70% of those over 100yrs.

Commonest causes - Alzheimer's disease. Vascular dementia, Lewy bodydementia, Fronto-temporal dementia

Rarer causes: Alcohol/drug abuse, pellagra, Huntington's, CJD,Parkinson's, Pick's disease, HIV, cryptococcosis, progressiveleukencephalopathy.

Ix: FBC, ESR; U&E; Ca2+; LFT; TSH; autoantibodies; folate/B12 (treat low-normals); syphilis serology; CT/MRI (any structural pathology?).



Dementing Disorders

Senile Dementia -Alzheimer's Type

Cause:Accumulation beta-amyloid peptide, a degradation product ofamyloid precursor protein, resulting in progressive neuronal damage,neurofibrillary tangles, increased numbers of senile plaques, and loss

of the neurotransmitter acetylcholine.

Neuronal loss is selective, and the hippocampus, amygdala, temporalneocortex and some subcortical nuclei, eg the nucleus basalis ofMeynert are especially vulnerable

Risk factors: Defective genes on chromosomes 1, 14, 19, 21; the apoE4variant brings forward age of onset. Insulin resistance may beimportant



Dementing Disorders

Ix: Diagnosis only confirmed at post-mortem. Brain imaging (CT;MRI; PET) and neuropsychological tests help rule out fronto-temporal, Lewy body and vascular dementias.

Tx: Evidence that cholinesterase inhibitors and memantine aremodestly effective in treating AD is good.Cholinesterase inhibitors appear to be effective in mild-moderateAD.Memantine, alone or in combination with cholinesterase inhibitors, iseffective in late stage disease. Memantine is an NMDA antagonist.

(NMDA=N-methyl-D-aspartate).Normalize blood pressure.Avoid atypical antipsychotics in dementia.Use low dose haloperidol multiple dose per day. Observe for EPSE.Avoid CPZ – risk of hypotension.



Dementing Disorders

Prevention:

Learn a new language

Take up a hobby

Do puzzles and crosswords.

Go through photo albums.

Routines at home.



Drug Abuse

Generally, illicit substance abuse is not a significant problem in theelderly. However, misuse of over the counter drugs such as nicotineand caffiene, laxatives and OTC analgesics and prescription drugssuch as benzodiazepines, opiates, and analgesics frequently becomesa problem in this age group.

Dependence on these medications may result from careless prescriptionof long-term treatments for common problems of ageing such asinsomnia and arthritis.

Older patients may abuse anxiolytics to allay chronic anxiety or to ensuresleep.

The clinical presentation of older patients with alcohol and othersubstance use disorders varies and includes confusion, poor personalhygiene, depression, malnutrition, and the effects of exposure andfalls.



Drug Abuse

The sudden onset of delirium in older persons hospitalized for medicalillness is most often caused by alcohol withdrawal. Alcohol abuse alsoshould be considered in older adults with chronic gastrointestinalproblems.

With the best of intentions, doctors sometimes believe that it is “cruel” to

withdraw patients from these medications, especially if the patient hasbeen using the drug for years and is advanced in age.

However, it is important to consider whether withdrawal may actuallyenhance quality of life by diminishing chronic side-effects such asdepression

The maintenance of chronically ill cancer patients with narcoticsprescribed by a physician produces dependence, but the need toprovide pain relief takes precedence over the possibility of narcoticdependence and is entirely justified.



Alcohol Abuse

Older adults with alcohol dependence usually give a history of excessivedrinking that began in young or middle adulthood. They usually aremedically ill, primarily with liver disease, and are either divorced,widowed, or are men who never married. Many have arrest recordsand are numbered among homeless persons.

With decreasing tolerance for alcohol in advancing age, there is a

corresponding increase in risk of intoxication and adverse effects.Males predominate, although there is an increase in prevalence ofalcohol problems in women in their 8th and 9th decades.

Risk factors for late onset of alcohol problems include: female gender;higher socioeconomic class; physical ill-health; precipitating life

events; neurotic personality; psychiatric illness.

Wernicke's encephalopathy and Korsakoff psychosis are importantsequelae in “old cases”.



Alcohol Abuse

Principles of management

· Prognosis is good if alcohol problems commence secondary topractical problems.

· Encourage and facilitate involvement in non-drinking social activities.

· In extreme cases consider need for supervision of finances.

· Orientate towards reducing physical problems.

· Moving to residential care may reduce social isolation.



Anxiety Disorders in the Elderly

By far the most common disorders are phobias (4 to 8 percent). The

rate for panic disorder is 1 percent.

Because of concurrent physical disability, older persons react moreseverely to PTSD than younger persons.

Obsessions and compulsions may appear for the first time in olderadults, although older adults with OCD usually had demonstratedevidence of the disorder (e.g., being orderly, perfectionistic,punctual, and parsimonious) when they were younger.

Theories which seek to explain the aetiology of anxiety disorders inthe elderly include:1. Existential theories eg the person may deal with the thought of

death with a sense of despair and anxiety, rather than withequanimity and Erikson's “sense of integrity”. 2. Physiological theories: The fragility of the autonomic nervoussystem in older persons may account for the development of anxietyafter a major stressor.



Depression

Depressive symptoms are present in about 15 percent of all older

adult community residents and nursing home patients.

Age itself is not a risk factor for the development of depression, butbeing widowed and having a chronic medical illness are associatedwith vulnerability to depressive disorders.

Late-onset depression is characterized by high rates of recurrence.

The presenting symptoms may be different in older depressedpatients from those seen in younger adults because of an increasedemphasis on somatic complaints in older persons.

Older persons are particularly vulnerable to major depressive

episodes with melancholic features, characterized by depression,hypochondriasis, low self-esteem, feelings of worthlessness, andself-accusatory trends (especially about sex and sinfulness) withparanoid and suicidal ideation.

Dementia vs pseudo-dementia



Geriatric Depression Scale (Short Version)

Answers indicating depression are boldfaced. Each answer counts one point; scores greater than 5 indicate probabledepression.

1. Are you basically satisfied with your life? Yes/No

2. Have you dropped many of your activities and interests? Yes/No

3. Do you feel that your life is empty? Yes/No

4. Do you often get bored? Yes/No

5. Are you in good spirits most of the time? Yes/No

6. Are you afraid that something bad is going to happen to you? Yes/No

7. Do you feel happy most of the time? Yes/No

8. Do you often feel helpless? Yes/ No

9. Do you prefer to stay at home, rather than going out and doing new things? Yes/No

10. Do you feel you have more problems with memory than most? Yes/No

11. Do you think it is wonderful to be alive now? Yes/No

12. Do you feel pretty worthless the way you are now? Yes/No

13. Do you feel full of energy? Yes/No

14. Do you feel that your situation is hopeless? Yes/ No

15. Do you think that most people are better off than you are? Yes/No

(From Yesavage JA. Geriatric Depression Scale. Psychopharmacol Bull . 1988;24:709, with permission.)



Other Psychiatric Illnesses affecting the Elderly

Somatoform Disorders:

Hypochondriasis is common in persons over 60 years ofage, although the peak incidence is in those 40 to 50 yearsof age. The disorder usually is chronic, and the prognosisguarded. Repeated physical examinations help reassurepatients that they do not have a fatal illness, but invasive

and high-risk diagnostic procedures should be avoidedunless medically indicated.

Telling patients that their symptoms are imaginary iscounterproductive and usually engenders resentment.Clinicians should acknowledge that the complaint is real,that the pain is really there and perceived as such by thepatient, and that a psychological or pharmacologicalapproach to the problem is indicated.




Delusional Disorder

The age of onset of delusional disorder usually is between ages 40 and55, but it can occur at any time during the geriatric period.

In one study of persons older than 65 years of age, pervasivepersecutory ideation was present in 4 percent of persons sampled.

Delusions can take many forms; the most common are persecutory -patients believe that they are being spied on, followed, poisoned, orharassed in some way. Persons with delusional disorder may becomeviolent toward their supposed persecutors.

Some persons lock themselves in their rooms and live reclusive lives.Somatic delusions, in which persons believe they have a fatal illness,

also can occur in older persons.




Delusional Disorder

Among those who are vulnerable, delusional disorder can occur underphysical or psychological stress and can be precipitated by the deathof a spouse, loss of a job, retirement, social isolation, adversefinancial circumstances, debilitating medical illness or surgery, visual

impairment, and deafness.Delusions also can accompany other disorders such as dementia of the

Alzheimer's type, alcohol use disorders, schizophrenia, depressivedisorders, and bipolar I disorder which need to be ruled out.

Delusional syndromes also can result from prescribed medications or be

early signs of a brain tumor




Paraphrenia:

a psychotic illness characterised by delusions and hallucinations, withoutchanges in affect, form of thought, or personality

It develops over several years and is not associated with dementia. Somebelieve that the disorder is a variant of schizophrenia that first

becomes manifest after age 60.

Patients with a family history of schizophrenia show an increased rate ofparaphrenia




Schizophrenia:

Although first episodes diagnosed after age 65 are rare, a late-onsettype beginning after age 45 has been described.

Women are more likely to have a late onset of schizophrenia thanmen.

Another difference between early-onset and late-onset schizophreniais the greater prevalence of paranoid schizophrenia in the late-onsettype

Older persons with schizophrenic symptoms respond well to

antipsychotic drugs. Medication must be administered judiciously,and lower-than-usual dosages often are effective for older adults



Sexual Issues

Factors influencing the sexual life of younger adults are relevant to

older people too (e.g. social stresses, illness, and side-effectsof medications).

In addition, the elderly may experience added problems related tothe specific physiological changes that accompany ageing.

Dementia sufferers may become sexually demanding as part of thedisinhibition that frequently characterises this disorder.

Health carers may fail to detect sexual problems experienced byolder people as a sexual history is commonly overlooked. Thismay result from incorrect assumptions that carers often make

regarding sexuality in this age group.The client too may assume that his or her sexual dysfunction is a

â €˜normalâ€™ aspect of ageing.

Some practical remedies are: hormone replacement therapy;vaginal lubricants and topical oestrogen; and, of course, Viagra.



Personality Issues

Personality traits often become more prominent and rigid in oldage; in particular traits such as cautiousness, introversion, andobsessionality

Since personality disorder is by definition lifelong, any significantchange in personality needs explanation. Both organic andfunctional brain disorders may manifest as â €˜a change inpersonalityâ €™.

Personality problems are often the cause of Diogenessyndromeâ €”also called senile squalor syndromeâ€”in whicheccentric and reclusive individuals become increasingly isolated

and neglect themselves, living in filthy, poor conditions. Theyare often oblivious to their condition and resistant to help,necessitating intervention.

Suicide



Suicide

Old age is a risk factor for suicide and it is estimated thatapproximately 20% of all suicides are of the elderly. There is a

male predominance of 2:1 in this age group.

Predictive factors for suicide in the elderly:

· Increasing age

· Male

· Physical illness (35-85% cases)· Social isolation

· Widowed or separated

· Alcohol abuse

· Depressive illness, current or past (80% cases)

· Recent contact with psychiatric services

Most elderly persons who commit suicide communicate theirsuicidal thoughts to family or friends before the act of suicide

Sl d



Sleep Disorders

Sleep-related phenomena reported more frequently by older than byyounger adults are sleeping problems, daytime sleepiness, daytimenapping, and the use of hypnotic drugs.

Clinically, older persons experience higher rates of breathing-relatedsleep disorder and medication-induced movement disorders than

younger adults.Among the primary sleep disorders, dyssomnias are the most frequent,

especially primary insomnia, nocturnal myoclonus, restless legssyndrome, and sleep apnea.

Of the parasomnias, rapid eye movement (REM) sleep behavior disorder

occurs almost exclusively among elderly men.

The conditions that commonly interfere with sleep in older adults alsoinclude pain, nocturia, dyspnea, and heartburn. The lack of a dailystructure and of social or vocational responsibilities contributes topoor sleep.



Eld Ab



Elder Abuse

Elder abuse is an all-inclusive term representing all types ofmistreatment or abusive behaviour towards older adults. Thismistreatment can be an act of commission (abuse) or omission(neglect), intentional or unintentional, and of one or moretypes:

· Physical, sexual verbal, or psychological abuse

· Physical or psychological neglect

· Financial exploitation

The abuse or neglect results in unnecessary suffering, injury, pain,

or loss and leads to a violation of human rights and a decreasein the quality of life.

Eld Ab



Elder Abuse

Epidemiology of elder abuse

Occurs in both domestic and institutional settings:

· Domestic setting: Approximately 4-6% of elderly people reportincidents of abuse or neglect in domestic settings. The most

common forms of abuse are verbal abuse and financialexploitation by family members and physical abuse by spouses.Gender distribution (of victims) is equal and economic statusand age are unrelated to risk of abuse. Importantly, elder abuseis under-reported.

· Institutional settings: No data exists for the extent of abusewithin institutional settings. However, one survey of nursinghome staff in a US state disclosed that 36% of staff hadwitnessed at least one incident of physical abuse in thepreceding year, while 10% admitted having committed at leastone act of physical abuse themselves.

Elder Abuse



Elder Abuse

The main risk factors for elder abuse are: dependency and socialisolation of the victim; carer has mental or substance misuseproblems; absence of a suitable guardian. Factors vary according tothe type of abuse; for example, dependency is a risk factor forfinancial or emotional abuse, but not necessarily for physical abuse.Also the causes of spouse abuse may differ from the causes of abuse

by adult offspring.

Prevention of elder abuse is the best approach and a number ofmeasures have proved effective including:training and support of carers; reducing isolation of elders; respitecare; CPN visits; etc.

Responding to abuse effectively requires a multidisciplinary approachand a proactive system of assessment of suspicious cases (a numberof assessment instruments have been developed3,4)

Pharmacokinetics



Pharmacokinetics

· The physiological changes associated with ageing mean that the olderpatient's system “handles” drugs quite differently from that of ayounger individual.

· Absorption generally remains the same, although there are reductionsin gastric pH and mesenteric blood flow.

· Distribution of drugs is altered however: reduced body mass, bodywater, and plasma proteins, together with increased body fat causesincreased levels of free drug and longer half-lives (especially ofpsychotropics).

· Drug metabolism is reduced due to decreased blood flow to the liver

and loss of efficiency of liver microsomes.

· Excretion is reduced with the drop in renal clearance thataccompanies old age. Thus drug effects are generally prolonged andcumulative and the risk of toxicity is high.

Pharmacodynamics



Pharmacodynamics

Dopaminergic system - there are less DA cells in the basal ganglia;thus there is increased sensitivity to the EPSEs of neuroleptics (notdystonias).

· Cholinergic system - there is a normal reduction in cholinergicreceptors with advancing age (and a gross reduction in DAT).

· Noradrenergic system - NA levels decrease with age, which may causethis age group to become increasingly vulnerable to mood disorders.

· Narcotics and sedative hypnotics - there is increased sensitivity tosedatives in the elderly due to a reduction in the number of availablereceptors.

The implications of these changes are that elderly patients are moresensitive to almost all drugs used in psychiatry.



Pharmacokinetics and Pharmacodynamics

General principles of prescribing include:

· Start with a very low dose.

· Increases should be made slowly.

· Maximum efficacy is often achieved at significantly lower dosesthan in younger adults.

· Beware of dangerous side-effects such as postural hypotensionand arrhythmias.

· The elderly are particularly sensitive to EPSEs and anti-

cholinergic side-effects.

· Beware of drug interactions due to common problem ofpolypharmacy in the elderly.




General principles of prescribing continued:

Atypical neuroleptics are generally better tolerated thanconventionals.

· SSRIs, SNRIs, and NARIs are generally safer than TCAs; while

MAOIs and lithium may be useful in resistant depression.

· Monitor lithium therapy closely as levels can fluctuate easilyand long-term effects on thyroid and renal function are notinfrequent.

· Always consider suicide risk as old age is a risk factor for

suicide.

A pretreatment medical evaluation is essential, including anelectrocardiogram (ECG).





Most psychotropic drugs should be given in equally divideddoses three or four times over a 24-hour period. Olderpatients may not be able to tolerate a sudden rise in drugblood level resulting from one large daily dose.

Any changes in blood pressure and pulse rate and other sideeffects should be watched.

For patients with insomnia, however, giving the major portion ofan antipsychotic or antidepressant at bedtime takes advantageof its sedating and soporific effects.





Liquid preparations are useful for older patients who cannot, orwill not, swallow tablets.

Clinicians should frequently reassess all patients to determine the

need for maintenance medication, changes in dosage, anddevelopment of adverse effects.

If a patient is taking psychotropic drugs at the time of theevaluation, the clinician should discontinue these medications,if possible, and, after a washout period, reevaluate the patientduring a drug-free baseline state

Services for the Elderly



Services for the Elderly

In principle, the ideal service should plan to: Maintain the elderly person at home for as long as possible

Respond quickly to medical and social problems as they arise

Ensure coordination of the work of those providing continuing care

Support relatives and others who care for the elderly at home

Promote liaison between medical and social and voluntary services

These include: primary care, CPN, domiciliary services, residential and

nursing care, acute and long term hospital services, day andoutpatient care, informal carers

Palliative Care and Living Wills



Palliative Care and Living Wills

PALLIATIVE CARE is an approach that improves the quality of lifeof patients and their families facing the problem associatedwith life-threatening illness, through the prevention and reliefof suffering by means of early identification and impeccableassessment and treatment of pain and other problems,

physical, psychosocial and spiritual.

A LIVING WILL is an advance directive (usually written andwitnessed) made by an individual regarding their preferencesfor future treatment during their final illness. Usually the person

specifies the degree of irreversible deterioration after whichthey want no further life-sustaining treatment. They may alsogive clear instructions refusing certain medical interventions

Thank You For Your Attention! !



Thank You For Your Attention! !

Questions?

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