Transcript Approach to Illness in the Older Patient

Gerontology and Geriatrics
Dr Gary Sinoff
Department of Gerontology
University of Haifa
Study of the Elderly
• Focuses on aging and old age
• Individual aspects
• Social aspects
• Young discipline
“Anyone can get old.
All you have to do is
live long enough.”
Groucho Marx
Goals of Gerontology
• To increase our knowledge about aging
and old age
• To improve the quality of life in old age
Goals of Geriatric Medicine
• Maximize the positive aspects of aging.
• The compression of morbidity.
• Delaying the onset of chronic disease and
maximizing function.
Definitions
DEFINITION OF AGING
A PROCESS OF IRREVERSIBLE
ACCUMULATION OF DELETIRIOUS
CHANGES IN THE CELLS AND
TISSUES WITH ADVANCING AGE
[TIME] THAT INCREASE THE RISK OF
DISEASE AND/ OR DEATH.
Aging Process
• Variable and complex
• The life span for humans is based on several
factors but is seems to be limited to 120
years
• Difficult to distinguish between aging and
disease
• Normal aging is an inborn or innate process
How do we define “old” today?
Young Old: 65-74
1942
Middle Old: 75-84
1936
Old Old: 85+
1923
Defining Old Age
• Chronological Age
• Biological Age
• Psychological Age
• Sociological Age
Chronological Age
• Commonly used indicator – 65 and over
• Limitations
- People’s functional capabilities vary
- May not capture the diversity of
people
Demographics
Changing Global Age Structure 1996
Changing Global Age Structure 2025
World and Regional Life Expectancy
90
80
70
60
World
More Developed
Less Developed
Least Developed
50
40
30
20
10
20 yrs increase in past 50
0
1950-55
1975-80
2000-05
2025-30
2045-50
Source: United Nations, 2001
World Population
Dynamics
TOP TEN
Regional Distribution of Population aged > 60
in millions
700
600
500
Start Learning Chinese or Hindi
1950
1990
2025
400
300
200
100
0
Oceania
North
America
South
America
Africa
Europe
Asia
Life expectancy
• Average number of years you can expect
to live.
• Increased largely because of reduction in
early mortality
immunization, safety, engineering, food
preservation/nutrition),
somewhat through medical innovation
(antibiotics and diagnostics)
Life Expectancy by Age
25
Male 65
Male 75
Male 85
Female 65
Female 75
Female 85
20
15
10
5
0
1960-62
1970-72
1980-82
1989-91
Year of Birth
The Population Explosion
Growth of World Population
1830
1930
1960
1975
1987
1999
1 billion
2 billion
3 billion
4 billion
5 billion
6 billion
thousands of years
100 years
30 years
15 years
12 years
12 years
The
Grey
Tsunami
?
The Grey
Tsunami ?R.O.M.P.
Collingwood
April 24, 2008
Dr. Carolyn Bennett M.P.
Squaring of the survival curve
The Demographic Transition
Demographic Transition
Stage 1: Death rates and birth rates both high.
Stage 2: Fall in death rates, Population increases.
Stage 3. Decline in birth rate stabilizes population.
Stage 4. Birth and death rates both low, population
stable.
Stage 5 (new). Higher death rates than birth rates,
populations contract.
Population Pyramids for the
four demographic transition phases
Approach to Illness in the Older
Patient
In older adults, the
presenting problem
is just the “tip of the
iceberg” of a
pathological process,
which takes careful
diagnostic
assessment to
uncover
GOMER
‫ע = עוף‬
G = Get
O = Out of
‫ח = מחדר‬
M = My
E = Emergency
R= Room
‫מ = המיון‬
‫ש = שלי‬
To be old is to be sick
• Most seniors are healthy and active.
• Three quarters of the seniors report their
health to be good, very good or excellent.
Most seniors live in nursing homes.
• Just 5% of males and 9% of females in
NH.
• Most are over 85 years of age.
• Decline of percentage since 1970’s.
Principles of Geriatrics
1. Onset of a new disease affects a previous vulnerable
organ system.
2. Due to impaired physiological reserves, older patients
present at an earlier stage.
3. Multiple abnormalities which can be treated and small
improvements yield dramatic improvements
4. Many findings which are abnormal in young, are
common in the elderly.
5. Symptoms in elderly often from multiple causes,
therefore the “law of parsimony” does not apply.
6. Treatment and prevention is equally or more effective
than in younger.
“O” Complex of Geriatric Medicine
DON’T FORGET “FAILURE TO THRIVE”
THE “CASCADE” OF OLD AGE
The Epidemiological Transition:
Changing Pattern of Causes of Death
25
T
h 20
o
u 15
s
a 10
n
d 5
s
1950
1960
1970
Infectious Diseases
Diabetes
Cancer
1985
1993
Tuberculosis
Diseases of circulatory system
Source: World Health Statistics, 1989, 1995
‫תחלואה ותמותה בתשישות‬
Disabilities
60
52.5%
50
40
33.4%
65+
15-64
0-14
30
20
10
18.7%
9.1%
8.7%
1.1%
0
% with any disability
% with severe disability
History and Examination
History
HISTORY
•
•
•
•
•
•
•
More time consuming
Depends on senses
Cognitive state
Ignoring symptoms
Atypical symptoms
Social problems
Non-verbal communication
- smells
- body language
Body Language
• Very important when a language barrier exists
• Usually at a subconscious level
• Components of body language
eye contact
facial expressions
proximity
posture
gestures
The Curse of the Modern Society
• Mobile phones
All Systems BUT ALSO!!!
– Social
– Living Conditions
– Past experiences
– Economic
– Family support systems
– Activities
– War experiences
Sympathy or Empathy
Sympathy
The act or capacity of entering into or sharing the
feelings or interests of another wherein whatever
affects one similarly affects the other.
versus
Empathy
The action of understanding, being aware of, being
sensitive to, and experiencing the feelings,
thoughts, and experience of another.
PHYSICAL
EXAMINATION
PHYSICAL EXAMINATION
• Ask permission to initiate procedures
• Need for assistive devices
• Respect the patient’s beliefs
• Allow ample time and area of privacy
GERIATRIC EXAMINATION
• What components are often missed in
routine exams?
– Visual Impairment
– Hearing Deficit
– Malnutrition
– Cognitive Impairment
– Depression
– Mobility
– Urinary Incontinence
– Physical Disabilities
Remember
...‘the elderly patient is admitted to hospital
not because of social problems but
because of medical problems with social
consequences or social problems with
medical consequences’
(Isaacs, 1992)
Time and Money
• TIME: Average length of time spent on care
giving was about eight years, with about onethird of the respondents providing care for 10
or more years.
• MONEY: Almost all respondents reported
helping the care recipient with some expenses,
most frequently with food, transportation, or
medications.
The vast majority of long-term care is provided
informally and privately, at no public cost.
American Society on Aging, 2000
Caregiver for Elderly
 Getting to and from doctor
and other appointments.
 Helping someone clean their
home.
 Communicating with health
care professionals.
 Assisting someone or
arranging for home repairs.
 Contacting or helping
someone communicate with
community service
organizations.
 Arranging for or helping
someone to arrange for Meals
on Wheels.
 Assisting someone to pay
their bills.
 Helping arrange for home
health care or hospice
services.
‫שיעור הבא‬
Physiology