ELDERLY and DISABILITY

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ELDERLY and DISABILITY
Sharon Gondodiputro dr., MARS.,MH Dept. Of
Public Health Faculty of Medicine Unpad
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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.

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• 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

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• 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.

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• 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.

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• 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.

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• 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

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• 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.

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• 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.

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• 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 systems
  homeostatic reserve (homeostenosis)
• Begins in the third decade, progressive, but
  varies in speed for each individual
• Pra lansia 49 -59 tahun
• Lansia gt 60 tahun

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• Is influenced by
• genetic factor,
• diet,
• environment and
• personal habits

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Several principles from this concept

• Individuals become more dissimilar as they age,
  rejecting any stereotype of aging
• Abrupt decline in any system/function ..gt 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.

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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 Obesity Anorexia
Eyes and ears Presbyopia Lens opacification ? High frequency acuity Accomodation ?Suspectibility to glare Difficulty discriminating words if background noise is present Blindness Deafness
Respiratory Lung elasticity ?Chest wall stiffness Ventilation perfusion mismatch ? O2 saturation Dyspnea, hypoxia
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ORGAN OR SYSTEM AGE RELATED PHYSIOLOGIC CHANGE CONSEQUENCES OF AGE RELATED PHYSIOLOGIC CHANGE CONSEQUENCES OF DISEASE, NOT AGE
Endocrine Impaired glucose homeostatis 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 dysfunction Serum Na, ? Serum K Impotence Osteomalacia,fractures
Cardiovascular Arterial compliance and ?Systolic BP (LVH) Beta adrenegic responsiveness, baroreceptor sensitivity and SA node automaticity Hypotensive response to ? HR, volume depletion or loss of a trial contraction Cardiac output and HR response to stress Impaired blood pressure to standing, volume depletion Syncope Heart failure Heart block
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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 Anemia False negative PPD response False positive rheumatoid factor, antinuclear antibody Auto immune disease
Renal GFR ? urine concentration-dilution Impaired excretion of some drugs Delayed response to salt or fluid restriction or overload, nocturia ? Serum creatinine, renal failure ? Or ? serum Na
Genitourinary Vaginal or urethral mucosal atrophy Bladder contractility Prostate enlargement Dyspareunia, Bacteriuria ? Residual urine volume BPH Symptomatic UTI Urinary incontinence, urinary retention, Prostate cancer
Musculoscletal ? Lean body mass and muscle , bone density Strength Osteopenia Functional impairment Hip,vertebral fractures
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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 stomach Constipation, Fecal incontinence Cirrhosis Osteoporosis B12 def Fecal impaction
Nervous system Brain atrophy ? Brain carechol synthesis , brain dopaminergic synthesis, righting reflexes, stage 4 sleep. Benign senescent forgetfulness Stiffer gait ?Body sway Early awakening, insomnia Dementia Delirium Depression Parkinsons disease Falls Sleep apnea
THE FRAIL ELDERLY
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THE FRAIL ELDERLY

• Syndrome that results from a multisystem
  reduction in reserve capacity
• Increased risk of disability and death from minor
  external stresses ..gt extraordinarily thin
  tightrope in an attempt to balance physiologic
  function

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FIVE CLASSIC GERIATRIC PROBLEMS

• FALLS
• DEMENTIA
• DEPRESSION
• URINARY CONTINENCE
• IRRATIONAL DRUG THERAPY (POLYPHARMACY)

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APPROACH TO THE PATIENT

• Priorities in elderly are likely to differ from
  those of younger people gt Quality of life
• Caregiver issues requires attention as well as
  the patient, since the health and well being of
  the two are closely linked.

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COMPREHENSIVE GERIATRIC ASSESSMENT

1. Physical assessment
2. Mental status assessment
3. Functional assessment
4. Social assessment
5. Home environment assessment

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Physical Assessment

• History taking
• Auto/Allo anamnesis
• visual impairment
• hearing loss
• Falls
• Incontinence
• drug ingestion
• dietary patterns
• sexual dysfunction
• depression and anxiety

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Interviewing older patients and their family
members

• Be prepared to spend more time with older
  patients and more slowly
• Always address the patient first
• Involve caregivers and family members early in
  the patients care
• Recognize the emotional concerns underlying any
  explicit requests
• Do not make significant changes in a treatment
  plan based solely on the familys report without
  evaluating the elderly patient directly

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• 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

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• 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 0300
• Folsteins Mini Mental Status Examination (MMSE)
• Elderly Cognitive Assessment Questionnaire (ECAQ)

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Geriatric Depression scale
A score gt 5 points is suggestive of depression. A
score gt 10 points is almost always indicative of
depression. A score gt 5 points should warrant a
follow-up comprehensive assessment.
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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)
gt7 Normal
5-6 borderline
0-4 Probable case of cognitive inpairment
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• 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

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• Functional assessment
• Information about function can be used in a
  number of ways
• As baseline information
• As a measure of the patientss need for support
  services or placement
• As an indicator of possible caregiver stress
• As a potential marker of spesific disease
  activity
• To determine the need for the therapeutic
  interventions

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• Measurement
• Activities of daily living (Katz)

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• Social and economic assessment
• Evaluates the patients perception of his own
  health status, his environment, his family
  situation, financial status and leisure
  activities

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• Home environment assessment
• The main objectives
• To understand the home environment of the elderly
  and home hazards
• To see the interaction between the elderlys
  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

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• 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.

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Polypharmacy
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