ELDERLYELDERLY and and DISABILITYDISABILITY

Sharon Gondodiputro dr., MARS.,MHDept. Of Public Health Faculty of

MedicineUnpad

Fact Sheets !!!! About Fact Sheets !!!! About ElderlyElderly

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 The number of older people who are no are no

longer able to look after themselves longer able to look after themselves in in developing countries is forecast to developing countries is forecast to quadruple by 2050. quadruple by 2050.

Many require long-term care, including Many require long-term care, including home-based home-based nursing, community, nursing, community, residential and hospital-based care. 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 We need to reinvent our assumptions of old reinvent our assumptions of old ageage

Society needs to break stereotypes and Society needs to break stereotypes and develop new models of ageing for the 21st develop new models of ageing for the 21st century. Everyone benefits from century. Everyone benefits from communities, workplaces and societies that communities, workplaces and societies that encourage active and visible participation of encourage active and visible participation of older peopleolder 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 :Is influenced by :– genetic factor, genetic factor, – diet, diet, – environment and environment and – personal habitspersonal 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

Accomodation⇑Suspectibility to glareDifficulty discriminating words if background noise is present

BlindnessDeafness

Respiratory

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 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 dysfunctionSerum Na, ⇑ Serum KImpotenceOsteomalacia,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 contractionCardiac 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

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

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

Parkinson’s disease

Falls

Sleep 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, televisionDraw 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 ScoreScore

Memory

11 I want you to remember this number. Can you repeat after me (4517). I shall test you again in 15 min.

11

22 How old are you? 11

33 When is your birthday? OR in what year were you born?

11

Orientation and information

4 What is the year? 11

55 date? 11

66 day? 11

77 month? 11

88 What is this place called? Hospital/Clinic 11

99 What is his/her job? 11

Memory Recall

10 Can you recall the number again? 11

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