GERIATRICS.palliative care

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GERIATRICS : AN INTRODUCTION :

GERIATRICS : AN INTRODUCTION DR.PANKAJ ANAND( M.D.) CONSULTANT FORTIS ESCORTS HOSPITAL,JAIPUR

Slide 2:

“To know how to grow old is the master-work of wisdom, and one of the most difficult chapters in the great art of living.” Henri Amiel 1821-1881 (from Journal In time , Sept 21, 1874)

Aging population:

Aging population ¼ of the population of the developed world and 1/10 of the developing world is now above 60 In 25 yrs 25% of world population is expected to cross 60

Distribution of Elderly Population by Age Groups(World):

Distribution of Elderly Population by Age Groups(World)

Current Drivers – Demographic - Aging:

Current Drivers – Demographic - Aging Source: U.S. Census Bureau

DEMOGRAPHIC TRANSITION IN INDIA:

DEMOGRAPHIC TRANSITION IN INDIA AGE 1971 1981 1991 2001 < 14Yrs. 41.2% 39.6 % 37.5 % 34.3% 15-59Yrs 52.0 % 54 % 55.5 % 58.7% >60 Yrs. 6.0 % 6.4 % 6.7 % 8.1%

Geriatric population-INDIA:

Geriatric population-INDIA 1951- 5.3% 1981- 6.4% 2001- 8.1% 2025 ( expected)-13.3% (1.2 billion ) 40% below poverty line 73% illiterate

Physiological Changes of Ageing:

Physiological Changes of Ageing A developmental process starting at conception A genetically determined process Environmental factors can accelerate ageing Diseases become more common while ageing

Ageing Skin:

Ageing Skin Epidermis thinner and fragile Dermis less elastic and flexible Hypodermis thinner and less padding UV light accelerates skin ageing Senile purpura

Ageing Eye:

Ageing Eye Ptosis Entropion Ectropion Dry eye Tearing Pterygium uneven cornea with light scattering Hyperopia (farsightedness) Smaller pupil requiring brighter light to read Slower dark adaptation Reduced contrast sensitivity

Ageing Ear:

Ageing Ear Reduced sweat glands with increased ear wax affecting hearing Cochlea degeneration causing high tone loss Tips to communicate with people with hearing impairment: Obtain attention Let the person see your face & mouth Well illuminated environment At about 1 meter away Reduce background noise Speak slowly

Ageing Kidney & Bladder:

Ageing Kidney & Bladder Reduced kidney ability to excrete water, waste products and drugs Less tolerate water depletion Loss of circadian rhythm with nocturia Smaller and less expansible bladder with frequency of urine Less contractable bladder with hesitancy Bigger prostate with fair urine stream Less able to suppress bladder contraction with urgency

Ageing Bones and Joints:

Ageing Bones and Joints Continual loss of bone mass from the 4 th decade Hormonal change with more bone resorption than formation Less Ca absorption Shorter and stoop Brittle with easy fracture New bone formation at the verge of joints Cartilage thinner

Ageing Brain & Nerves:

Ageing Brain & Nerves 30,000-50,000 neurons die each day with diminishing reserve IQ slowly decline after the age of 25 Reduced short term memory Decreased retrieval ability Interrupted and less deep sleep Reduced pain, touch, temperature, and vibration sensations Reduced postural control and balance

Ageing Heart & Vessels:

Ageing Heart & Vessels Heart becomes more rigid with decreased output Heart beat less responsive to stress Heart beat less variable with each breathing Irregular heart beat more common with ageing Systolic blood pressure increases with age Pulse pressure widened with hardened vessels Less efficient venous return prone to postural hypotension

Ageing Lungs:

Ageing Lungs Lungs become more rigid with early closure of small airways Less efficient blood gas exchange Chest wall becomes more rigid too Reduced Lung Volume and Vital Capacity Bronchial villi thinner and cough reflex less effective Reduced ability to cope with challenges like climbing stairs, running Reduced immunity prone to chest infection

Ageing Reproductive Organ:

Ageing Reproductive Organ Menopause with hormonal changes and symptoms Flushing, sweating, agitation, palpitation, insomnia Dry vaginal mucosa Less sperm count and viability Delayed ejaculation Decreased libido and climax

Ageing Digestive Organs:

Ageing Digestive Organs Saliva glands secret less with dry mouth Taste and smell senses decline Less heathy teeth affecting chewing/nutrition Stomach muscle weakened and less hungry Small intestine villi absorb less calcium, vitamin B12, folic acid Large intestine muscle weakened and secrets less mucus prone to constipation Less liver blood flow and function with fall in toxic substance/drug clearance Bile thicker with cholesterol prone to gallstones

Ageing Immunity:

Ageing Immunity Both cellular and humoral immunity decline prone to infection/reactivation of TB Less effective in detecting and destroying cancer cells Less response to infection with fever Autoimmune diseases increase with age

HOW ARE ELDERLY DIFFERENT:

HOW ARE ELDERLY DIFFERENT Multiple pathology Under reporting of illness Attitude of relatives Missing symptoms Masking by known diseases Difficult to obtain proper history Atypical presentation

Palliative medicine and care of the elderly :

Palliative medicine and care of the elderly therapeutic interventions that can preserve function and help patients maintain quality of life frank discussions on the usual course of illness recognition and management of caregiver stress management of physical and psychological symp­toms of both acute and chronic illnesses .

Stage of Chronic illness: Early:

Stage of Chronic illness: Early Discuss : diagnosis prognosis and course of disease disease modifying therapies goals of care, hopes, and expectations advance care planning Manage comorbidities Advise financial planning/consultation with a social worker for future needs including long-term care Inform patient and family about support groups inquire about desire for spiritual support Behavioural and pharmacologic symptom control Treat mood disorders

stage of Chronic illness:Middle:

stage of Chronic illness:Middle Assess efficacy of disease modifying therapy Review course of disease Reassess goals of care and expectations Confirm advance directives and ensure a health-care proxy is appointed Recommend PT/O'I therapies to preserve function and promote socialization Behavioral and pharmacologic symptom control Treat mood disorders Suggest support groups for patient and caregiver Offer social and emotional support to caregivers Review long-term care options and resource needs

Stage of Chronic illness: Late:

Stage of Chronic illness: Late Discuss, goals of care with patient and family Confirm previous advance directives Actively manage symptoms Review financial resources and needs Review long-term care needs and discuss option; Consider hospice referral/planning to ensure peaceful death Assess spiritual needs

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Common sources of suffering and discomfort in the elderly

Pain:

Pain studies show that pain is under-treated in the elderly In acute pain, treating the cause is often the best way to relieve pain. However, the patient should be given analgesic pain relief to provide comfort in addition to treating the underlying cause. Patients suffering from moderate to severe acute pain should be started on opioids; they do not need to go through the WHO ladder in stepwise faction.

Analgesic prescribing in the elderly:

Analgesic prescribing in the elderly Acetaminophen/paracetamol is the first-line treatment for chronic pain in the elderly due to its safety profile. NSAIDs are also indicated for mild pain and may be more effective than acetaminophen/ paracetamol but need monitoring. newer COX-2 inhibitors are safer. Mild musculoskeletal and neuropathic pain can also be treated with capsaicin cream.

Analgesic prescribing in the elderly:

Analgesic prescribing in the elderly Morphine, oxycodone, and hydrocodone are the most commonly used opioids for severe pain in the elderly. Fentanyl transdermal patch: for patients who cannot tolerate oral therapy. Antidepressants, anticonvulsants, and glucocorticoids :adjuvant therapy for neuropathic pain. Carbamezapine, valproate, and gabapentin also are effective for neuropathic pain

Nausea and vomiting:

Nausea and vomiting Common causes of nausea and vomiting in the elderly are drug reactions, reaction to opioids, benign positional vertigo, gastroparesis due to diabetes, constipation.

Nausea and vomiting:

Nausea and vomiting Treatment depends on the cause Nausea from opioids is usually dopamine mediated. Haloperidol is a highly effective antiemetic Serotonin antagonists such as ondansetron and granisetron are used in chemotherapy related nausea. Patients with a conditioned nausea and vomiting response may benefit from taking benzodiazepines prior to the noxious stimulus. gastroparesis due to diabetes, phenothiazines or antihistamines .

Constipation:Etiology:

Constipation:Etiology Lesions of gut:dysmotility,tumour Neurological:paraplegia,MS,parkinson’s dz. Metabolic:hypercalcemia,porphyria Drugs inc.Laxative abusive Endocrine:Hypothyroidism Psychiatric :Depression Mech.Compression: Malignancy

Constipation:Diagnosis:

Constipation:Diagnosis History Physical Examination Routine blood, urine and stool tests Scopy:sigmoid,Colon Barium

Constipation:Management:

Constipation:Management Normal Frequency:3/day to 1/3 days Diet and lifestyle Treat the cause Oral laxative : Bulk forming:psyllium,Methylcellulose,bran Stimulants:Habit forming Stool softeners Lubricants Osmotics

Slide 34:

Initial constipation prophy­laxis is a stool softener three times a day plus a mild stimulant like senna. If this does not control symptoms, then bisacodyl (suppositories or oral) can be added. The next step is addition of osmotic agents such as sorbitol or polyethylene glycol. Sodium phosphate enemas are very effective The last step in relieving constipation is giving high colonic tap water enemas. High colonic enemas are given by warming 2 L. of saline or water to body temperature, hanging the bags at the ceiling level, and infusing rectally over 1 h.

Diarrhoea:

Diarrhoea Diarrhoea : predisposes to dehydration and electrolyte disturbance. common causes : leakage around a faecal impaction antibiotics, Clostridium difficile enterocolitis, gastrointestinal bleeding, malabsorption, medications, stress.

Diarrhoea:

Diarrhoea After reversible causes of diarrhoea are excluded, patients can be treated symptomatically. In patients who are mobile and drink enough fluids, bulk agents/fibres may be ideal agents to control diarrhoea. If this is not efficacious, then loperamide, kaolinpectin, or tincture of opium may control symptoms. Octreotide is effective to reduce gastrointestinal secretions and fistulae but is expensive.

Cough :

Cough Chronic persistent cough frequently occurs in malignancies and is particularly common in pulmonary neoplasms. Non-malignant causes of chronic cough in the elderly include oesophageal reflux disease, COPD, heart failure, post-nasal drip. medications such as ACE inhibitors.

Cough:

Cough Treatment depends upon the cause. Cough secondary to extension of bronchial cancer may improve with steroids and palliative radiotherapy. malignancy and post-obstructive pneumonia cough may improve with antibiotics. antihistamines, antitussives, expectorants, and decongestants are recommended as first-line therapy, but there is no convincing evidence that they are effective.

Cough:

Cough Patients with dry cough may be given a trial of demulcents and local anaesthetics to soothe the throat. Opioids at low doses are also helpful Terminal patients, with weak or absent cough reflex, cannot effectively clear their airways and frequently develop 'death rattle' Anticholinergics such as scopolamine, hycosine hydrobromide, atropine, and glycopyrrolate reduce secretions in terminal patients with death rattle.

Dyspnoea:

Dyspnoea subjective symptom patients can experience shortness of breath even if pulse oximetry and respiratory rate are normal. 70 per cent of cancer patients and 50-70 per cent of non-cancer patients experience dyspnoea in the last 6 weeks of life.

Dyspnoea:

Dyspnoea Management of dyspnoea requires identification of cause, treatment of reversible causes, and therapy to relieve the symptom. Diuretics, bronchodilators, and antibiotics relieve shortness of breath due to congestive heart failure, asthma/COPD, and pneumonia, respectively. They may also be useful as a temporizing measure in patients with a pulmonary malignancy causing bronchospasm or obstructive pneumonia.

Dyspnoea:

Dyspnoea Oxygen therapy relieves symptoms, improves exercise tolerance, and is the only therapy proven to prolong life in patients with COPD. Opioids are highly effective in reducing symptoms of dyspnoea. Often, patients require lower doses than those needed to treat pain. Opioids, steroids, oxygen, and bronchodilators usually are used together and have synergistic effect.

Slide 43:

Said the little boy ‘some times I drop my spoon’ Said the little old man ‘’ I do that too’ The little boy whispered ‘I wet my pants’ ‘I do that too’ laughed the old man ‘I often cry’ said the boy. The old man nodded, ‘ so do I’ ‘ but worst of all , said the little boy , the grownups don’t pay attention to me’ And then he felt the warmth of the wrinkled old hand. ‘ I know , what you mean’ [A light in the Attic- Shel Silverstein]

Slide 44:

THANK YOU

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