Human Behavior--Late Adulthood/death/dying Flashcards
gerontology
the study of social, biological and psychological aspects of aging
geriatrics
clinical physical issues related to aging
geriatric psychiatry
mental health and aging
- differentiating changes of normal aging from symptoms of psychiatric disorders
- modifiability of illness in late-life
- distinguishing between changing in early-onset psychiatric disorders who have now aged and disorders that began in late life (depressed early in life and depressed later in live vs. just depressed later in life)
- Modifiability of normal aging to improve (mental health) functioning
Geriatric psychiatry is divided in to two groups:
- young-old = 65-90
2. old-old = 90 and beyond
About how many people are aged 65+ right now?
about 40 million
About ________ of population will be older adults in 2050. _____ of the population is older adults now.
- 25%
- about 12-14%
The projected amount of 85+ demographic is ______ in 2050 which is the ______ growing age demographic. Why?
- 20 million
- fastest
Intellectual performance peaks in ________, plateaus until ______ and declines rapidly in ______.
- 30s
- early 60s
- late 70s
Fluid intelligence ______ starting in the mid-60s.
decreases
What is fluid intelligence?
- one’s ability to think and react quickly
- mental flexibility and speed of information processing
- learn new information
Crystallized intelligence is ____ in old age.
stable
What is crystallized intelligence?
knowledge or experience accumulated over time and verbal skills
What are the 4 normal cognitive changes of late adults?
- remote memory preserved (recent memories will take longer to recall)
- simple focused attention is preserved (divided attention is more challenging)
- verbal abilities are preserved (word retrieval is more difficult)
- reasoning and problem solving is maintained by using strategies developed in middle adulthood; new problems, however, can be challenging
What is the key to interacting with an older adult?
BE PATIENT!
What is the Erikson’s stage of life that corresponds with late adulthood?
Integrity vs. Despair
[Virtue = Wisdom]
There are more older _______ [M/F] than _______ [M/F].
- females
- males
Wisconsin has _______ of the population as 65+ years old.
12.6-12.9
There is no flow of funds for the geriatric community, therefore we must encourage _______ aged people to be healthy so they can take care of the baby boomers.
0-17
What is the projected population of Wisconsin in 2030?
1.36 million (about 3x as in 2000)
____ percent of Wisconsin’s 65+ population is aged 90+.
5% or more
For every 100 women, there are ___ men who are 65-69 years old. This trend ______ with age so that by the 100s, there are about _____ men for every 100 women.
- 87
- declines
- 24
Whites make up _____ of population now, but projected to be only _____ of population in 2050.
- 80.5%
- 60%
The African American population is ________ in percentage of the US population. This is because _______ is being adequately managed.
- increasing
- longevity
The Hispanic population is expected to _____ in percentage of the population in 2050. The rate at which their population is growing is ______.
- double
- very fast
In the 90+ demographic, there are about _____ widowed men and _____ married men, whereas there are about ____ widowed women and _____ married women.
- 49%
- 43%
- 84%
- 6%
The ______ population is growing. This demographic’s needs are very different depending of the person.
centenarian
In terms of cognitive changes, there is a decline in _____ and ______ for older adults.
- ADLs
- IADLs (interactive actions of daily living)
The brain weight ____ with age by _____ by age 80. Cerebral blood flow _____ by _____ percent. Ventricles and sulci ______.
- decreases
- 17%
- decreases
- 20%
- enlarge
Most neuronal cell loss is in the ____ and ______ of the brain, whereas the _______ [3 structures] do not have cell loss.
- hippocampus
- frontal lobes
- hypothalamus, cerebellum, brain stem
_____ decreases in white matter of the brain in older adults. The greatest sensory loss is in ______ and _____.
- myelin
- vision
- hearing
Neurogenesis occurs predominantly in _____ and _____ (hippocampal structure).
- subventricular zone
- subgranular zone
______ and _____ promotes neurogenesis.
- Physical activity
- exercise
_______ suppresses cell proliferation.
chronic stress
People become less intelligent as they grow older. True/False.
FALSE!!
In older adults, _____ memory is preserved while ____ memory takes longer to recall.
- remote
- recent
In older adults ______ attention is preserved whereas ______ attention is more challenging.
- simple focused
- divided
In older adults’ language, ______ are preserved whereas ______ is more difficult.
- verbal abilities
- word retieval
Executive functioning, reasoning and problem solving are ____. These were developed during ______.
- maintained
- middle adulthood
Why must you be patient with older adults faced with a new challenge?
new problems are more challenging in older adulthood
A rapid decline in cognition, especially in recent memory is a hallmark of ________.
Alzheimer’s
The _____ stage of Alzheimer’s is mild cognitive impairment.
prodromal
The biggest characteristic that differentiates normal, mild cognitive impairment (MCI) and Alzheimer’s is the loss of _______. MCI patients may have trouble with _____, but they can still do them, whereas Alzheimer’s patients cannot.
- ADLs [FUNCTIONING]
- IADLs
Currently there are ____ million people with Alzheimer’s disease and if there is no improvement, there will be ____ million 2050.
- 5.3
- 13.5
Many causes of death are declining, but Alzheimer’s has shown a ______.
growth of 66%
Suppose an 80yo is scanned. They are found to have amyloid plaques–a hallmark of Alzheimer’s. Does this patient have Alzheimer’s disease?
not necessarily because some amyloid plaques are normal; must look at clinical symptoms
In aging adults, generalized global atrophy starts at the _____ and goes to the ______, resulting in ____ and ____.
- hippocampus
- frontal lobe
- memory loss
- aphasia
In a PET scan looking for amyloid plaques, a normal brain appears ____ whereas an AD brain appears _____.
- darker
- to light up
More and more older adults are entering the _______. About _____ percent of older americans are in the {same first word} now.
- workforce
12. 2%
You see an old man from a distance. You assume is grumpy and crazy, but he is not. _________ doesn’t become pathological.
personality
Define Integrity (Erikson) [4]
- sense of satisfaction that life has been productive and worthwhile
- acceptance of self
- ability to accept and face death
- active participation in the process of losing independence
Define Despair (Erikson) [4]
- loss of hope and a sense that life has no purpose/meaning
- misanthropic and contemptuous
- belief that they have not contributed to anything
- fear of death
______ are more stubborn in the aging population.
Men
If an old person is reminiscing and you are getting so bored you want to pull your hair out, what should you do?
LISTEN!! at least for a little bit; they like to talk about the past
What is bereavement?
a fact of life; the state of being sad becomes someone close to you has died (grief)
About ______ people die in the US annually and there are about ______ bereaved people for each death. This means about _______ of our population are bereaving annually.
- 2.5 million
- 4
- 3%
About _____ have acute grief (normal), whereas ______ have complications, including major depression (15-30%), PTSD and complicated grief (10-20%)
- 70%
- 30%
What are the 5 stages of grief?
- denial
- anger
- bargaining
- depression
- acceptance
What are some physical symptoms of grief?
headaches, muscle aches/pains, more frequent colds, panic, feeling “stuck”
About _____ of grief may trigger ______.
10-20%
clinical depression
Significant functional impairment of grief lasts ____
less than 2 months
_______ [ethnicity] males, age 85+ complete suicide nearly ____ times the general population.
- white
- six
_____ have a 2-fold risk of developing dementia when they are depressed.
women
Delayed discharges when a patient is depressed _____ healthcare costs.
increase
In older adults that are married, who is usually their primary caregivers?
their spouses (who are also older adults)
What are late life depression consequences?
-premature deaths from co-morbidities, increased CVD, diabetes, Alzheimer’s, poorer quality of life, etc.
To treat later life depression, you can prescribe _______, ______ and/or ______. Roughly _____ will get better with treatment.
- antidepressants
- psychotherapy
- electroconvulsive therapy
- 60%
Alzheimer’s is ______ reversible, but cognitive impairment can be _____ in at-risk individuals, and even _____ if treated with antidepressants.
- not
- delayed
- reversed slightly
Is amyloid plaque clearance sufficient in treating Alzheimer’s?
NO! clearance must happen BEFORE pathology
What are some general challenges facing the elderly? (5)
- ageism
- barriers for care (patient related, provider relate)
- socioeconomics
- living situation
- elder abuse and neglect
_____ of 65-75yo describe themselves as in good health. _______ of those above 75yo.
- 75%
- 66%
Define countertransference.
physician’s feelings towards older persons: fear of their own old age; conflicts about aging/death of parents/grandparents; lack of awareness of own feelings
Because symptoms of countertransference overlap with those from common medical illnesses, only _____ of geriatric depression in primary care is accurately diagnosed.
25-50%
What are 4 things you look for when trying to differentiate depression in the elderly versus countertransference?
- physical appearance
- physical health
- emotional state
- living conditions
For men and women 65+yo, the National Institute on Alcohol Abuse considers ______ to be the maximum amount for “moderate” alcohol use. This is because of the elderly’s ______.
- 1 drink per day
- lean body mass
In 2010 in 65+yo, roughly ____ were below the poverty level with ____ being white, ____ african americans, _____ asians and _____ hispanics.
- 9%
- 6.6%
- 19.5%
- 15.8%
- 18.3%
Older ___ had a higher poverty rate than older _____.
- women
- men
The income of older adults is composed of _____ social security, _____ retirement. (+ other income)
- about 50%
- 18.3%
Different age groups have _____ abilities in terms of _______. ______ is the most differentiating ability [separated into (a) 65-74 (b) 75-84, (c) 85+]
- different
- ADL
- walking
______ is one of the largest killers over 65yo, but the rate is _____ overall. _______ and _____ affect 65+yo the most in terms of chronic conditions.
- heart disease (26-30%)
- hypertension (52-54%)
- arthritis (43-53%)
Most of the elderly live _______ (up to 89yo), but _____ are most likely to live alone in a household (up to 100+)
- with others in the household
- women
Most adults ______ or older are institutionalized do to their disabilities.
90 years old
What are the 6 types of elder abuse? What is the most common type? Second most common? Third?
- physical = 2nd most common
- sexual
- emotional
- financial = 3rd most common
- exploitation/victimization
- neglect/abandonment = MOST common
The prevalence of elder abuse is ______ and it affects more ______ than ______.
1-12%
women
men
The majority of elder abuse occurs ________ and the majority of perpetrators are ________.
- in home setting
- family members (usually a spouse or adult child)
What are some risk factors for elder abuse?
older than 75; female; unmarried/widowed/divorced; lack of access to resources; low income; social isolation; minority status’ low level education; functional debility/taking multiple meds; substance abuse by caregiver/elder person; psychiatric disorders/character pathology; previous history of family violence; caregiver burnout/frustration; cognitive impairment (mod. cog. impairment/dementia); fear of change of living situation
What are 3 things that lead to successful aging?
- low risk of disease/disability due to disease
- high mental/physical functions
- active engagement with life
What factors contribute to wisdom? What does wisdom contribute to?
- extensive practical knowledge, overcome more adversities in life, emotional maturity, education, etc.
- physical/social functioning
What are the 7 neurobiologic factors of wisdom?
- prosocial attitudes
- pragmatic decision-making (future gratification)
- moral decision-making
- emotional regulation
- self reflection
- value relativism (consider other’s points of view)
- tolerance of ambiguity
The prevalence of alcoholism and drug dependence in the elderly is _____.
4-8%
Integrity
- Sense of contentment
- Acceptance for who you are
- Contemplate life’s major endeavors
- Active participation in the process of losing
Despair
- Misanthropic and contemptuous
- Sense that life is meaningless
- Sense they haven’t contributed, fear death
What are 3 physician barriers to discussing death and dying?
- Death is something to be avoided rather than natural
- Death is a failure of medical care
- Death of a pt reflects negatively on the doctor
What are 5 characteristics of the American view of a “good death”
- Not burdening others
- Involved in decision making
- Dying isn’t prolonged
- Pain/symptoms controlled
- Strengthening relationships
Advanced directives are ________________.
Legally binding
What are 3 types of advanced directive?
- Living will
- Health care proxy
- DNR
In the case there is not advanced directive who often intervenes?
Hospital ethics committees
What is the default pathway?
People end up in a nursing home.
What is the AMAs view on euthanasia
A criminal act and never appropriate
Is providing medically needed analgesia, to a terminally ill patient ethical if it shortens their life? Why?
Yes. The intention is to relieve their pain, not shorten their life.
In what state is euthanasia legal?
Oregon
What did the NEJM study on legalizing euthanasia in Oregon show?
- Physicians became more involved in end of life care - better care
- There was no flood of people to Oregon to die
- Those requested stated a need for control and independence
- 36% of those who filled prescriptions did not use it
How long must you reside in Oregon before you can qualify for euthanasia?
6 months
Palliative care is ________________
Not hospice care!
What does palliative care do?
- Provides relief from suffering
- Comfort measures from symptoms - pain, tremors, nausea
- Figures out what the patients goals are
Palliative care should exist with ______________________.
Life prolonging interventions
What does hospice care do?
- Comfort and supports persons at the end of life
- Emphasize quality over life prolonging goals
- Treats patients, focus on care, team approach
- Addresses medical, social, emotional, and spiritual needs
- Neither hastens not postpones death
- Regards dying as normal
__________ is the primary goal of hospice care.
Comfort - provide physical, social, emotional and spiritual support.
What are the criteria for hospice admission?
- Recommendation of physician
- Life expectancy of 6 months or less
- No longer seeking cure
What are some common indications that a person is dying? (5)
- Very tired, increased sleep
- Refuse food/drink
- Pulse inc, bp goes down, kidneys release renin
- Changes in cognition, memory, orientation
- Last hoorah is common
What changes in social interactions can a dying person experience? (5)
- Core group of loved ones
- Don’t care about previous interests
- Complete any old business
- Express gratitude and love
- Ask/grant forgiveness
What are psychological changes a dying person might experience? (5)
- Make peace with higher power.
- Permission to leave family
- Need to know family will take care of each other
- Increased confusion/restless
- See vision of dead loved one
What are 4 characteristics a dying person in their final hours?
- Unresponsive
- Bluish discoloration and cold hands/feet
- Decrease or increase in breathing
- Death rattle
What causes the “death rattle”
Pharyngeal secretions
Why will a dying person have bluish discoloration of their hands and feet?
Blood diverted to major organs
Grief
a subjective feeling of loss - known etiology, relatively predictable - reaction to major loss
Mourning
Process of resolving grief
Bereavement
State of mourning
What is the attachment theory?
Because of our ability to make attachments, the loss of a loved one is painful
What can grief be confused with?
Depression
What is Phase 1 of grief and how long does it last?
Shock/Denial: 2-3 months
What is Phase 2 of grief and how long does it last
Intense concern/Preoccupation w/ deceased : 6 months to a year
What is Phase 3 of grief?
Resolution - recovery, reorganize, accommodate
Complicated Grief
Get “stuck” in grief - Trouble accepting loss
What are people with complicated grief at higher risk for? (6)
- Depression
- Anxiety disorders
- Substance abuse
- Cardiac problems
- Poor self care
- Increased suicide/accidents
What are 2 characteristics of a good death?
- Free from avoidable distress and suffering for patients, families and caregivers
- Consistant with cultural and ethical standards
Thanatology
Study of death and dying
What are Dr. Kubler-Ross stages of dying
- Denial - disbelief
- Anger - blame others
- Bargaining
- Depression
- Acceptance
Do the stages of dying go in any particular order?
No
Where do most americans want to die?
Home: 60-70%
Hospital: 20-40%
Where do most people die?
Hospital: 50%
Nursing home: 30%
Home: 20%
Context of death: expectation (2)
Timely vs. untimely
Context of death: circumstances (3)
- Intentional - suicide
- Unintentional - trauma
- Subintentional - substance abuse
When did Oregon pass their “Death with Dignity” law
2004
Dying people meed less pain medication when the are not _____________.
Forced fluids
Using humor to combat grief is __________.
Normal
What are the benefits of humor/laughter
- Stimulates endorphins
- Stimulates secretion of protective enzymes in stomach
- Increases blood flow to brain
- Strengthens immune system
- Ab workout
How long does normal grief last
Up 12-24 months - usually less
What are symptoms of grief? (7)
- Somatic
- Sleep/appetite disturbances
- Impaired cognition - absent mindedness
- Social withdrawal/disinterest
- Auditory/visual hallucinations
- Questioning spiritual/religious beliefs
- Relief, numbness, helplessness, sadness, guilt
Grief is _____________.
Multifaceted - social, cognitive, etc.
Despair/depression w/ guilt includes
Anger, guilt, sadness, anxiety - can occur with grief
What things occur with Phase 2 of grief?
Anger, sadness, guilt, anhedonia, insomnia, thoughts of the dead, dreams
What occurs during Phase 3 of grief?
Can think about past with pleaure
What are risk factors of complicated grief?
- Men
- Prior depression
- Sibling deaths
Most people are willing/unwilling to discuss end of life care?
Willing - waiting for doctors to bring it up - doctors are waiting for patients
Where is hospice care is best delivered?
In the home
What commonly occurs in the final hours of human life?
Loss of swallow and cough reflexes - Cough (CN IX) and Tickle (CNX)
Geriatricians _______ rather than ______ chronic illness.
manage; cure
________ are more likely than chronic illness to cause loss of mobility leading to disability. Management of _________ is imperative.
- fractures from falls
- osteoporosis
Describe how you prevent osteoporosis:
- increase weight bearing exercise
- increase calcium/vitamin D
- meds that decrease bone resorption (blocks osteoclasts or stimulating osteoblasts)
_______ is a medication that blocks osteoclasts whereas _____ is a medication that stimulates osteoblasts.
ALENDRONATE SODIUM (Fosamax) TERIPARATIDE (Forteo)
There is a decreased availability of NTs such as ________, increased availability of ____ [enzyme] and decreased responsiveness of ______.
- norepinephrine, dopamine, GABA and ACh
- monoamine oxidase
- NT receptors
Changes in NT availability are related to which psychiatric symptoms?
depression/anxiety
There is a _____ of sleep in the elderly, ______ sleep quality or both (normal).
loss; poor
You must be careful when prescribing _______ because they produce different effects in elderly than in younger patients. For example, antihistamines (diphenhydramine) as sleep agents can cause ______ in elderly patients.
- psychoactive agents
- delirium
When symptoms of grief return on holidays or special occasions, these are called ______.
anniversary reactions
The mortality is high for close relatives, especially _____ in the 1st year of bereavement.
widowed men
When dealing with a dying patient, what does the doctor want to avoid?
completely detaching emotionally from the patient because this could least to subpar care
