Late Adulthood/Death and 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 changes in early-onset psychiatric disorders who have now aged, and disorders that began in later life
- Modifiability of normal aging to improve functioning
Two groups of Geriatric Psychiatry
- Young-old (65-90)
2. Old-old (90 and beyond)
Fastest growing segment of US population
85 and older
- Projected 10 million by 2025
- Projected 20 million by 2050
Why is there an increase in the older population?
Baby boom
States with highest percentage of 65 and older population
North Dakota South Dakota Iowa Arkansas Florida West Virginia Pennsylvania Maine Connecticut Rhode Island
Projected population growth in Wisconsin (65 and older)
2000: .70 million
2030: 1.36 million
Ratio of men to women in 65 and over population
More women than men
- Ratio favors women as we age
Which racial group is the fastest growing in the 65+ population
Hispanic (White 65+ population is decreasing)
Marital Status of 90+ (Males vs Females)
Males: 42.9% Married; 49.3% Widowed
Females: 6.3% Married; 84.2% Widowed
Centenarians: Proportion of total population
Increasing between 1980 and 2000s
Centenarians (Male/Female ratio)
Percent males decreases as approaching 100 years old
Percent females increases as approaching 100 years old
Cognitive Changes of aging
1) Intellectual performance (peak in 30s, plateau through 60s, rapid decline in 70s)
2) Decrease in fine touch sensation
3) Decline in ability to rise from chair and preform ADLs
4) Mild Neuronal cell loss, blood flow decreases
5) Myelin decreases in white matter
6) Sensory losses (all senses)
7) Random cell loss except in hypothalamus, hippocampus, cerebellum, brainstem, and frontal lobes
Neurogenesis
1) Birth of new neurons (from neural stem cells)
2) New cells compete with old cells (losers die)
3) Occurs throughout life
4) Chronic Stress suppresses cell proliferation
5) Physical activity and exercise promote
Neurogenesis occurs in predominately what two regions of the brain?
Subventricular zone lining lateral ventricles
Subgranular zone - part of dentate gyrus of hippocampus
(May even occur in neocortex and cerebellum)
Fluid Intelligence
Decreases
- One’s ability to think and react quickly
- Mental flexibility and speed of information processing
- Learn new information
Crystallized Intelligence
Stable
- Knowledge or experience accumulated over time and verbal skills
Cognitive changes in Normal Aging
- Memory: Remote memory preserved; recent memory takes longer
- Attention: Simple focused attention is preserved; divided attention is more challenging
- Language: Verbal abilities preserved; word retrieval more difficult
- Executive function, Reasoning and Problem Solving: Maintained - use strategies developed in middle adulthood
Projected number of AD cases in Individuals above age 65
Currently: 5.3 million
By 2050: 13.5 million
What disease has had the highest percentage change in causes of death
Alzheimer’s Disease
What increases in the brain with Alzheimer’s
Neurofibrillary tangles and Amyloid plaques
First two structures to atrophy in Alzheimer’s
Hippocampus, then Frontal lobe
Erik Erikson Stage 8
Integrity vs. Despair
1) Integrity is a sense of satisfaction that life has been productive and worthwile
2) Despair is a loss of hope and a sense that life has no purpose or meaning
Common Life Changes in Aging
- Retirement
- Physical Changes: senses
- Health
- Mobility
- Memory
- Death of spouse, other family, and friends
- Home and personal possessions
- Income
Older Adult Responses to Loss or Changes
Denial Guilt Loneliness Overly-Critical Rigidity Stubbornness Selective Memory Anger Reminiscence Depression/Anxiety
How many people die in the US annually
2.5 million (60 million worldwide)
Bereavement
4 Bereaved people for each death
10 million bereaved people in US (3% pop.)
Complications to Bereavement (30%)
- 1-2 million individuals yearly
Major Depression (15-30%) PTSD (based on circumstances of death) Complicated Grief (10-20%)
Stages of Grief
1) Denial
2) Anger
3) Bargaining
4) Depression
5) Acceptance
Prevalence of Depression in the elderly (Most to Least)
Nursing Home Residents > Primary Care Outpatients > Community Residents
Percent of Older adults > 60 who suffer from significant depressive symptoms
20%
Suicide Rates
Increase as we age
White males 85+ complete suicide nearly 6x the general population
Late Life Depression: Consequences
- Premature Deaths from co-morbid cardiovascular and cerebrovascular diseases
- Increases the risk of Dabetes, Cardiovascular disease and Alzheimer’s disease
- Increased healthcare costs and utilization of resources
- Increased suffering, functional impairment and poorer quality of life
- Increased caregiver burden
Modifiability of Illness in Later Life
1) Depression in the elderly respond robustly to antidepressants and psychotherapy
2) Alzheimer’s: Not much can be done
Challenges Facing the Elderly
Ageism Barriers for Care Socioeconomics Living Situation Elder Abuse and Neglect
Ageism
Discrimination towards older people including negative stereotypes held by younger adults
Maximum amount for moderate alcohol use in 65+
one drink/day
Alcoholism and drug dependences
4% and 8% (Likely 10 to 15 percent)
65+: Poverty
Roughly 9% Below poverty level
Older women had higher poverty rate than older men
65+: Employment
17.2% older Americans were in the workforce
65+: Education
High school or higher: 78.3%
Bachelor’s degree or higher: 21%
Highest income source for population aged 90 and over
Social Security (47.9%)
65+: Percentage living with spouse
Men: 72%
Women: 42%
Top Source of Health Insurance for persons 65+
Government: Medicare
Limitations in ADL (Activities of Daily Living)
Highest for those 85+ (mostly due to walking limitations)
65+: Chronic Health conditions
Women > Men
Types of Elder Abuse
Physical Abuse Sexual Abuse Emotional Abuse Financial Exploitation Victimization Undue Influence Neglect/Abandonment Self-Neglect
Top three most common types of elder abuse
1) Neglect - depriving an elder of something needed for daily living
2) Physical Abuse
3) Financial exploitation
Successful Aging
Low Risk of Disease and disability due to disease
High mental and physical functioning
Active engagement with life
Caveats: Can those with functional limitations or chronic health problems age successfully
Wisdom
Extensive practical knowledge, ability to reflect on and apply that knowledge in ways that make life more bearable and worthwhile, emotional maturity, and creativity
Cognitive Reserve
Capacity of an adult brain to cope with brain pathology in order to minimize symptomatology
Classification of Brain Reserve:
1) Passive Model - Brain reserve
2) Active Model - Cognitive Reserve - Compensation
A Good Death:
“Free from avoidable distress and suffering for patients, families and care givers and consistent with cultural and ethical standards” - Institute of Medicine
Thanatology
Study of Death and Dying (Many physicians poorly trained in this area)
Stages of Dying (Kubler-Ross)
1) Denial
2) Anger
3) Bargaining
4) Depression
5) Acceptance
* stages may not go in order and may go back and forth
Physician Barriers to Treating Death
- Death is something to be avoided rather than a natural part of life
- Death is failure of our medical care
- Death of a patient is a negative reflection on the doctor
American View of a “Good Death”
- Dying not prolonged
- Pain and symptoms controlled
- Not being burden to others
- Control over decision-making
- Strengthening Relationships
Where do Americans Die (Want to Die vs. Where they actually die)
Want to Die
- Home (60-70%)
- Hospital (20-40%)
- Nursing Home (0%)
Where they die
- Hospital (50%)
- Nursing Home (30%)
- Home (20%)
Circumstances of Death
Intentional - suicide
Unintentional - trauma
Sub-intentional - Substance abuse
Advance Directives
A patient’s wish or choice about end of life care
- Includes living wills, health care proxy, and do not resuscitate orders
Euthanasia
AMA - Physician-assisted suicide is a criminal act and is never appropriate
It is legal and ethical to provide medically needed analgesia to a terminally ill patient even if it coincidentally shortens the patient’s life
Oregon Death with Dignity Law
Allows dying patients to take home lethal doses of prescription medication
- Physicians tended to become more involved
- No flood of people to Oregon to die (Must be 6 month resident)
- Those who requested assistance include need for control and independence
- 36% of those who filled prescription did not use them
Palliative Care (NOT hospice care)
- Providing relief from suffering as one nears death with complex medical conditions
- Comfort measures from symptoms
- Assistance with determination of goals
- Can and Should co-exist with life prolonging interventions
What is Hospice
Provides comfort and support to persons nearing the end of life (forgoes life prolonging goals in favor of quality of life goals)
Comfort is the primary goal
Criteria for Hospice Admission
- Recommendation of personal physician
- Life expectancy of 6 months or less if the illness runs its normal course
- No longer seeking cure
- Desire to stay out of hospital
Changes in Physiology Weeks and Days Before Death
- Increased Sleep
- May refuse food and drink
- Decreased reserve for physical activity
- Decrease in blood pressure and blood volume
- Changes in cognition/memory/orientation
- “The Last Hoorah”
Changes in Social Interactions
- Withdrawal from social interactions
- Interactions with core group of loved ones
- No longer care about previous interests
- Complete any old business
- Express gratitude and love
- Ask and grant forgiveness
Final Hours of Life
- Unresponsive
- Bluish discoloration
- Decrease blood pressure
- Decrease Breathing
Death Rattle
Pharyngeal secretions in final hours
Grief normally lasts:
Up to 12-24 months (usually less)
Grief
Mourning
Bereavement
Grief: Subjective feeling of loss
Mourning: Process of resolving grief
Bereavement: State of mourning the death of a loved one (state of being deprived)
Attachment Theory
It is because of our ability to make attachments that makes loss of a loved one so painful
- Grief is the price we pay for attachment or loss
Grief as a normal process
- Shock/Denial (2-3 months)
- Intense concern/ Preoccupation with the deceased (6 months to 1 year)
- Despair/Depression
- Recovery - reorganize
Phase 3 of Grief: Resolution
- Can think about the past with pleasure
- Regaining interests in activities
- Forming new relationships
Complicated Grief
Men (especially young men) > Women
Sibling deaths - more intense because of shared history
- Twin death = loss of identity
- Non-twins = loss of one of the most long term significant relationships
2 Months Depression in Grief - Major predictor of prolonged grief disorder
- Cardiac problems and impaired immune response
- Increased suicide and accidents
- Poor self care
