MENTAL HEALTH AND OLDER ADULTS

WORLD MENTAL HEALTH DAY 2013

Ward One Grand Rounds Friday November 1st, 2013

DR. SHIVAN A.C. MAHABIR Psychiatry Department, SWRHA

Case History

P. S. 78 yr old female Pensioner Widowed. Lives with her son in Point Fortin Roman Catholic Housewife Attended Primary School only.

Case History

P/C: Thinking her daughter wanted to poison her Eating mud Wandering away from home Throwing away household items

HxP/C: Memory problems starting within last 5 yrs Paranoia for 1 year Travelled to USA 6/12 ago. May have gotten ill and been admitted to a psychiatric hospital there. Returned to Trinidad 3/52 ago. Since the behaviour as above along with c/o talking to herself, talking about the past and occasional aggressive behaviour.

Case History

Past Psychiatric Hx:
     

Known psychiatric patient Attended Point Fortin POPC many years ago but defaulted Diagnosis – unknown Past Psychiatric Medication – Stelazine ? Past Psychiatric Hospital Admissions ? Pre-morbid level of functioning

Past Medical Hx: + HTN

Case History

MSE:
       

Clean Cooperative Oriented to person and place ONLY Mood – even Affect – Congruent Speech – relevant Denied Hallucinations + Paranoid Delusions Insight and Judgement were intact

MMSE: 18/30 (Moderate Impairment)

3% .? Intestinal Parasites ? Allergies Creatinine 1.Case History  Physical Examination:  Lump in Left Axillary Region  Referred to Surgical Unit  Blood Ix:     Eosinophilia . Rpt on following day 165 HbA1C: 5.2 CK 1338 .

Case History  Differential Diagnoses:      ? Dementia ? Type ? Schizophrenia Hypertension Renal Impairment Lump in Axilla for Evaluation .

sensory deficits. dependence. isolation).Psychiatric illnesses in older people include:  Pre-existing psychiatric disorders in the aging patient  New disorders related to the specific stresses and circumstances of old age (e. as well as psychiatric complications of neurological and systemic illnesses. The elderly are more likely to manifest physical symptoms of psychiatric disorder than younger adults   . bereavement.g. Disorders due to the changing physiology of the aging brain. infirmity.

4% for bipolar disorder. In people >65 yrs approximately: 1. ~30% in old age homes have cognitive impairment 30-50% patients >65 yrs in general hospital wards have psychiatric disorder) .1% for schizophrenia. 12.5% for neurosis and personality disorder3.Prevalence of Psychiatric Illness in the Elderly 5% of people older than 65 yrs suffer from moderate to severe dementia and the prevalence increases to over 30% of those over 85 yrs2. 1.

and other late-onset problems. . but the discipline also concerns itself with depressive illness. paranoid states. Dementia is generally the main focus of interest in psychogeriatrics. Cognitive assessment and physical examination are always essential parts of psychiatric management of the older person.Psychogeriatrics Psychiatric problems often coexist with physical problems.

and religious institutions). . social services. Psychiatric care of the elderly interfaces with multiple services. both state and independent (e. consideration of the role and the needs of carers are important aspects of holistic care.g. housing and welfare services. charity organisations. the legal system.Psychogeriatrics Since older people are often dependent on others.

· CBF in frontal and temporal lobes and thalamus decreases with age. by 10% by the age of 80.Neuro-Physiological Aspects of Aging · The weight and volume of the brain decreases by 5% between ages 30 and 70 yrs. · There is some nerve cell loss in the cortex. while there are also changes in the components of the cytoskeleton. substantia nigra. and by 20% by the age of 90. and purkinje cells of the cerebellum. The cytoplasm of nerve cells accumulates a pigment. (lipofuscin). · MRI shows decreased cortical grey matter with little change to white matter. There may also be reduction in dendritic processes. hippocampus. · Tau protein (NFT)/ Senile plaques/ Lewy bodies .

Problem solving deteriorates due to declining abstract ability and increasing difficulty applying information to another situation.Psychological Aspects of Aging Cognitive assessment is often complicated by physical illness or sensory deficits. plateaus until 60-70. . Short-term memory (STM) does not alter with age. and then declines. IQ peaks at 25 yrs. However. except for remote events of personal significance which may be recalled with great clarity. Long-term memory (LTM) declines. working memory (WM) shows a gradual decrease in capacity and this is worse with increased complexity of task and increased memory load.

which may be due to reduced processing speed or to the fact that verbal IQ depends largely on familiar “crystallised” information while performance IQ involves novel. . Tests of well-rehearsed skills such as verbal comprehension show little or no decline.Psychological Aspects of Aging There is a characteristic pattern of psychomotor slowing and impairment in the manipulation of new information. fluid information. Performance IQ drops faster than verbal IQ.

Losses include: loss of status. and loss of spouse/partner. and stigmatisation.Social Issues of Aging Increasing numbers of elderly live alone or in homes for the aged. The elderly face variable degrees of isolation. Increase in medical problems compounds the dependency and care needs. . Most elderly have limited income and are unemployed. marginalisation. loss of independence.

and social needs. · Social assessment (accommodation. physical. need for care. management. social. This implies that individual assessment. including full cognitive assessment · Functional assessment (evaluation of ability to perform functions of everyday living).Multi-disciplinary Assessment Elderly people suffering from mental health problems often have a range of psychological. and carers · Full physical and neurological examination · MSE. and follow-up requires collaboration between health. financial and legal issues. and voluntary organisations and family carers. social activities) · Assessment of carers' needs . Assessment of the older patient with mental illness includes the following: · Full history from the patient. family.

and medications kept in the house. neighbours. MSE needs to include an assessment of sight and hearing. family members. social activities. In addition. A domiciliary visit has the advantage of being more convenient and relaxing for the patient and it provides the health carer with an opportunity to assess living conditions. and carers may be available for interviewing.Multi-disciplinary Assessment The best place for performing an assessment is in the patient's home. .

MMSE .

Key questions for carers include: · Relationship to the patient · Amount of care provided · Degree of stress they are under · What help they would accept · Understanding and knowledge of the patient's illness · What expectations they have from services · Their awareness of support or voluntary organisations .

thinking. and judgement. Dementia is caused by a variety of diseases and injuries that primarily or secondarily affect the brain. the ability to process thought) beyond what might be expected from normal ageing.     . social behaviour. The impairment in cognitive function is commonly accompanied. It affects memory. learning capacity.e. or motivation. calculation.Dementia  Dementia is a syndrome – usually of a chronic or progressive nature – in which there is deterioration in cognitive function (i. such as Alzheimer's disease or stroke. and occasionally preceded. Consciousness is not affected. comprehension. orientation. by deterioration in emotional control. language.

because the onset is gradual.   Middle stage: as dementia progresses to the middle stage. the signs and symptoms become clearer and more restricting.Dementia Early stage: the early stage of dementia is often overlooked. including wandering and repeated questioning.     . Common symptoms include:  forgetfulness losing track of the time becoming lost in familiar places. These include:  becoming forgetful of recent events and people's names becoming lost at home having increasing difficulty with communication needing help with personal care experiencing behaviour changes.

aggression. and logorrhoea: . Memory disturbances are serious and the physical signs and symptoms become more obvious. flight of ideas.     Positive features include wandering. Symptoms include:  becoming unaware of the time and place having difficulty recognizing relatives and friends having an increasing need for assisted self-care having difficulty walking experiencing behaviour changes that may escalate and include aggression.Dementia Late stage: the late stage of dementia is one of near total dependence and inactivity.

Ca2+. . Huntington's. U&E. cryptococcosis. Pick's disease.Dementing Disorders Epidemiology . Vascular dementia. 5-10% prevalence above 65yrs. and 70% of those over 100yrs. LFT. TSH.Alzheimer's disease. Ix: FBC. syphilis serology. Commonest causes . 20% prevalence above 80yrs. Parkinson's. folate/B12 (treat lownormals). pellagra. Lewy body dementia. HIV. CT/MRI (any structural pathology?).Rare below 55yrs of age. Fronto-temporal dementia Rarer causes: Alcohol/drug abuse. ESR. progressive leukencephalopathy. autoantibodies. CJD.

Dementing Disorders Senile Dementia -Alzheimer's Type Cause: Accumulation beta-amyloid peptide. Insulin resistance may be important . eg the nucleus basalis of Meynert are especially vulnerable Risk factors: Defective genes on chromosomes 1. and the hippocampus. and loss of the neurotransmitter acetylcholine. 21. the apoE4 variant brings forward age of onset. amygdala. temporal neocortex and some subcortical nuclei. neurofibrillary tangles. resulting in progressive neuronal damage. a degradation product of amyloid precursor protein. increased numbers of senile plaques. 19. Neuronal loss is selective. 14.

Dementing Disorders  Ix: Diagnosis only confirmed at post-mortem. MRI.  Tx: Evidence that cholinesterase inhibitors and memantine are modestly effective in treating AD is good. Avoid CPZ – risk of hypotension. Lewy body and vascular dementias. Normalize blood pressure. Memantine is an NMDA antagonist. is effective in late stage disease. Memantine. alone or in combination with cholinesterase inhibitors. PET) and neuropsychological tests help rule out frontotemporal. . Brain imaging (CT. Use low dose haloperidol multiple dose per day. Observe for EPSE. (NMDA=N-methyl-D-aspartate). Cholinesterase inhibitors appear to be effective in mild-moderate AD. Avoid atypical antipsychotics in dementia.

Dementing Disorders  Prevention:      Learn a new language Take up a hobby Do puzzles and crosswords. Go through photo albums. . Routines at home.

and analgesics frequently becomes a problem in this age group. laxatives and OTC analgesics and prescription drugs such as benzodiazepines.Drug Abuse Generally. malnutrition. illicit substance abuse is not a significant problem in the elderly. . opiates. and the effects of exposure and falls. depression. However. The clinical presentation of older patients with alcohol and other substance use disorders varies and includes confusion. poor personal hygiene. Older patients may abuse anxiolytics to allay chronic anxiety or to ensure sleep. Dependence on these medications may result from careless prescription of long-term treatments for common problems of ageing such as insomnia and arthritis. misuse of over the counter drugs such as nicotine and caffiene.

.Drug Abuse The sudden onset of delirium in older persons hospitalized for medical illness is most often caused by alcohol withdrawal. doctors sometimes believe that it is “cruel” to withdraw patients from these medications. Alcohol abuse also should be considered in older adults with chronic gastrointestinal problems. With the best of intentions. but the need to provide pain relief takes precedence over the possibility of narcotic dependence and is entirely justified. However. it is important to consider whether withdrawal may actually enhance quality of life by diminishing chronic side-effects such as depression The maintenance of chronically ill cancer patients with narcotics prescribed by a physician produces dependence. especially if the patient has been using the drug for years and is advanced in age.

With decreasing tolerance for alcohol in advancing age.Alcohol Abuse Older adults with alcohol dependence usually give a history of excessive drinking that began in young or middle adulthood. . Males predominate. although there is an increase in prevalence of alcohol problems in women in their 8th and 9th decades. Risk factors for late onset of alcohol problems include: female gender. widowed. primarily with liver disease. They usually are medically ill. Many have arrest records and are numbered among homeless persons. there is a corresponding increase in risk of intoxication and adverse effects. Wernicke's encephalopathy and Korsakoff psychosis are important sequelae in “old cases”. or are men who never married. precipitating life events. neurotic personality. and are either divorced. higher socioeconomic class. psychiatric illness. physical ill-health.

· In extreme cases consider need for supervision of finances. . · Moving to residential care may reduce social isolation. · Encourage and facilitate involvement in non-drinking social activities. · Orientate towards reducing physical problems.Alcohol Abuse Principles of management · Prognosis is good if alcohol problems commence secondary to practical problems.

Existential theories eg the person may deal with the thought of death with a sense of despair and anxiety. punctual. older persons react more severely to PTSD than younger persons.. perfectionistic. and parsimonious) when they were younger.Anxiety Disorders in the Elderly  By far the most common disorders are phobias (4 to 8 percent). Physiological theories: The fragility of the autonomic nervous system in older persons may account for the development of anxiety after a major stressor. Because of concurrent physical disability. The rate for panic disorder is 1 percent.g. rather than with equanimity and Erikson's “sense of integrity”. Obsessions and compulsions may appear for the first time in older adults. 2. Theories which seek to explain the aetiology of anxiety disorders in the elderly include: 1.    . being orderly. although older adults with OCD usually had demonstrated evidence of the disorder (e.

but being widowed and having a chronic medical illness are associated with vulnerability to depressive disorders. and self-accusatory trends (especially about sex and sinfulness) with paranoid and suicidal ideation. The presenting symptoms may be different in older depressed patients from those seen in younger adults because of an increased emphasis on somatic complaints in older persons. Dementia vs pseudo-dementia    . feelings of worthlessness. Older persons are particularly vulnerable to major depressive episodes with melancholic features. Age itself is not a risk factor for the development of depression. hypochondriasis.   Late-onset depression is characterized by high rates of recurrence.Depression  Depressive symptoms are present in about 15 percent of all older adult community residents and nursing home patients. characterized by depression. low self-esteem.

Do you often feel helpless? Yes/No 9. Are you basically satisfied with your life? Yes/No 2. Psychopharmacol Bull. 1. Do you think that most people are better off than you are? Yes/No (From Yesavage JA. Geriatric Depression Scale. Do you feel happy most of the time? Yes/No 8. Do you feel you have more problems with memory than most? Yes/No 11. Do you feel full of energy? Yes/No 14. Do you feel that your life is empty? Yes/No 4. Do you feel that your situation is hopeless? Yes/No 15. Do you think it is wonderful to be alive now? Yes /No 12. Do you often get bored? Yes/No 5. Have you dropped many of your activities and interests? Yes/No 3. with permission.24:709. Are you in good spirits most of the time? Yes/ No 6. Are you afraid that something bad is going to happen to you? Yes/No 7. 1988. rather than going out and doing new things? Yes/No 10. Do you feel pretty worthless the way you are now? Yes/No 13.) . scores greater than 5 indicate probable depression.Geriatric Depression Scale (Short Version) Answers indicating depression are boldfaced. Do you prefer to stay at home. Each answer counts one point.

but invasive and high-risk diagnostic procedures should be avoided unless medically indicated. and the prognosis guarded. although the peak incidence is in those 40 to 50 years of age. that the pain is really there and perceived as such by the patient. Clinicians should acknowledge that the complaint is real.  .Other Psychiatric Illnesses affecting the Elderly  Somatoform Disorders:  Hypochondriasis is common in persons over 60 years of age. The disorder usually is chronic. Repeated physical examinations help reassure patients that they do not have a fatal illness. and that a psychological or pharmacological approach to the problem is indicated. Telling patients that their symptoms are imaginary is counterproductive and usually engenders resentment.

poisoned. the most common are persecutory patients believe that they are being spied on. followed. in which persons believe they have a fatal illness. or harassed in some way. but it can occur at any time during the geriatric period. . also can occur in older persons. Somatic delusions. Persons with delusional disorder may become violent toward their supposed persecutors. Delusions can take many forms.Other Psychiatric Illnesses affecting the Elderly  Delusional Disorder The age of onset of delusional disorder usually is between ages 40 and 55. Some persons lock themselves in their rooms and live reclusive lives. pervasive persecutory ideation was present in 4 percent of persons sampled. In one study of persons older than 65 years of age.

debilitating medical illness or surgery. social isolation. and bipolar I disorder which need to be ruled out. retirement. schizophrenia. alcohol use disorders. and deafness.Other Psychiatric Illnesses affecting the Elderly  Delusional Disorder Among those who are vulnerable. Delusional syndromes also can result from prescribed medications or be early signs of a brain tumor . visual impairment. delusional disorder can occur under physical or psychological stress and can be precipitated by the death of a spouse. Delusions also can accompany other disorders such as dementia of the Alzheimer's type. adverse financial circumstances. loss of a job. depressive disorders.

form of thought.Other Psychiatric Illnesses affecting the Elderly Paraphrenia: a psychotic illness characterised by delusions and hallucinations. Some believe that the disorder is a variant of schizophrenia that first becomes manifest after age 60. without changes in affect. or personality It develops over several years and is not associated with dementia. Patients with a family history of schizophrenia show an increased rate of paraphrenia .

and lower-than-usual dosages often are effective for older adults    . Medication must be administered judiciously. Another difference between early-onset and late-onset schizophrenia is the greater prevalence of paranoid schizophrenia in the late-onset type Older persons with schizophrenic symptoms respond well to antipsychotic drugs. Women are more likely to have a late onset of schizophrenia than men. a late-onset type beginning after age 45 has been described.Other Psychiatric Illnesses affecting the Elderly Schizophrenia:  Although first episodes diagnosed after age 65 are rare.

Health carers may fail to detect sexual problems experienced by older people as a sexual history is commonly overlooked. of course. the elderly may experience added problems related to the specific physiological changes that accompany ageing. illness.Sexual Issues Factors influencing the sexual life of younger adults are relevant to older people too (e. social stresses. In addition. Dementia sufferers may become sexually demanding as part of the disinhibition that frequently characterises this disorder. The client too may assume that his or her sexual dysfunction is a ‘normal’ aspect of ageing. and. Some practical remedies are: hormone replacement therapy.g. vaginal lubricants and topical oestrogen. Viagra. This may result from incorrect assumptions that carers often make regarding sexuality in this age group. . and side-effects of medications).

. poor conditions. introversion.Personality Issues Personality traits often become more prominent and rigid in old age. any significant change in personality needs explanation. and obsessionality Since personality disorder is by definition lifelong. living in filthy. necessitating intervention. They are often oblivious to their condition and resistant to help. Both organic and functional brain disorders may manifest as ‘a change in personality’. Personality problems are often the cause of Diogenes syndrome—also called senile squalor syndrome—in which eccentric and reclusive individuals become increasingly isolated and neglect themselves. in particular traits such as cautiousness.

Predictive factors for suicide in the elderly: · Increasing age · Male · Physical illness (35-85% cases) · Social isolation · Widowed or separated · Alcohol abuse · Depressive illness. current or past (80% cases) · Recent contact with psychiatric services Most elderly persons who commit suicide communicate their suicidal thoughts to family or friends before the act of suicide .Suicide Old age is a risk factor for suicide and it is estimated that approximately 20% of all suicides are of the elderly. There is a male predominance of 2:1 in this age group.

Of the parasomnias.Sleep Disorders Sleep-related phenomena reported more frequently by older than by younger adults are sleeping problems. and the use of hypnotic drugs. nocturia. dyssomnias are the most frequent. daytime napping. Clinically. dyspnea. The conditions that commonly interfere with sleep in older adults also include pain. nocturnal myoclonus. and heartburn. older persons experience higher rates of breathing-related sleep disorder and medication-induced movement disorders than younger adults. rapid eye movement (REM) sleep behavior disorder occurs almost exclusively among elderly men. restless legs syndrome. Among the primary sleep disorders. . and sleep apnea. especially primary insomnia. The lack of a daily structure and of social or vocational responsibilities contributes to poor sleep. daytime sleepiness.

. daytime withdrawal. clinicians must monitor the patients for unwanted cognitive. rebound insomnia. behavioral. residual sedation. including memory impairment (anterograde amnesia). Alcohol can also precipitate or aggravate obstructive sleep apnea When prescribing sedative-hypnotic drugs for older persons.Sleep Disorders Even modest amounts of alcohol can interfere with the quality of sleep and can cause sleep fragmentation and early morning awakening. and psychomotor effects. and unsteady gait.

sexual verbal. intentional or unintentional. and of one or more types: · Physical. or psychological abuse · Physical or psychological neglect · Financial exploitation The abuse or neglect results in unnecessary suffering. . injury. or loss and leads to a violation of human rights and a decrease in the quality of life. This mistreatment can be an act of commission (abuse) or omission (neglect). pain.Elder Abuse Elder abuse is an all-inclusive term representing all types of mistreatment or abusive behaviour towards older adults.

while 10% admitted having committed at least one act of physical abuse themselves. Importantly. . Gender distribution (of victims) is equal and economic status and age are unrelated to risk of abuse. The most common forms of abuse are verbal abuse and financial exploitation by family members and physical abuse by spouses.Elder Abuse Epidemiology of elder abuse Occurs in both domestic and institutional settings: · Domestic setting: Approximately 4-6% of elderly people report incidents of abuse or neglect in domestic settings. · Institutional settings: No data exists for the extent of abuse within institutional settings. elder abuse is under-reported. one survey of nursing home staff in a US state disclosed that 36% of staff had witnessed at least one incident of physical abuse in the preceding year. However.

CPN visits. but not necessarily for physical abuse. Also the causes of spouse abuse may differ from the causes of abuse by adult offspring. Prevention of elder abuse is the best approach and a number of measures have proved effective including: training and support of carers. for example. etc. reducing isolation of elders. Factors vary according to the type of abuse.4) . respite care. dependency is a risk factor for financial or emotional abuse. Responding to abuse effectively requires a multidisciplinary approach and a proactive system of assessment of suspicious cases (a number of assessment instruments have been developed3. absence of a suitable guardian. carer has mental or substance misuse problems.Elder Abuse The main risk factors for elder abuse are: dependency and social isolation of the victim.

· Excretion is reduced with the drop in renal clearance that accompanies old age. · Drug metabolism is reduced due to decreased blood flow to the liver and loss of efficiency of liver microsomes. · Absorption generally remains the same. together with increased body fat causes increased levels of free drug and longer half-lives (especially of psychotropics). and plasma proteins. . · Distribution of drugs is altered however: reduced body mass. although there are reductions in gastric pH and mesenteric blood flow. body water. Thus drug effects are generally prolonged and cumulative and the risk of toxicity is high.Pharmacokinetics · The physiological changes associated with ageing mean that the older patient's system “handles” drugs quite differently from that of a younger individual.

there is increased sensitivity to sedatives in the elderly due to a reduction in the number of available receptors. which may cause this age group to become increasingly vulnerable to mood disorders.there are less DA cells in the basal ganglia. The implications of these changes are that elderly patients are more sensitive to almost all drugs used in psychiatry. · Narcotics and sedative hypnotics . . · Cholinergic system .Pharmacodynamics  Dopaminergic system . · Noradrenergic system .there is a normal reduction in cholinergic receptors with advancing age (and a gross reduction in DAT).NA levels decrease with age. thus there is increased sensitivity to the EPSEs of neuroleptics (not dystonias).

Pharmacokinetics and Pharmacodynamics General principles of prescribing include: · Start with a very low dose. · Beware of dangerous side-effects such as postural hypotension and arrhythmias. · The elderly are particularly sensitive to EPSEs and anticholinergic side-effects. · Beware of drug interactions due to common problem of polypharmacy in the elderly. · Maximum efficacy is often achieved at significantly lower doses than in younger adults. · Increases should be made slowly. .

· SSRIs. A pretreatment medical evaluation is essential. while MAOIs and lithium may be useful in resistant depression. · Monitor lithium therapy closely as levels can fluctuate easily and long-term effects on thyroid and renal function are not infrequent.Pharmacokinetics and Pharmacodynamics General principles of prescribing continued: Atypical neuroleptics are generally better tolerated than conventionals. and NARIs are generally safer than TCAs. · Always consider suicide risk as old age is a risk factor for suicide. including an electrocardiogram (ECG). SNRIs. .

. For patients with insomnia. giving the major portion of an antipsychotic or antidepressant at bedtime takes advantage of its sedating and soporific effects. Older patients may not be able to tolerate a sudden rise in drug blood level resulting from one large daily dose. however. Any changes in blood pressure and pulse rate and other side effects should be watched.Pharmacokinetics and Pharmacodynamics General principles of prescribing continued: Most psychotropic drugs should be given in equally divided doses three or four times over a 24-hour period.

Clinicians should frequently reassess all patients to determine the need for maintenance medication. reevaluate the patient during a drug-free baseline state . if possible. If a patient is taking psychotropic drugs at the time of the evaluation. the clinician should discontinue these medications. after a washout period. or will not. changes in dosage. and development of adverse effects. swallow tablets. and.Pharmacokinetics and Pharmacodynamics General principles of prescribing continued: Liquid preparations are useful for older patients who cannot.

day and outpatient care. informal carers . acute and long term hospital services. the ideal service should plan to:  Maintain the elderly person at home for as long as possible Respond quickly to medical and social problems as they arise Ensure coordination of the work of those providing continuing care Support relatives and others who care for the elderly at home Promote liaison between medical and social and voluntary services     These include: primary care. CPN.Services for the Elderly In principle. domiciliary services. residential and nursing care.

Palliative Care and Living Wills PALLIATIVE CARE is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness. Usually the person specifies the degree of irreversible deterioration after which they want no further life-sustaining treatment. A LIVING WILL is an advance directive (usually written and witnessed) made by an individual regarding their preferences for future treatment during their final illness. psychosocial and spiritual. through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems. They may also give clear instructions refusing certain medical interventions . physical.

Thank You For Your Attention!!  Questions? .