Home Treatment and Palliative Care of the Elderly

Assist. Prof. Predrag Erceg

Overview

Geriatric medicine Home treatment Palliative care

Elderly heterogeneous population

Frailty

Numerous definitions Physiological syndrome characterized by diminished reserve and resistance to stressors Caused by cumulative decline in multiple physiological systems Susceptibility to poor outcomes (Fried et al. 2003)

What is Geriatrics?

Geriatrics is a subspecialty of medicine that focuses on health care of the elderly Age > 65 Focused on problems, not diseases

Problems

Older patients may have multiple problems that interact Geriatrics looks at these interactions (i.e. whole patient) Identifies current and potential problems

General Principles of Aging: Older People Are Different

Atypical Presentation of Acute Illness

Only 40% of elderly fit the classic one symptom=one disease model
Acute myocardial infarction without chest pain Acute hyperthyroidism without tachycardia, weight loss, etc. Acute infection without rising WBC count or typical fever Fatigue as chief presenting complaint of CHF

Giants of Geriatrics Geriatric Syndromes

Incontinence Immobility Instability Intellectual impairment Iatrogenesis

Why do we call them Giants?

Huge number of older people is faced with this problems Powerful impact on independence Common final path for large number of chronic diseases

Areas of Assessment
Functional assessment Mobility, gait and balance Sensory and Language impairments Continence Nutrition Cognitive/Behavior problems Depression Caregivers Medications

Functional assessment
ADLs (Activities of Daily Living) Dress Eat Ambulate Transfer/Toilet Hygiene If You can not do Your ADLs You are dead

Functional assessment

Instrumental Activities of Daily Living (IADLs)

Shopping Housekeeping Accounting/bill paying Food/meal preparation Travel/driving

These are less severe than ADLs, but clearly cause dysfunction and lead to dependency

Drug Treatment START LOW AND GO SLOW!

Home Care: definition of terms

The term home care includes all health and social services that may be provided in the home, ranging from homemaker, chore, and meal services to nursing and physician care Home health care is the term used for health services provided by health aides, nurses, physical and occupational therapists, and physicians Home medical care, or the house call, usually involves a physician or other primary care provider, such as a physician assistant or nurse practitioner

Indications for a Home Care Referral

Advanced age Frailty Multiple comorbidities Recurrent and frequent admissions Homeboundedness Impaired psychosocial or functional status Terminal care.

Services available in the home

Services available in the home

Services available in the home

Services available in the home

Medical equipment Intravenous infusion for hydration, chemotherapy, blood transfusion, antibiotics, total parenteral nutrition, pain management and other medications Mechanical ventilators Dialysis Medical alert devices Glucometers

Conducting a visit

Medical record Appointment Prepare a doctors bag Introduce yourself Ask for permission Listen History (patient/family)

Physical exam Functional assessment Environment assessment Plan Goals

Palliative care: definition (WHO)

Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual

What is Palliative Care?

It is difficult to define
It is not defined by:

Organ systems (cardiology, pulmonology, neurology ....) Therapeutic modalities (surgery, psychotherapy, radiotherapy ...) Age (pediatrics, geriatrics) Location of care (home, hospital)

Any disease, any age, any location

Personal definition
Comprehensive care of the patients with incurable disease
Goals: To reduce suffering To improve quality of life for the patients and their families

Is the palliative care reserved only for the patients with cancer in terminal stage?

Terminal stage of heart, renal, and respiratory failure Terminal stage of neurodegenerative diseases(amiotrophic lateral sclerosis, multiple sclerosis, dementia)

Which are the end of life criteria?

Therapeutic criteria:
Exhausted all curative therapeutic options

Symptoms criteria:
Uncontrolled symptoms with Karnofsky performance status of les than 50 (requires considerable assistance and frequent medical care)

Time criteria:
Prognosis of less than 3-6 months of life (cancer patients)

Physical

Psychosocial

SUFFERING

Emotional

Spiritual

Provides relief from pain and other distressing symptoms

Pain- 66% Insomnia- 49% Loss of apetite- 48% Depression- 38 % Nausea 30%

Affirms life and regards dying as a normal process

Intends neither to hasten or postpone death

Integrates the psychological and spiritual aspects of patient care

Offers a support system to help patients live as actively as possible until death

Offers a support system to help the family cope during the patients illness and in their own bereavement

Uses a team approach to address the needs of patients and their families

Enhances the quality of life

Applicable early in the course of illness, in conjunction with other therapies

Things to remember

Old age is not a synonym for a disease Any sudden loss in function should be considered as a consequence of disease Focus on problems, not organ systems Reduce suffering; improve functional capacity, and QUALITY OF LIFE

Questions?