Home and Palliative Care Final

8/3/2019 Home and Palliative Care Final

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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 syndromecharacterized by

diminished reserve andresistance to stressors

Caused by cumulativedecline in multiplephysiological systems

Susceptibility to pooroutcomes

(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



Older patients may have multiple

problems that interact

Geriatrics looks at these

interactions (i.e. whole patient)

Identifies current and potentialproblems

Problems



General Principles of Aging:

Older People Are Different

Atypical presentation of acute illness

Multiple concurrent problems

Non-specific symptoms Hidden illness

Under-reporting

Expected physiologic aging changes



Atypical Presentation of Acute

Illness

Only 40% of elderly fit the classic onesymptom=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 assessmentADLs (Activities of Daily Living)

D ress

E at

Ambulate

T ransfer/Toilet

H ygiene

“If You can not do Your ADL’s

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 GOSLOW!



Home Care: definition of terms The term home care includes all health and social

services that may be provided in the home, ranging fromhomemaker, 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 andoccupational therapists, and physicians

Home medical care, or the house call , usually involves aphysician or other primary care provider, such as aphysician 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 Professional

Physician

Nurse

Dentist

Podiatrist

Optometrist

Rehabilitation therapists:

Occupational

Physical

Speech

Respiratory

Psychologist

Dietitian

Pharmacist

Social worker



Services available in the home Diagnostics

Phlebotomy

X-rays

Electrocardiograms

Holter monitoringOximetry

Blood cultures



Services available in the home Ancillary/supportive

Home health aides

Personal care assistants

Homemakers

Chore aidesVolunteers

Home-delivered meals



Services available in the home Medical equipment

Intravenous infusion for hydration,

chemotherapy, blood transfusion, antibiotics, totalparenteral nutrition, pain management and othermedications

Mechanical ventilators

Dialysis Medical alert devices

Glucometers



Conducting a visit Medical record

Appointment

Prepare a doctor’sbag

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 withlife-threatening illness, through theprevention and relief of suffering by meansof early identification and impeccableassessment and treatment of pain and otherproblems, physical, psychosocial andspiritual



Personal definitionComprehensive care of the patients with

incurable disease

Goals:

To reduce suffering

To improve quality of life for the patientsand their families



Is the palliative care reserved only

for the patients with cancer interminal 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 (requiresconsiderable assistance and frequent medical

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

patients)



SUFFERING EmotionalPsychosocial

Physical

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

Off h l h



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 othertherapies



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?

Home and Palliative Care Final

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