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Home Treatment and Palliative
Care of the Elderly
Assist. Prof. Predrag Erceg
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Overview Geriatric medicine
Home treatment Palliative care
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Elderly – heterogeneous population
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Frailty Numerous definitions
Physiological syndromecharacterized by
diminished reserve andresistance to stressors
Caused by cumulativedecline in multiplephysiological systems
Susceptibility to pooroutcomes
(Fried et al. 2003)
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What is Geriatrics? Geriatrics is a subspecialty of medicine that
focuses on health care of the elderly
Age > 65
Focused on problems, not diseases
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Older patients may have multiple
problems that interact
Geriatrics looks at these
interactions (i.e. whole patient)
Identifies current and potentialproblems
Problems
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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
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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
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Giants of Geriatrics – Geriatric
Syndromes
Incontinence
Immobility Instability
Intellectual impairment Iatrogenesis
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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
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Areas of Assessment
Functional assessment
Mobility, gait and balance
Sensory and Language impairments Continence
Nutrition
Cognitive/Behavior problems Depression
Caregivers
Medications
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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”
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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
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Drug Treatment
START LOW AND GOSLOW!
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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
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Indications for a Home Care Referral Advanced age
Frailty
Multiple comorbidities
Recurrent and frequent admissions
Homeboundedness Impaired psychosocial or functional status
Terminal care.
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Services available in the home Professional
Physician
Nurse
Dentist
Podiatrist
Optometrist
Rehabilitation therapists:
Occupational
Physical
Speech
Respiratory
Psychologist
Dietitian
Pharmacist
Social worker
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Services available in the home Diagnostics
Phlebotomy
X-rays
Electrocardiograms
Holter monitoringOximetry
Blood cultures
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Services available in the home Ancillary/supportive
Home health aides
Personal care assistants
Homemakers
Chore aidesVolunteers
Home-delivered meals
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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
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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
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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
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Personal definitionComprehensive care of the patients with
incurable disease
Goals:
To reduce suffering
To improve quality of life for the patientsand their families
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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)
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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)
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SUFFERING EmotionalPsychosocial
Physical
Spiritual
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Provides relief from pain and
other distressing symptoms Pain- 66%
Insomnia- 49%
Loss of apetite- 48%
Depression- 38 %
Nausea – 30%
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Affirms life and regards dying as
a normal process
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Intends neither to hasten or
postpone death
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Integrates the psychological and
spiritual aspects of patient care
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Offers a support system to help
patients live as actively as
possible until death
Off h l h
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Offers a support system to help the
family cope during the patients
illness and in their own bereavement
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Uses a team approach to address the
needs of patients and their families
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Enhances the quality of life
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Applicable early in the course of
illness, in conjunction with othertherapies
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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
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Questions?
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