Life Expectancy
•There are certain genetic characteristics that centenarians (people who are 100 years old) have in common that appear to promote longevity while at the same time interfering with disease processes such as cancer.
Why do we age? Theories:
Wear and Tear Theory:
-The human body, like a machine simply wears out over time because of the accumulated stress placed on it.
Accumulation of Waste Theory
- Metabolic waste products accumulate and cause deterioration and death of cells. Examples include cholesterol build up in the arteries, and cataracts.
- Cells have a limited number of divisions that they can undergo before they are no longer able to divide and then contribute to waste (“cellular senescence”)
Biological Clock Theory
-Our genes act as a genetic clock; they pre-program us to only live for a certain amount of time.
Immune Theory
-One theory states that the ability of the immune system to respond to foreign substances diminishes with age, contributing to greater susceptibility to disease.
Gene Theory
-There is a theory that certain genes are actually responsible for producing the changes and decline that we associate with aging.
Free Radians:
-Are the product of interaction between oxygen and mitochondria in cells. These are theorized to contribute to cell death and aging process over time.
Prevalence of disability/ injury
• Prevalence of disability for young seniors has been declining
• Significant rises in disability are not noticed until after 75
• Rate of accidental death and injury leading to hospitalization is 3 times greater than at any other age. Risk of disability is increased because of:
>Slower reaction time
>Less muscle mass
>Decrease in sensory acuity
• Some suggest that the old are getting younger. For example, some suggest that today’s 70 year old is more like a 50 year old of 20 or 30 years ago.
• Even after the age of 85, disability is only reported by ½ of all seniors. Cognitive impairment is only reported by 9% of seniors after age 85.
•While women live longer, the presence of disability is greater for older women than for older men.
>For example, while aging men are also susceptible to osteoporosis, by the age of 70, females have commonly lost 30% of bone calcium. A significant problem is hip fractures, with 20% of elderly people dying within a year of fracture and 50% experiencing chronic disability.
• Even by age 85, only ½ of seniors self report disability
• Significant cognitive impairment is not a part of the “normal” aging process, and if it occurs, may be due to a variety of factors other than brain deterioration
Aging skin
Eccrine glands
- Any of the numerous small sweat glands distributed over the body’s surface that produce a clear aqueous secretion devoid of cytoplasmic constituents and important in regulating body temperature.
- In aging skin: The number of eccrine glands is reduced. Thus, aging appears to reduce the effectiveness of sweating as a mechanism to cool the body.
Skin
- In addition, both epidermis and dermis undergo a thinning process during later maturity.
- Dermis loses about 20% of thickness, along with depletion of subcutaneous fat.
- Walls of blood vessels undergo thinning as well.
- All of this contributes to making older person more susceptible to temperature variations. In addition, the older person’s skin is more susceptible to bruising and tearing.
Elderly and prescriptions
• People over the age of 65 are given ¼ of all prescribed medications.
• Elderly people do not metabolize drugs as efficiently. They are 2 – 7 times more likely to suffer adverse side effects.
•When research is done on drugs, it’s very rare that companies conduct research on elderly. These drugs are formulated for young healthy adults. This is why elderlies don’t react as well to meds.
•Age can affect the body’s ability to metabolize and eliminate medications:
>E.g. a person at 70 takes twice as long as someone at 50 to eliminate antianxiety medications from his or her system.
• If the half life of a medication for younger persons it is about 45 hours, then for someone who is 70 or older it is about 90 hours (see next slide for definition of half life)
• The liver isn’t as efficient at metabolizing and kidneys are as efficient at excreting.
• In some cases where older persons receive sedatives a paradoxical effect may be noticed, such that the person becomes agitated rather than sedated. This is due to changes in how medications are processed.
•Half-life: The amount of time it takes for half of a dose of medication to be eliminated from the body: it is measured by when the medication concentration in the blood plasma reaches half of the concentration at initial dosing.
Polypharmacy
- The term “polypharmacy” is used to describe the prescription of multiple medications to one individual.
- Often specifically defined as 4 or more or 5 or more medications
- Usually understood to be in persons 65 years and older
- Nearly 50% of older adults take one or more medications that are not medically necessary. Research has clearly established a strong relationship between polypharmacy and negative clinical consequences
Define: Presbycusis Lentigo senilis Cataract Ageism Crystallized intelligence Fluid intelligence Senescence Osteoporosis Exit events
Presbycusis: Progressive loss of hearing and sound discrimination, particularly for consonants and high frequency sounds
Lentigo senilis: Large freckles that are associated with aging (“age spots”). Commonly found on backs of hands, arms and face.
Cataract: The condition that occurs when the lens of the eye becomes opaque or cloudy and produces diminished vision and increased sensitivity to glare.
Ageism: Discrimination against individuals on the basis of age, inferring that elderly people are inferior to those who are younger.
Crystallized intelligence: Knowledge and cognitive ability that are maintained over the lifetime. It includes problem-solving, wisdom, judgment, and generally, knowledge and abilities that have been reinforced by practice/experience, education, and opportunity for demonstration.
Fluid intelligence: Intelligence that is largely innate and independent of education and experience; includes good short term memory, ability to acquire new information comparatively easily; and speed.
Senescence: Mental and physical decline associated with the aging process.
Osteoporosis (porous bones): A condition in which bones are brittle, fragile and prone to fracture. More prominent in postmenopausal women and persons who are Caucasian, Asian, or of small stature (persons with Down syndrome are prone to osteoporosis)
Exit events: Losses experienced by older persons that signify closing out of life. The accumulation of such losses can lead to loneliness and depression for some persons: loss of job through retirement, loss of long-time spouse, loss of driver’s licence, movement into personal care home, etc.
Other Health Issues
Elderly people commonly experience a sudden reduction in blood pressure when standing up quickly, this can lead to fainting.
This is often referred to as “postural” or “orthostatic” hypotension
The elderly may often experience drops in blood pressure after eating or taking a hot bath.
There is evidence of an increased rate of depression after the age of 75. One explanation is the increased weight of accumulated losses or EXIT events.
Dementia
- Dementiais a general term that refers to a variety of brain disorders that cause permanent physical changes in the brain.
- Dementia is often associated with eventual cognitive decline and impairment of functioning.
- Not to be confused with Delirium which is a temporary and reversible state even though they both can present in similar ways.
- Is diagnosed when a person has multiple cognitive deficits including memory impairment & one or more of the following: Aphasia, Agnosia, Apraxia, Disturbance in executive functioning
- Dementia does not necessarily mean “continuing decline” or “irreversibility”, though many of the conditions that cause dementia are progressive degenerative diseases.
- Can be the result of a medical condition – Alzheimer Disease, AIDS, Huntington’s, head injury, Parkinson’s disease – or from persisting effects of exposure to toxic substances – alcohol, or some combination.
Symptoms:
- Memory impairment can be for new learning and/or previously formed memories.
- Person will have difficulty with complex tasks (sequencing behaviours)
- Poor sense of spatial relationships is common
- Insight is usually poor to nil
- Judgment is also markedly impaired
-Reasoning ability is affected so individuals have difficulty with problem solving
>Eventually people become unable to deal with new situations.
Define: Aphasia Agnosia Apraxia Executive Functioning Neurofibrillary tangle Amyloid plaques
Aphasia – impaired or absent comprehension or production of speech
Agnosia – inability to recognize or comprehend meaning of various sensory stimuli
Apraxia – impairment of skilled or purposeful movement; psychomotor deficit where the person can’t carry out the proper use of the object although they know what it is and what it is supposed to do
Executive functioning –think abstractly, to plan, initiate, sequence, monitor & stop complex behaviour
Neurofibrillary tangles are twisted protein fragments that accumulate inside nerve cells. They are one of the characteristic structural abnormalities found in the brains of patients with Alzheimer disease.
Amyloid plaques are sticky buildup which accumulates outside nerve cells, or neurons. Amyloid is a protein that is normally found throughout the body. For reasons as yet unknown, in AD, the protein divides improperly, creating a form called beta amyloid which is toxic to neurons in the brain.
-Plaques begin to form that consist of these degenerating neurons and clumps of the amyloid protein itself. The body cannot break these clumps down and dispose of them, so they accumulate in the brain
Alzheimer’s Disease
- AD is a progressive, degenerative, irreversible dementia
- Damage increases and can’t be repaired
- Symptoms: Progressive Loss of memory, Loss of judgment & reasoning, Changes in mood and behaviour
- Approximately 5-10% is familiar caused by a gene mutation (early onset)
- It is believed to be caused by the death of neurons & disruption of neurotransmitters
- Also involves neurofibrillary tangles & beta-amyloid plaques. “plaques,” which are numerous tiny, dense deposits scattered throughout the brain that become toxic to brain cells at excessive levels, and “tangles,” which interfere with vital processes, eventually choking off the living cells. When brain cells degenerate and die, the brain markedly shrinks in some regions
- disease leads to nerve cell death and tissue loss throughout the brain. Over time, the brain shrinks dramatically, affecting nearly all its functions.
- ventricles grow larger, sulci are noticeably widened and there is shrinkage of the gyri
There are two different types of Alzheimer’s:
Sporadic
Familial Autosomal Dominant
Sporadic
- 90-95% of cases are Sporadic
- Usually occurs after 65
- May or may not be a family history
- No single cause identified, but some proposed causes are: slow viruses, problems with immune system, chemical imbalances, head injury, environmental pollutants
Familial Autosomal Dominant
-Associated with several chromosome sites:
>Chromosome 1, with age of onset between 40-85
>Chromosome 14, with onset between 28-65
>Chromosome 21, with onset between 45-65
-While there is a 50% chance of inheriting the disease associated gene, expression likely depends on a “trigger”. This suggests that not all persons who have the gene will necessarily develop AD.
Variations in Alzheimer’s
- can span 3 – 20 years, with the average length of the disease between 8 – 12 years.
- the order in which symptoms appear, and the length of each stage will vary.
- About twice as many women as men have AD or a related dementia
Testing for Alzheimer’s Disease
- Only way to know for certain is a brain autopsy after death
- There is no definitive clinical test for Alzheimer disease.
- Therefore, a series of tests is used to rule out treatable causes of dementia.
- The basic workup consists of a thorough history and physical examination and a cognitive screening test such as the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA) or the Blessed Dementia Scale.
Diagnosing / Treatment Alzheimer’s
Diagnosis:
-Although Alzheimer’s disease can be diagnosed definitely only at autopsy (even here, 11% of dementias cannot be categorized despite microscopic examinations), the diagnostic accuracy of the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRDA) criteria is as high as 85% to 90%.1
Treatment:
- No treatment can stop AD. However, for some people in the early and middle stages of the disease, the drugs tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), or galantamine (Reminyl) may help prevent some symptoms from becoming worse for a limited time.
- These drugs help some people function better in daily activities such as bathing and eating, and may improve memory, language and other cognitive abilities.
Definitions of Death
-the irreversible cessation of vital functions, especially as it involves brain activity
The Grief Process
-People who are dying, and their families and loved ones, experience a process of grief and loss.
-Kubler-Ross’s Stages of Grief is one theory that explores people’s reaction to loss.
>people do not move through the process in a linear manner. Some people may not experience some stages at all, or to greater or lesser extents than others. Some may return to “previous” stages, or experience more than one at once. Some may remain in one stage.
Kubler-Ross
DENIAL [and Psychological Isolation]
- “It can’t be true”; “I don’t believe it”; these are natural reactions on hearing about one’s imminent death
- Let the person set the pace; listen, be empathic, keep communication open; don’t insist that he or she must accept his or her death
- Denial defends against overwhelming anxiety; over time the need for denial will usually diminish
ANGER
- Comes with the realization that the person’s life will be ended, and that he or she will be prevented from continuing to participate in life and from doing the things and being with the people that are important; it comes from envying the living
- Continue to listen to the person; allow them to express their anger; don’t take the anger personally; by remaining calm you help the person to defuse their own anxiety & remove the need for defensiveness
BARGAINING
- This is an effort to maintain hope; it’s the idea that if only I can be given more time I will dedicate myself in some way to being a better person.
- In fact, hope is believed to be consequential in some cases, for example, the father who “hangs on” just long enough to see his daughter married
DEPRESSION (& Preparatory Depression)
-Is experienced when the dying person arrives at understanding that his or her death is inevitable
This is a time of reflection, of life review, and sometimes of regrets. It’s a time of preparation for separation from loved ones
-Continuing to allow the person to experience and express how he or she feels is important; at times, this may mean simply being with the person in silence [don’t feel that you have to know all the words to say; listening is better than saying too much]
ACCEPTANCE
-Family and close friends are more important at this time. This is a stage of resolution. The person has worked through their own grief and is prepared for death. In this last stage, the person appears almost devoid of feeling. It is a time of separation.
Supporting and Caring for the Person who is Dying
Physical considerations
- When needed, provide nutrition, hygiene, rest, help with elimination and comfort needs, and assistance with pain relief as required
- Manage the physical and social environments to ensure that they are conducive to comfort and rest
Emotional considerations
- Spend time with the person to provide support
- Provide opportunities to talk about self, dying and feelings
- Listen to the person when he or she does want to talk about self, approaching death and feelings
- Do not take away the person’s hope or force him or her to talk about death. LET THE PERSON LEAD THE WAY.
Spititual
-Help the person address spiritual needs by listening, supporting, and enabling appropriate spiritual leaders to provide their support when desired.
Health Care Directives
• Health Care Directives (sometimes called “living wills” or “Advance Care Directives”) allow people to express their wishes for treatment in the event that they become unable to express their wishes.
• HCDs are written when a person is competent/able to state what they want in the future under certain circumstances. A simple example may involve a patient with terminal cancer who fills out a HCD stating a wish that no CPR be performed in the event of a cardiac arrest.
• HCDs also allow people to appoint a health care proxy. This is a person who is authorized to make care decisions on that person’s behalf in the event that person becomes unable to express their wishes.
It is vital that a health care proxy makes decisions that he/she believes that the patient would want, rather than what the proxy thinks is the right thing to do
What is the purpose of a Health Care Directive?
-The Health Care Directives Act allows person to express their wishes regarding the amount and type of health care and treatment they wish to receive in the event they become unable to speak or otherwise indicate their wishes. It also allows someone to appoint another person [‘proxy”] with the power to make medical decisions for them if they are not able to make them
What is the effect of a Health Care Directive?
-The wishes expressed in the Directive are binding on friends, relatives and health care professionals (unless they are not consistent with accepted health care practices), and will be honoured by the courts.
Right to Die
-There are many concepts related to a person’s right to die at a time of their own choosing.
-You are now aware that Canada has implemented Medical Assistance in Dying Legislation.
-At this time, nurses DO NOT participate in the administration of a substance that can cause death. Only physicians and Nurse Practitioners have the legal authority to do so.
-Under the current structure of the law, it is also illegal to “counsel” a person to commit suicide. (See the statement for more guidance). What this means for nurses is that nurses can provide information on MAID, but SHOULD NOT encourage a patient to obtain MAID.
-Most recently (February 2020), the Liberal government is introducing a bill to remove the requirement that death must be “reasonably foreseeable”
–Types:
>Euthanasia The act or practice of painlessly putting to death persons suffering from incurable or distressing (terminal) diseases
>Assisted suicide is generally used to mean providing a person with the means to end their own live.
Euthanasia
EUTHANASIA: The act or practice of painlessly putting to death persons suffering from incurable or distressing (terminal) diseases.
There are two types of euthanasia: ACTIVE and PASSIVE.
>Active: Deliberately hastening death; doing something to the person to hasten death.
>Passive: Omission of care or inaction to prolong life. Individuals can define the conditions under which they choose not to have life-saving measures implemented (either at the time of choice or through a health care directive).
Define:
Hospice
Bereavement
HOSPICE
-Refers to caring for terminally ill persons in a home-like environment. The emphasis is on treating the dying person with dignity and on being acutely sensitive to the wishes of the dying person.
BEREAVEMENT
-Refers to the loss of a loved one through death. It is a statement of fact and doesn’t refer to how the person reacts to the death. Someone who has lost a loved one to death is bereaved.
Grieving
Refers to the distress caused by the death of a loved one. It appears to have different stages that are typically characterized by:
- Shock & numbness
- Preoccupation with the deceased person & with expressions of grief
- Acceptance of loss and integration back into the mainstream of society
Length & intensity of grieving process is individualized, & depends on a number of factors (?):
- How well you knew person
- Age of person
- Whether death was sudden or prolonged
- Personality; culture; religion; presence or absence of support network
- Grief is not necessarily an orderly progression through specific stages.
- Although there seems to be a characteristic pattern, each person has his or her own experience with grief.
- The intensity of pain can vary from time to time, with pain returning “just when I thought I was doing fine.
Supporting a person who is grieving
• Grief is not an illness that needs to be fixed, but is a normal reaction to loss • How can we support people experiencing grief? • Avoid platitudes: >“everything will be alright” >“everything happens for a reason” • Avoid judgments: >“you shouldn’t feel this way” >“that’s not a nice thing to say” • Instead Do: >Simply be with the person >Sit and listen to the person >Permit the person to express his or her real thoughts and feelings without judgment >Respond with empathy
