Topics On Care Of Elderly
- Topics On Care Of The Elderly
Parkinson's Disease 1. What are the causes to Parkinson's disease? Parkinson’s disease is a neurodegenerative condition that affects a specific part of the brain called basal ganglia. It is still a mystery what causes the neurodegeneration process. This part of the brain coordinates movements of the body, making it smooth and purposeful. As a result of the degeneration of nerves there, movements of muscles become affected. Movement is stiff and coarse, hence gives the typical features of Parkinson’s disease, being tremors and rigidity. This degeneration may be genetic, due to ageing, due to environmental toxin. 2. Who are more prone to getting this illness? Many people have a conception that this is a elderly's illness, is it true to say so? what is the age range of the patients? what which age group is the most common? Older people tend to develop Parkinson’s disease. It is common among those above age 50 years, with the average age being 60 years old. The incidence and prevalence of PD increases with age. The reasons why older people tend to develop the condition is because number of brain cells on the whole is reduced in old age, so easier to get imbalance of neuro chemicals at the basal ganglia. a. Is there a difference in the risk of male and female? Males tend to have higher risk of developing PD than female. Not sure what the reasons are. b. How does our daily life affect our risk of getting this illness? e.g. lifestyle, eating habits, stress level, hereditary, etc. Environmental factors linked to development of PD include manganese or iron toxicity, carbon monoxide poisoning, chronic alcohol abuse, heavy metal toxicity, exposure to pesticides, use of illegal drugs, repeated trauma to the head (brain) as in boxers, hereditary (has a genetic basis in some families with PD). Stress increases production of free radicals in the body, and these free radicals may cause or aggravate neurodegeneration potentiating PD. 3. What are the symptoms of Parkinson's disease? Initial stages – may just present with mild tremor or shaking of one limb and usually affecting only one side of the body. As it progresses, it gradually involves both upper and lower limbs of both sides. Intermediate stages – person usually have postural instability and may present with falls. Their sense of balance is affected, usually falling forward or backward. They are unsteady on their feet and maintains a stooped posture. They usually walk with little or no arm swing, taking small steps. But as they are stooped, they end up walking faster and faster, like someone chasing after their own centre of gravity, and finally they fall. They would also have a ‘masked like facies’ – meaning little facial expression and blinking of the eyes. They may also drool saliva because of slow swallowing of their saliva. Advanced stages – their instability worsens and need assistance in walking or even confined to a wheelchair. They start having difficult swallowing and in more advanced cases, may even be tube fed because of inability or unsafe to swallow. In advanced stage, they may also become demented. 4. How does doctors diagnose and confirm that the patient have contracted this illness? This is a clinical diagnosis and the main features are the presence of 3 out of 4 signs – tremor, rigidity, postural instability and slowness in movement or to initiate movement. Blood test and brain scans are usually normal. 5. How do you treat this disease? The main stay of treatment is to address the imbalance between inadequate dopamine and excessive acetylcholine. Various medications are available – either to increase dopamine (using levodopa) or via dopamine receptors (using dopamine receptor stimulant like bromocriptine) or reducing acetylcholine (e.g artane). In some cases, and when the patient is relatively young, surgery may be able to reduce the tremors and rigidity when medications do not work well. a. What is the most important factor for recovery? Medications and exercise is important. The condition can be controlled by medications and there is no know treatment to heal the condition completely. 6. Is it possible to recover fully from it? No 7. How long does it take to recover? and what is the recovery process like? Patients usually respond to medical treatment for the first 5 years or so, later, they become less and less responsive and may develop complications as a result of the medications – e.g. ‘end of dose effect’ – just before the next dose of medication, patient become very stiff and trembles; ‘peak dose dyskinesia’ – where after a dose of medication is taken, the person develops involuntary movement as though he had an excessive dose of medicine. 8. Is there anything we can do to prevent ourselves from getting this illness? Mainly to reduce degeneration of nerve cells of the brain – take antioxidant rich food - food rich in Vit C, Vit E and gingko biloba. Food rich in Vit B12 (like meat, eggs), folate (green leafy vegetables), brightly coloured fruits (strawberries, blue berries, tomatoes, lantern peppers). Meat should be taken only in moderation. Exercise is important, so as physiotherapy to improve muscle mass and improve balance and walking stability. Do feel free to add on if there is any piece of information that i have missed out and your would like to share. This article would be due on 12/7 thus it will be good if we can arrange the interview with the patient and their family during next week. Patient that I have arranged for your interview presented with shaking of the hands and falling.
Medicine and The Elderly It is sometimes evitable for the elderly to be taking medicine. There are some gender differences in the way elderly takes medicine. Elderly men tend to be more stoic and tend not to see a doctor until they are quite sick, and once they are well, they also have a tendency to default their follow up. Women, on the other hand, tend to seek consultation earlier and they tend to be more ‘obedient’ in following the orders of the doctor with respect to taking their medications. Hence, I am not surprised that your dad is one of those who ‘always disobey doctor’s prescribed medications’. However, I feel that the key to getting those who are not so compliant into taking their medications is patient education. Half-truths are as damaging as ignorance, or may be even worst. People have the tendency to think that traditional Chinese medicine (TCM) is not medicine. In fact, medicines are basically chemical agents that are meant to improve the person’s health, either by enhancing the health or treating the disease. Western medicine are man-made or man-modified chemical agents, while some TCM are naturally occurring chemical agents. Both can be beneficial to the person if taken for the correct indications and at the correct dose, and both can be equally damaging if abused. Similarly, all these chemical agents are absorbed in the gut and all will pass through the liver, detoxified and excreted either through the liver (via bile) or through the kidneys (via urine). So, both also have the potential to damage the liver and the kidney if taken at the wrong dose or for the wrong indications. In Western medicine, through various studies, we actually know that certain combinations of medicine are beneficial for the person; for example, the use of ACE inhibitors in a diabetic patient with high blood pressure can protect their kidneys from damage due to their diabetes. I am sure it is the same for TCM where they have their own system of combining herbs for the treatment and protection of the body. The point is, therefore, that they should obtain their TCM from a suitably qualified TCM Practitioner, just as they would get their Western medicine from a suitably qualified doctor. Since we do not know exactly the chemical content of naturally occurring herbs, it is always prudent not to take it with Western medicine. But knowing our local elderly, you know that some of them will do so regardless of what you tell them. Therefore, if they must, take their TCM at least 2 hours apart from their Western medicine. TCM should not be taken at all if the person is taking certain Western medicine – example, oral anticoagulants like Warfarin. This is because depending on the type of TCM, they could either enhance the effect of Warfarin and cause bleeding, or reduce the effect of Warfarin and render it ineffective as a blood thinner. Other ways of ensuring compliance of taking medicine include simplifying the regime. Some regimes are so complicated that it is confusing to the elderly. For example, a certain medicine to be taken before food once a day except two days of the week that it is taken twice a day. Using a pill box to organize the pills helps. The elderly also should have an understanding of what they are taking, rather than just swallow a whole lot of medicine without knowing what they are for. If you detect a genuine difficulty in compliance to medicine because the person just cannot remember in spite of all the above aids given, it could be that the person is suffering from dementia and this warrants an assessment. When a person takes a medicine and develops a rash or hives which are widespread and itchy, then this person may be allergic to the medicine taken. He has a drug allergy and not skin allergy. Sometimes, the offending agent may not be so obvious. It may be some air borne dust, insect bite, food or even heat, friction, sunlight and exercise. The skin reacts to these stimuli by releasing certain chemicals that cause swelling, itch, redness and warmth. In the elderly, a common cause of itchy skin is actually xeroderma or dry skin. The different types of skin allergy are eczema, allergic contact dermatitis, urticaria and angioedema. Skin allergy may be a symptom of other medical conditions like asthma, skin infections and blood disorders. If skin allergy is left untreated, the patient may have a poor quality of life because of the itch, which varies in intensity. Their sleep may be disturbed. The scratching will damage the skin and increases the risk of skin infection. The underlying medical condition like asthma and blood disorder may not be discovered.
Geriatric Care For Chronic Diseases Introduction: Over the years, the pattern of diseases changes from acute to chronic. While in the past, patients often die from acute conditions, like acute myocardial infarction, now, it is not uncommon to find many survivors, perhaps, not of just one AMI, but a number, and in the process, developed chronic or even intractable heart failure. The same goes for strokes and fractures. With improved and safer living environment, better nutrition and medical healthcare available, the average life expectancy of the Singapore population has risen to 78 years old in males and 82 years old in women. This increase in life expectancy also meant that whatever medical conditions that they had developed at a younger age would accumulate and carry over into old age. Not only that, these conditions would also manifest changes associated with end organ damage as a result of years of having that condition. For example, a person may have high blood pressure from age of 50, and by 65 years old, he would have had high blood pressure for 15 years, and may start developing end organ damage like strokes, peripheral vascular disease, heart disease and or kidney damage. As he grows older, he may develop certain conditions that are more prone in the elderly, like diabetes (affecting eyesight, sensation and nerves), Parkinson’s disease (affecting balance and movement), enlargement of prostate (affecting urination), arthritis (pain, instability and weakness) and so forth. At the same time, bodily and organ changes occurs due to ageing. Atrophy of organs and tissues occurs and their functional and reserve capacity declines. They become even more prone to further insults from trauma, infection, inflammation, toxins, chemicals and drugs. All these meant that the older person is prone to have medical conditions and their complications affecting many organs. Sorting out which is caused by disease, which is caused by ageing, which is acute, which is chronic or acute on chronic, becomes more complicated. Many chronic conditions have no cure. In the light of an elderly person with multiple and chronic medical problems intertwined with ageing issues and poor reserves, geriatric care becomes the mainstay of management. The traditional model of medical care takes the ‘organ specific’ route. In other words, a heart condition is managed by a cardiologist, lung condition by a respiratory physician, strokes by neurologist, dementia by psychiatrist and so on. But from the above scenario, it would be translated to having multiple specialists managing a single elderly person with chronic diseases. Multiple specialists, however, does not necessarily translate to better care as each look only towards their own area of specialty and this often lead to multiple doctors’ appointments and polypharmacy. There is also no single doctor to take charge of coordinating care and medications, and this role may sometimes fall onto a caregiver who is likely to be a layperson, and sometimes, even the maid. The elderly person also does not manifest illness in the same way as the younger population. Neuropathy may mask the pain of a septic or gouty arthritis while dementia may cause them to forget that they had a recent fall or trauma, or some symptoms which may be useful to aid in their diagnosis. A change in environment, such as hospitalization, could cause acute confusion in an elderly person with borderline dementia. A chest infection, even before the first signs of cough, phlegm or fever, may manifest as a fall or incontinence. Thus, illnesses may present as vague or totally unrelated symptoms which are peculiar yet common in the elderly: like instability, immobility, incontinence and impaired cognition, also referred to as the Giants of Geriatric Medicine. As in all medicine, the key to treatment is early detection. Such vague presentations may make diagnosis difficult. Late diagnosis lead to higher morbidity, a longer hospital stay, higher medical cost, poorer outcome and higher mortality. Yet, with early diagnosis and appropriate treatment, outcomes in the elderly remained good, even in ICU cases. In studies of patients admitted to the ICU, when severity of illness is controlled, differences in survival between age groups disappear. Preadmission health status, functional status, and physiologic states were more important predictors of long-term survival after intensive care than age was. Response to treatment by the elderly is also different from the young. The difference in response stem from age related immune responses, changes in pharmacokinetics and pharmacodynamics. Thus, it led Ignatz Nascher to propose that disease and medical care of the aged should be recognised as a separate specialty and invented the term “geriatrics” in 1909. However, the growth of geriatric medicine and healthcare of the elderly is often attributed to the pioneering work of Majorie Warren who successfully treated and rehabilitated seemingly hopeless elderly patients in the UK in the 1930s. Today, the British Geriatric Society defines Geriatric Care as that branch of general medicine concerned with the clinical, preventive, remedial and social aspects of illness in older people” and the goal of geriatric care is “to restore an ill and disabled person to a level of maximum ability and wherever possible return the person to an independent life at home.” The wide definition necessarily implies that geriatric care must be delivered in both hospitals and community, requires a multidisciplinary approach and shares overlapping philosophies with preventive, rehabilitation, palliative and family medicine. Principles of geriatric care The cornerstone of geriatric care is a comprehensive geriatric assessment (CGA), where any elderly presenting to the doctor should have an opportunistic assessment – not just of the complaints which brought them, but also to ‘hidden’ conditions like incontinence, depression, dementia, osteoporosis and falls. These ‘hidden’ problems are commonly found in chronic diseases like stroke and arthritis. CGA is likely to identify conditions which could be treated early or potential problem areas which should be monitored closely. The second cornerstone of geriatric care is an obsession with functional abilities (or disabilities) of the elderly person. This obsession with function arose from the concept of ‘ageing in place’. ‘Ageing in place’ is
Forgetfulness It's Not Always What You Think Introduction Many people regardless of age worry about becoming more forgetful. Whenever I spoke in a forum about forgetfulness and dementia, many in the audience would say they have all the symptoms I described. They think forgetfulness IS dementia. In the past, memory loss and confusion were considered a normal part of aging. However, scientists now know that most people remain both alert and able as they age, although it may take them longer to remember things. The interest in emory and dementia has lead to an increased numbers of 'Memory Clinics' to spring up in most Hospitals. There has also been much progress in the understanding of this aspect of cognition, and different names have come up to describe the different stages in the continuum between normal cognition to the stage of obvious dementia: Age associated memory impairment (AAMI): In AAMI, the person is usually 50 years or older with subjective memory decline (i.e. person often realizes that his memory is declining) and objective evidence of memory loss (with memory test, and score of at least 1 SD below mean of younger patients). However, there is adequate intellectual function and absence of dementia or memory affecting diseases e.g. stroke, cancer or poorly controlled diabetes. By definition, AAMI does not interfere with Activities of Daily Living. Incidence of dementia among patients with AAMI is about 2.5% per year. Mild cognitive impairment (MCI): In MCI, the cognitive changes are serious enough to be noticed by the individual or people around them, but not severe enough to interfere with daily life or independent function. The disabilities they have also do not meet the diagnostic criteria for dementia. MCI is classified based on the cognitive skills that are affected. MCI that primarily affects memory is known as "amnestic MCI." With amnestic MCI, a person may start to forget important information that he or she would previously have recalled easily, such as appointments, conversations or recent events. MCI that affects thinking skills other than memory is known as "nonamnestic MCI." Thinking skills that may be affected by nonamnestic MCI include the ability to make sound decisions, judge the time or sequence of steps needed to complete a complex task, or visual perception. Some MCI remains stable for years; some may improve while some will progress to dementia. Some studies have suggested an annual conversion rate from MCI to dementia as 3.3 – 4.2%. Dementia: People who have serious changes in their memory, personality, and behavior may suffer from a form of brain disease called dementia. The term dementia describes a group of symptoms that are caused by changes in brain function. Dementia symptoms may include poor recent memory; asking the same questions repeatedly; getting disoriented about time, people, and places; becoming lost in familiar places; being unable to follow directions or instructions; and neglecting personal safety, hygiene and nutrition. People with dementia lose their abilities at different rates. There are many cognitive tests that can be administered to assess functions of various parts of the brain. Most of these tests assess short-term memory (either as a 4 digit number, 3 or 5 unrelated objects to remember and recall later), orientation to time, person and place, language, ability to follow instructions and or abstract thinking skills. The commonly used ones are the Mini Mental State Examination (MMSE), Chinese Mini Mental State Examination (CMMSE), Elderly Cognitive Assessment Questionnaire (ECAQ), Abbreviated Mental Test (AMT), Montreal Cognitive Assessment (MoCA) and the Clock Drawing Test (CDT) or Clock Completion Tests (CCT). Scores that are below the ‘cut-off’ for that test indicates cognitive impairment. The various components tested in the above tests will enable us to decide if they fit into the diagnostic criteria for dementia, as dementia is a common cause of cognitive impairment in older people. In cases which are inconclusive after using these ‘bedside’ tests or when they are being assessed for decision making capacity, neuropsychological tests may be necessary. The most commonly used criteria to diagnose dementia is the DSM IV criteria. DSM IV criteria: The development of multiple cognitive deficits manifested by both (1) Memory impairment (impaired ability to learn new information or to recall previously learned information) (2) One (or more) of the following cognitive disturbances: (a) Aphasia (language disturbance) (b) Apraxia (impaired ability to carry out motor activities despite intact motor function) (c) Agnosia (failure to recognize or identify objects despite intact sensory function) (d) Disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting) The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning. The course is characterized by gradual onset and continuing cognitive decline. The cognitive deficits in Criteria A1 and A2 are not due to any of the following: (1) Other central nervous system conditions that cause progressive deficits in memory and cognition (e.g., cerebrovascular disease, Parkinson's disease, Huntington's disease, subdural hematoma, normal-pressure hydrocephalus, brain tumor) (2) Systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection) (3) Substance-induced conditions The deficits do not occur exclusively during the course of a delirium. The disturbance is not better accounted for by another Axis I disorder (e.g., Major Depressive Episode, Schizophrenia). There are many causes of dementia, namely, Alzheimer’s disease (AD), Vascular Dementia (VaD), Dementia with Levy Body (DLB), Frontotemporal Dementia (FTD), Dementia associated with Parkinson’s Disease etc. The two most common forms of dementia in older people are Alzheimer's disease and vascular dementia. These types of dementia are irreversible, which means they cannot be cured. In Alzheimer's disease, nerve cell changes in certain parts of the brain result in the death of a large number of cells. Symptoms of Alzheimer's disease begin slowly and become steadily worse. As the disease progresses, symptoms range from mild forgetfulness to serious impairments in thinking, judgment, and the ability to perform daily activities. Eventually, patients may need total care.