Ageing & Palliation. Dr. Thiru Thirukkumaran Palliative Care Services Northwest Tasmania

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Gavin Simon
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1 Ageing & Palliation Dr. Thiru Thirukkumaran Palliative Care Services Northwest Tasmania

2 How this Session is planned? What is palliative Care? What changes take place when a young adult becomes elderly? What are the implications on society with ageing? How Palliative Care approach is helpful in Elderly patients?

3 What is palliative Care?

4 Research suggested that defining palliative care is problematic. This appears to be true as the literature provides several definitions of palliative care.

5 Palliative Care Australia: Strategic Plan, Palliative care is specialized health care of dying people which aims to maximize quality of life and assist families, carers and their communities during and after death

6 WHO Definition of Palliative Care Palliative care is an approach that improves the quality of life of patients & 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. Palliative Care: provides relief from pain and other distressing symptoms; affirms life and regards dying as a normal process; intends neither to hasten nor 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, including bereavement counselling, if indicated; will enhance quality of life, and may also positively influence the course of illness; is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.

7 Palliative Care Models of Service Delivery

8 In Simple English. The active total care (Holistic Care) of patients whose disease is not responsive to curative treatment. But the new model of PCS includes symptom management of early stages of cancer patients who have life prolonging treatment. To achieve better symptom control, multidisciplinary approach is paramount. The goal of palliative care is achievement of best quality of life for patients and their families. Palliative care management is not to shorten or postpone death. It allows the patient to live as actively as possible until death.

9 Multidisciplinary Approach in Palliative care Why?

10 Example: Concept of Total Pain The experience of pain is influenced by physical, emotional, social & spiritual factors. Attitudes Extent of Nociceptive insult Beliefs Previous Pain Experiences Cognitive Understanding Individual Pain Experience Cultural factors Individual coping Strategies Current emotional status

11 Who provides palliative care services? Palliative care involves coordination of the skills and disciplines of many service providers. Those involved in palliative care may include: 1. Specialist providers: medical, nursing and allied health staff who have significant experience in the area 2. Generalist providers: those clinicians (medical, nursing and allied health) working in other areas of the health system who have a professional involvement with people requiring palliative care; and 3. Support services: including those who assist with the processes of daily living, enhancing quality of life, and/or providing emotional and spiritual support

12 Palliative care services Palliative care services can be provided in the home, in communitybased settings like nursing homes, palliative care units, and in hospitals. People who are dying need to be able to move freely between these places in response to their medical care and support needs. The pattern of care will be different for every individual, and may depend on factors like: geography, services in an area, and the needs and desires of the person, family members and friends. In general, palliative care is best provided within close proximity to the person's local environment and community.

13 Elderly WHO defines those aged years as elderly, and those older as aged. In terms of demographic ageing, the statistical figure given to the population in older ages is conventionally taken as 65 years and older.

14 What changes take place when a young adult becomes elderly? 1) Physical Changes 2) Psychological Changes 3) Shifting Social pattern 4) Financial Burdens 5) Spiritual needs

15 Spiritual Needs. Spiritual needs are different My Beliefs / Values... Death.! Not every one But many worried about the uncertainty going from known place to unknown place. Never travelled before.. Who is there.? I have to make some thing right!.. I need to talk to some one! I want to record my thoughts about my life

16 Financial Burdens How much I have to pay to the N/home? Social Isolation Shifting Social patterns. pay as you go system in many ways Psychological Changes. Physical impairment, social isolation, slow thinking process, feeling of loosing control, needing assistance & dependency lead to frustration, depression & other psychological conditions

17 Physical Changes in Vital Organs Heart / Lung / Kidneys / Brain / Liver Other Systems Blood Vessels / Intestine / Skin / Hair Functional Status Decline in Activities of Daily Living

18 Heart: 1. The cardiac output decreases with ageing 2. Increase in diastolic & systolic myocardial stiffness, due to interstitial fibrosis in the myocardium 3. Arteriosclerosis develops.

19 Circulatory System : 1. A progressive increase in blood pressure with ageing 2. High blood pressure is a significant risk of stroke, Coronary Heart Disease and Congestive Heart Failure 3. Atherosclerosis increase with ageing 4. Raise fibrous plaques in the blood vessels (30 % increase by 70 years)

20 Lungs: 1. The lungs show impaired gas exchange 2. Decrease in vital capacity and 3. Slower expiratory flow rates.

2. Decline the total number of glomeruli per kidney 3. Decrease tubular function with ageing 4.

21 Kidneys: 1. A gradual decrease in the volume & weight of the Kidneys ( 9 th decade renal size is about 70 % of the 3 rd decade) 2. Decline the total number of glomeruli per kidney 3. Decrease tubular function with ageing 4. Both the concentrating and diluting ability of the kidneys also slowly deteriorates. 5. Urinary incontinence (in 17 % men & 23 % women over 65 years) Bladder capacity decreases with ageing 6. Prostate BPH in older men (90 % present in 80 years)

22 Brain: 1. Age related Cerebral Atrophy 2. High risk of TIA / Stroke

23 Skin : 1. Atrophy of the epidermis occurs & turnover rate of cells decreases with age 2. Decrease in epidermal cell growth and division contribute to the increased incidence of decubitus ulcers in older patients. 3. Dermal collagen becomes stiffer and less pliable with age; elastin is more cross-linked and has a higher degree of calcification. These changes cause the skin to lose its tone and elasticity, resulting in sagging and wrinkling.

24 Oesophagus: 1. Oesophagus motility disturbances [ decrease peristaltic response / delay in transit time / decreased relaxation of the lower sphincter on swallowing] 2. Non peristaltic contractions is common in elderly Stomach: 1. The incidence of atrophic gastritis increases significantly with age. [Severe atrophic gastritis results in achlorhydria, deficient intrinsic factor secretion]

25 Colon: 1. A decrease in intestinal motility occurs with age. 2. The colon becomes hypotonic, which leads to increased storage capacity, longer stool transit time and greater stool dehydration. [Leads to chronic constipation with ageing]

26 Liver: 1. The liver decreases in weight by as much as 20 % after the age of Alteration in hepatic drug metabolism

27 Osteoporosis: 1. Osteoporosis is a skeletal disorder characterized by a decrease in bone mass which may result in mechanical failure of the skeleton. The decrease in bone mass is an age-related phenomenon. 2. Beginning in the fourth decade there is a linear decline in bone mass at a rate of about 10 % per decade for women and 5 % per decade for men. 3. By the 8 th & 9 th decades 30 % to 50 % of the skeletal mass maybe lost.

28 Menopause: 1. Nowhere are the development of age-related changes more apparent than in the human female. 2. Several consequences of the menopause & they are: - the vasomotor instability or hot flashes. - Changes in skin temperature, skin resistance - High risk of arteriosclerotic cardiovascular disease - waking episodes. Insomnia with possible physiological psychological disturbances - Osteoporosis Oestrogen Hormone play a role

29 Musculoskeletal System : 1. The age-dependent decline in body mass due to loss & atrophy of muscle cells. 2. Age-related changes also occur in the innervation of muscle but the exact pathologic process is not well understood.

30 What are the implications on society with ageing? Healthcare Resources Disabilities / multiple healthcare problems & Frequent hospital visits Increasing demand of healthcare resources Prolonged in-patient stay (prolong recovery; waiting for placement ) Need more home visit by community professionals Social Support Large proportion of home care services for older people Increase community dwellers with respite care needs Nuclear families ; husband & wife (both) are working less family support Economy: Need more funding to augment the health /social services Pension funding / transport

31 POPULATION PYRAMID AUSTRALIA IN 1990 & 2010

32 OLDER PEOPLE In the 12 months to 30 June 2010, the number of people aged 65 years and over in Australia increased by 94,800 people, representing a 3.3% increase. The proportion of the population aged 65 years and over increased from 11.1% to 13.5% between 30 June 1990 and 30 June 2010 Population Aged 65 years and Over

33 Statistics Tasmania at a Glance 2011 POPULATION (Estimated resident population as at 30 June) Males Females Persons to 14 years to 24 years to 64 years Aged 65 and over Median age of population years

34 Tasmania at a Glance 2011 [ Statistics] HEALTH AND WELLBEING Life expectancy at birth Males years Females years Standardised death rate (per 1,000 standard population) Average Medicare services processed Per person number Per male number Per female noumber Persons with private health insurance % CAUSES OF DEATH Leading causes of death per 100,000 population(a) Cancer (Malignant neoplasms) rate Ischaemic heart disease rate Stroke rate Significantly increasing number of older people in Tassie; Why?

35 How Palliative Care approach is helpful in Elderly patients?

36 Disease Trajectories

37 Palliative Care approach to Elderly Patients -1 The principles of palliative care can be applied to any person and in any setting. Palliative care encompasses all other non-curative diseases/ illnesses such as End stage COPD / Heart failure / Chronic renal & Liver failure / Neurological conditions. End of life care incorporates the frail elderly who enter a terminal phase due to the ageing process.

38 Factors underlying adverse drug reaction in the Elderly Increasing Age Altered renal / hepatic Multiple Poor memory/ Function Pathology Eye sight Altered Pharmacokinetics/ Poly pharmacy Poor Pharmacodynamics Compliance Increased adverse drug reactions

39 The Department of Human Services have outlined the followings in the planning of care for people with life threatening illness and their carers & families. 1) The health and residential care workforce practices the palliative care approach; 2) There is equitable access to a level of specialist palliative care across the state; 3) The mix of bed-based and community-based specialist palliative care services is appropriate; 4) Care and referral pathways are clearly defined and options are identified; 5) Communication strategies ensure general practitioners, community care providers and other health providers are fully informed of, and able to participate in, the care plan for patients under their care; 6) Effective and efficient links exist between hospitals and community based services; and, 7) Sufficient numbers of appropriately trained specialist palliative care providers are available to provide care across a region (DHS, 2004, p.2).

40 How do you define EOLC? The management of patients during last few days, weeks or month of their life, from a point when it become clear that the patient is in a progressive state of decline

41 Is there any differences in treating End stage malignant, non-malignant or Elderly patients in End of life care? Answer is NO difference in comfort care

42 End stage non-malignant & Elderly in End of life care Look for patients wishes & understandings This includes sensitive EOLC communication / Advanced care planning & supporting the patient / family Multidisciplinary approach & co-ordination among the services ( GP / Community Nurses /Specialist Palliative care Services / Allied health services ) Rationalise the oral medications give only the essentials drugs to keep the patient comfortable through the appropriate route (example: Pain patch or Syringe driver for some one can t swallow. Symptom Management

43 Main Distressing Symptoms in the EOLC Pain SOB Secretions / Death Rattle Anxiety Confusion & Terminal restless Nausea / Vomiting Bowel / Bladder obstruction & related issues Cancer wound management

44 Rural Palliative care Challenges The rural palliative care challenges may also include a lack of education and a lack of palliative care expertise. (Cairns and Yates 2003) Clearly this is a major problem in our area & Palliative Care Services NW/ Tassie is organising work shops, informal discussions with local Community Teams (GPs & CNs) & organising teaching sessions Rural palliative care faces particular challenges in supporting a client and his or her family within the community where that person has chosen to die at home. Another major issue in NW Tassie!- lack of resources / Staff

46 Thank You!

What is palliative care? What is palliative care? Dr Claire L Hookey

What is palliative care? What is palliative care? Dr Claire L Hookey Palliative Care an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening