Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat the University of Pécs and at the University of DebrecenIdentification number: TÁMOP-4.1.2-08/1/A-2009-0011

GERIATRIC CARE MANAGEMENT FORSUCCESSFUL AGING

Gyula Bakó and Márta BalaskóMolecular and Clinical Basics of Gerontology – Lecture 21

Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat the University of Pécs and at the University of DebrecenIdentification number: TÁMOP-4.1.2-08/1/A-2009-0011

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Characteristics of old age

Multimorbidity affects the majority of this populationdisturbance of mobility, self-reliance,communication and social activity inactivity

Increased tendency to develop pain syndromes inactivity

Psychological featuresrigidity; disorders of memory, judgement, emotions and orientation, decreasein cognitive performance inactivity

Isolation (loneliness) inactivityRapid immobilization, loss of self-reliance

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General health-related problems• pressure ulcers (decubitus)• incontinence• feeding disorders• falls• altered mental activity• sleep disorders• mood disorders and pain

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Limitations of everyday activities caused by diseases

age-groups(years)

men women

60-69 40 % 50 %70< 60 % 72 %

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Living conditions of the elderly over65 years of age living in community

Age-groupsLiving alone Living with non-relativesLiving with other relatives (not spouse)Living with spouse

males females75-84 85+ 65-74 75-84 85+65-74

13,0

78,2

6,62,2

19,3

71,2

7,42,0

28,1

47,0

21,1

3,8

33,2

51,1

14,11,7

53,3

27,7

16,82,2

56,8

10,2

27,5

5,5

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Circumstances of seniorsIn Hungary 73% of elderly people live in a household where all members are above 60 years of age. Thus, in need more and more people must depend on other persons, relatives, on the social system or on civil organizations.

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Eldercare systems

Nursing homeSenior day-care facilities In-home care (home care services)HospitalizationAdaptive mechanisms in people getting older get reduced in any change of the environment!

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Housing of people over 65 years of age, living in community Care in a nursing home or in other facility providing long-term care. Considering the type of facility:• It must be assessed whether the person

is in need to become a resident in a geriatric facility. • It should be decided about whether the

patient is at the appropriate place.

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For housing options the followings should be assessed • health needs, • social support – mistreatment, • cognitive functions – dementia, • physical abilities – degree of self-

reliance, • in-home care – continuous supervision

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Housing of peopleover 65 years of ageThe most important needs in facilities for elderlies:• certified chief nurse, • registered nurses, • nurses, • full-time social workers, • therapeutic health professionals,• pharmacists, • rehabilitation therapeutists, • dentists, • nutrition specialists, • cleric services, • medical services.

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Ethical approaches • If a patient suffers from dementia – he lacks

decision-making capacity – his wishes are often overruled by his family or the staff.

• Will to live is important. • Right to be informed.• Medication of such patients who refuse

taking pills is a problem.• Physical abuse – neglect – unprofessional

care.

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Senior day-care facilities

The patients who are no longer able to conduct their lifestyle, but their functions are still relatively maintained. Thus, there is no need for them to be monitored continuously. Housing, meal, and limited assistance with hygiene and drug administration are provided.

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In-home care (home care services) It is advantageous for those who would like to stay at home, but they need some kind of assistance temporarily or permanently because of their medical conditions or disability.

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HospitalizationMore than half of the hospital beds are occupied by patients over 65 years of age!Prevention:• Their activity should be maintained during

hospitalization.• Beds with adjustable height (for sitting or

lying down)– more comfortable. • Infusion, oxygen administration as required.• Glasses, hearing aids, reading….. and

communication!• Appropriate medication.

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Aims of therapy in the elderly• Transition from hospital to (nursing)

home • Relief of e.g. pain• Improvement in self-care, independence• Improvement of physical activity and

fitness• Improvement in functional abilities,

better quality of life (QOL)• Complete recovery (?)

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Primary goal: maintenance or recovery of independenceIn elderlies the possibilities are limited, BUT the expectations are more modest.

Moving Feeding

ClothingHygiene

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Improvement of physical activity and independence • Physiotherapy and occupational therapy for the improvement

of daily activity. • Improvement of muscle strength, stability of joints and

mobility.1 Evaluation of opportunities at home (e.g. warm

environment before and during exercise).2 Teaching and coaching exercises:

- for maintenance and improvement of joint mobility, - for strengthening and training muscles around the joints,

carrying out aerobic exercisesSince atrophy and weakness of the m. quadriceps femoris is not a consequence but rather a cause of the arthrosis of the knee! Exercises also improve proprioception of the joint.

3 Teaching the appropriate use of orthesis and that of the optimal technique of getting up from the ground.

• Eliminating fall-promoting intrinsic (diseases, medications) and extrinsic factors (remove slippers, thresholds, install shower, hand rail).

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Physiotherapy

Effects:- Increases aerobic

capacity- Alleviates pain- Improves muscle

strength- Improves coordination- Improves gait - Improves quality of life

Forms:- Isometric and isotonic

exercise- Exercise improving the

efficacy of locomotion- Exercise improving

coordination - Therapeutic underwater

exercise • Others: thermotherapy, cryotherapy,

mechanotherapy, low-frequency electrotherapy, interference, pulse magnetic therapy

• Therapeutic exercise is the most important element

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Geriatric care and management• It is a really complicated task. • There is a need for multidisciplinary approach

performed by a team. • In Hungary the conditions are not optimal. • The demand is huge. The resources do not

meet the demands. • There is a shortage in the number of health

care providers and the lack of a financial background is also obvious.

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PatientPhysio-therapy

Past

oral

ca

reLogo-pedics

Neuro-

psycho-logyExercise

treatment

Phys

ician

Facio-oral tract

therapy

Socia

l wo

rker

Nursing

service Occu

pa-

tiona

l the

rapy

Personalized geriatric teamwork

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Successful agingSelection (evaluation, analysis, acceptance of the

situation)Ranking of aims, choice of priorities.

Optimization (recruitment)Recruitment of resources necessary for achieving the objectives (e.g. establishment of new routes, learning, trainig, practicing, honing new skills).

Compensation (planning, execution)New strategies (e.g. lists, using ortheses , special tools).

Results: More limited, irrevocably changed, but independent and

useful life.

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Factors influencing aging 1

Aging well

LifeActivity

Social Resources

Material Security

Physical Health and Functional

Status

Cognitive Efficacy

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Factors influencing aging 21 Caloric restriction

A 30% reduction in caloric intakeincreases life expectancy by 40-50 percent (in rodents).Okinawa island – traditionally low caloric intake.40 times as many people live there above the age of 100 years.Rats:• 40% reduced diets – 60 months survival (normal 30 months).• 30% caloric restriction decreases core temperature by 1°C.

Low metabolic rate increases life-span. Fruit flies (Drosophila melanogaster) live twice as long in an 18 °C than in a 30 °C environment.A persistently cold environment reduces life-span because of sustained increase in metabolic rate.

2 Physical fitness (Heat tolerance also becomes enhanced.)

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Advantages of physical fitness: a Active muscles are able to take up glucose without insulin. b Trained muscles are able to burn fats upon exercise (longer than

15 min). With training, on their surface the number of lipoprotein lipase enzyme copies increases.

c In active muscles local metabolites and epinephrine induce vasodilation decreasing total peripheral resistance.

d Physical training stimulates bone formation. A high peak bone mass developed by the age of 25-30 and increased bone formation later on delays the onset of aging-associated osteoporosis.

e Exercise induces elevations in HDL (“good” cholesterol) and suppresses LDL level (atherogenic “bad” cholesterol).

f Exercise helps maintain a healthy BMI and muscle mass.g Physical activity reduces stress without the side-effects of

alcohol or those of tranquillisers.h Exercise ameliorates aging sarcopenia and cognitive decline.i Exercise reduces the risk of thrombosis and that of cancer.

Factors influencing aging 3

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3 Stress, glucocorticoid levels (Frequent and high glucocorticoid levels lead to hyperstimulation of the hippocampus and consequent loss of memory – it may contribute to Alzheimer’s disease)

4 Growth hormone and/or sex steroids5 Antioxidant vitamins, dietary polyphenols6 Melatonin (antioxidant and has a role in sleep regulation)7 Glutamate levels. Glutamate is an excitatory neurotransmitter,

high levels of which (e.g. induced by cerebral ischemia) damage and finally kill neurons (excitotoxin).

8 Cognitive training /psychological balance (life-long learning, positive thinking, religion, etc.)

9 Hormesis Ideal portions of manageable stress (heat shock – 41°C, exercise, caloric restriction, alcohol, acetaldehyde, irradiation, heavy metals, pro-oxidants, hypergravity) stimulate Heat Shock Proteins – HSP, prolong life in animal experiments and in humans. (Measuring and grading, determining the “ideal” dose, age-related modification of doses is a challenge.)

Factors influencing aging 4

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The myth of the “Fountain of Youth”– strange trialsThroughout history, people have been attempting to prolong life, to maintaine or to regain youth at any price.• In 1889 Charles Edouard Brown-Séquard advocated

hypodermic injection of a fluid prepared from the testicles of guinea pigs and dogs, as a means of prolonging human life.

• In 1920 Szergej Voronov experimented with transplantation of monkey testicle as a means to prevent age-related decline in males.

• Placenta products/mother’s milk are believed in and used as means of rejuvenation of the skin and that of the body.

• Stem cells (e.g. ependymal stem cells in the brain) are used at attempts to help the recovery of irreversible organ damage, but even in case of success, anti-aging use is debatable

• RNA-containing creams are sold in order to rejuvenate skin.

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Evolutionary and philosophical considerations• Antagonistic pleiotropy

(breeding and life span, GnRH, human menopause)Prolonged fertility and breeding would shorten life, because of lethal complications at giving birth and proliferative/carcinogenic side-effects of gonadal hormones.

• Is this a disease or is it a programmed phase of life (programmed obsolescence)?

• Benefit for the community or for individuals (apoptosis and senescence).Without senescence and death of former generations there would be no place for new generations.