Managing Geriatric Care for Successful Aging in Elderly Populations - Challenges and Solutions

1. 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 Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011

2. 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 Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011 Gyula Bakó and Márta Balaskó Molecular and Clinical Basics of Gerontology – Lecture 21 geriatric care management forsuccessful aging

3. Characteristics of old age • Multimorbidityaffectsthemajority of thispopulationdisturbance of mobility, self-reliance,communication and socialactivity inactivity • Increasedtendencytodeveloppainsyndromes inactivity • Psychologicalfeaturesrigidity; disorders of memory, judgement,emotions and orientation, decreaseincognitive performance  inactivity • Isolation (loneliness) inactivity • Rapid immobilization, loss of self-reliance

4. General health-relatedproblems • pressureulcers (decubitus) • incontinence • feedingdisorders • falls • altered mentalactivity • sleepdisorders • mooddisorders and pain

5. Limitations of everydayactivitiescausedbydiseases

6. Living conditions of the elderly over65 years of age living in community 2,2 2,0 1,7 2,2 3,8 5,5 6,6 7,4 14,1 16,8 21,1 27,5 27,7 10,2 51,1 71,2 78,2 47,0 56,8 53,3 33,2 28,1 19,3 13,0 65-74 75-84 85+ 65-74 75-84 85+ males Age-groups females Living alone Living with spouse Living with other relatives (not spouse) Living with non-relatives

7. Circumstances of seniors • In 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.

8. Eldercare systems • Nursing home • Senior day-care facilities • In-home care (home care services) • Hospitalization • Adaptive mechanisms in people getting older get reduced in any change of the environment!

9. 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.

10. 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

11. Housing of peopleover 65years of age • The most important needsinfacilitiesforelderlies: • certified chief nurse, • registered nurses, • nurses, • full-time social workers, • therapeutic health professionals, • pharmacists, • rehabilitation therapeutists, • dentists, • nutritionspecialists, • cleric services, • medical services.

12. Ethical approaches • If a patient suffers from dementia – he lacks decision-making capacity – his wishes are often overruled by his family or the staff. • Willtoliveis important. • Right to be informed. • Medication of such patients who refuse taking pills is a problem. • Physical abuse – neglect – unprofessional care.

13. 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.

14. 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.

15. Hospitalization • More 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.

16. Aims of therapyintheelderly • 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 (?)

17. Primary goal: maintenance or recovery of independence • In elderlies the possibilities are limited, BUT the expectations are more modest. Moving Feeding Hygiene Clothing

18. 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 exercises • Since atrophy and weakness of them. quadriceps femoris is not a consequence but rather a cause of the arthrosis of the knee! • Exercises also improve proprioceptionof 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).

19. Physiotherapy • Therapeutic exercise is the most important element • 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-frequencyelectrotherapy, interference, pulse magnetic therapy

20. 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.

21. Personalized geriatric teamwork Physician Nursing service Occupa-tionaltherapy Patient Physio-therapy Exercise treatment Facio-oral tract therapy Logo-pedics Social worker Neuro-psycho-logy Pastoral care

22. Successful aging • Selection (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.

23. Factors influencing aging1 LifeActivity Material Security Social Resources Aging well Cognitive Efficacy Physical Health and Functional Status

24. Factors influencing aging2 • 1Caloric restrictionA 30% reduction in caloric intakeincreases life expectancy by 40-50 percent (inrodents). • Okinawa island – traditionally low caloric intake.40 times as many people livethereabove theage of 100years. Rats: • 40% reduced diets – 60 months survival (normal 30months). • 30% caloric restrictiondecreases core temperature by 1°C. • Low metabolic rate increases life-span. Fruitflies (Drosophila melanogaster) livetwiceaslongin an 18 °C thanin a 30 °C environment. • A persistentlycoldenvironmentreduceslife-spanbecause of sustainedincreaseinmetabolicrate. • 2Physical fitness (Heat tolerance alsobecomesenhanced.)

25. Factors influencing aging 3 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.

26. Factors influencing aging4 3Stress, glucocorticoid levels (Frequent and high glucocorticoid levels lead to hyperstimulation of thehippocampus and consequent loss of memory – itmaycontributetoAlzheimer’s disease) • 4Growth hormone and/or sex steroids • 5Antioxidantvitamins, dietarypolyphenols 6Melatonin (antioxidant and has a roleinsleepregulation) 7Glutamate levels. Glutamate is an excitatory neurotransmitter, high levels of which (e.g. inducedbycerebralischemia) damage and finally kill neurons (excitotoxin). 8Cognitivetraining /psychological balance(life-longlearning, positivethinking, religion, etc.) 9Hormesis 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 lifeinanimalexperiments and inhumans. (Measuring and grading, determining the “ideal” dose, age-related modification of doses is a challenge.)

27. The myth of the “Fountain of Youth”– strange trials • Throughout 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 SzergejVoronov 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.

28. 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 senescenceand death of former generations there would be no place for new generations.