Manifestation of Novel Social Challenges of the European

Manifestation of Novel Social Challenges of the European Union in the Teaching Material of Medical Biotechnology Master’s Programmes at the University of Pécs and at the University of Debrecen Identification number: TÁMOP-4. 1. 2 -08/1/A-2009 -0011

Manifestation of Novel Social Challenges of the European Union in the Teaching Material of Medical Biotechnology Master’s Programmes at 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 FOR SUCCESSFUL AGING

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 Characteristics of old age Multimorbidity affects the majority of this population disturbance of mobility, self-reliance, communication and social activity inactivity Increased tendency to develop pain syndromes inactivity Psychological features rigidity; disorders of memory, judgement, emotions and orientation, decrease in cognitive performance Isolation (loneliness) inactivity Rapid immobilization, loss of self-reliance

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 General health-related problems • pressure ulcers (decubitus) • incontinence • feeding disorders • falls • altered mental activity • sleep disorders • mood disorders and pain

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 Limitations of everyday activities caused by diseases age-groups (years) 60 -69 70< men women 40 % 60 % 50 % 72 %

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 Living conditions of the elderly over 65 years of age living in community 2, 2 6, 6 2, 0 7, 4 1, 7 14, 1 3, 8 21, 1 2, 2 16, 8 27, 5 27, 7 78, 2 71, 2 13, 0 19, 3 65 -74 75 -84 males Living alone Living with spouse 5, 5 51, 1 47, 0 28, 1 33, 2 85+ 65 -74 Age-groups Living with other relatives (not spouse) 10, 2 53, 3 56, 8 75 -84 85+ females Living with non-relatives

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 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.

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 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!

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 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.

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 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

Housing of people over 65 years of age The most important needs in facilities for elderlies: • certified chief nurse, • registered nurses, • full-time social workers, • therapeutic health professionals, • pharmacists, • rehabilitation therapeutists, • dentists, • nutrition specialists, • cleric services, • medical services. TÁMOP-4. 1. 2 -08/1/A-2009 -0011

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 Ethical approaches • If a patient suffers from dementia – he lacks decisionmaking 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.

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 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.

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 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.

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 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! communication • Appropriate medication.

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 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 (? )

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 Primary goal: maintenance or recovery of independence In elderlies the possibilities are limited, BUT the expectations are modest. Moving Feeding Hygiene Clothing

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 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 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).

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 Physiotherapy • Therapeutic exercise is the most important element Forms: Effects: - Isometric and isotonic exercise - Increases aerobic capacity - Exercise improving the efficacy - Alleviates pain of locomotion - Improves muscle strength - Exercise improving - Improves coordination - Improves gait - Therapeutic underwater - Improves quality of life exercise • Others: thermotherapy, cryotherapy, mechanotherapy, lowfrequency electrotherapy, interference, pulse magnetic therapy

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 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.

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 Oc cu pa th tiona era l py ng rsi Nu rvice se Physician Personalized geriatric teamwork Phys i ther oapy Patient Facio ract t oral py a ther cise Exer nt tme a e r t Pastoral care our Ne -logy ho yc ps So cia lw or ke r Logo -ped ics

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 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.

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 Factors influencing aging 1 Life Activity Social Resources Cognitive Efficacy Aging well Material Security Physical Health and Functional Status

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 Factors influencing aging 2 1 Caloric restriction A 30% reduction in caloric intake increases 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. )

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 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.

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 Factors influencing aging 4 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 steroids 5 Antioxidant vitamins, dietary polyphenols 6 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. )

TÁMOP-4. 1. 2 -08/1/A-2009 -0011 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 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.

Evolutionary and philosophical considerations TÁMOP-4. 1. 2 -08/1/A-2009 -0011 • Antagonistic pleiotropy (breeding and life span, Gn. RH, 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.