Wednesday, February 24, 2010

Depression in the Elderly

Depression in the elderly is very common, although it is not a normal part of aging. Late-life depression affects about 6 million Americans age 65 and older, but only 10% receive treatment for depression. This is likely because the symptoms of depression in the elderly are often confused with the effects of multiple illnesses and the medicines used to treat them.

How Does Depression in the Elderly Differ from Depression in Younger People?

Depression in later life frequently coexists with other medical illnesses and disabilities. In addition, advancing age is often accompanied by loss of key social support systems due to the death of a spouse or siblings, retirement and/or relocation of residence. Because of their change in circumstances and the fact that they're expected to slow down, doctors and family may miss the diagnosis of depression in elderly people, delaying effective treatment. As a result, many seniors find themselves having to cope with symptoms that could otherwise be easily treated.

Depression tends to last longer in elderly adults. It also doubles their risk to develop cardiac diseases and increases their risk of death from illness, while reducing their ability to rehabilitate. Studies of nursing home patients with physical illnesses have shown that the presence of depression substantially increased the likelihood of death from those illnesses. Depression also has been associated with increased risk of death following a heart attack. For that reason, making sure that an elderly person you are concerned about is evaluated and treated is important, even if the depression is mild.

Depression in the elderly is more likely to lead to suicide. The risk of suicide is a serious concern among elderly patients with depression. Elderly white men are at greatest risk, with suicide rates in people ages 80 to 84 more than twice that of the general population. The National Institute of Mental Health considers depression in people age 65 and older to be a major public health problem.

What are the Risk Factors for Depression in the Elderly?

Factors that increase the risk of depression in the elderly include: Being female, unmarried (especially if widowed), stressful life events, and lack of a supportive social network. Having physical conditions like stroke, hypertension, atrial fibrillation, diabetes, cancer and dementia further increases that risk. While depression may be an effect of certain health problems, it can also increase a person's risk of developing other illnesses—primarily those affecting the immune system, like infections.

The following risk factors for depression are often seen in the elderly:

Certain medicines or combination of medicines
Other illnesses
Living alone, social isolation
Recent bereavement
Presence of chronic or severe pain
Damage to body image (from amputation, cancer surgery, or heart attack)
Fear of death
Previous history of depression
Family history of major depressive disorder
Past suicide attempt(s)
Substance abuse

Persons who develop their first depression in old age are very likely to have very small abnormal areas seen on head imagery that indicate tiny spots in the brain that may not be receiving adequate blood flow. Consequent chemical changes in these cells may enhance the likelihood of depression, apart from any life stress.

What Other Problems Affect Treatment of Depression in the Elderly?

The stigma attached to mental illness and psychiatric treatment is even more powerful among the elderly and is often shared by members of the patient's family, friends, and neighbors. This stigma can keep elderly patients from seeking treatment. In addition, depressed older people may not report their depression because they believe there is no hope for help.

Elderly people may also not be willing to take their medicines because of side effects or cost. In addition, having certain other illnesses at the same time as depression can interfere with the effectiveness of antidepressant medicines.

Alcoholism and abuse of other substances may interfere with effective treatment, and unhappy life events—including the death of family or friends, poverty, and isolation—may also affect the patient's motivation to continue with treatment.


Monday, February 22, 2010

New Computer Technologies Help Elderly People Stay Independent

Thanks to a wide array of new computer technologies, the quality of life is improving for millions of seniors in the United States, without them having to give up their independence.

According to the Family Caregiver Alliance, based in San Francisco, there are an estimated 22.4 million households involved in giving care to people age 50 and older. These baby boomers, most of whom balance the schedules of two working parents with raising kids, are stressed to the maximum and appreciate any assistance they can find to help them take care of their parents and improve the quality of life for everyone. Computer technology companies see an opportunity to help them do just that, while taking the strain off the nation’s limited, expensive long-term care resources. The strain on long-term care services for the elderly is a global problem. From 1900 to 1997, the number of elderly people in the U.S. increased from 3.1 million to 34.1 million—an eleven-fold increase—while the total population only tripled. And projections show that the elderly populations of the U.S. will more than double to about 79 million by 2050, according to the Population Resource Center. Within the next few years, 50% of the European Union's population will be over 65, and in Italy, retirees will outnumber active workers by 2030.

Companies such as ADT, Honeywell, General Electric, Intel, and Phillips Medical Systems are actively pursuing the demographic of middle-aged people concerned about helping their parents ease into their twilight years with less guilt and more peace of mind than they would have if they moved their parents to assisted-living facilities. They are developing a variety of computerized systems for seniors, and such technology is an answered prayer for many people. One such solution is the ADT Quietcare system, a home-monitoring system that employs motion and temperature detectors to record the daily activity of seniors living on their own. Twelve times a day, the Quietcare system updates the status of the monitored individual into a central monitoring site, where loved ones can check up on them via the Internet and respond if anything goes awry. According to Nancy Chisholm, western regional Vice President of ADT, "I think (the technology) has tremendous potential. With the rising cost of health care, this really is a cost-effective solution for adult caretakers."

ADT’s system was first used by living Independently, Inc., in New York, for the nursing home industry. It was introduced to the consumer market by ADT just a few months ago. The monitoring system works in conjunction with a computerized pendant worn around a person’s neck to alert caregivers of a problem. The system costs about $299 to activate, and a $90 monthly fee pays for the monitoring. Five sensors, each about the size of a small cell phone, are installed in a home—in the individual’s bathroom, outside the bathroom, outside the bedroom, on the refrigerator door, and near the medicine cabinet. Another sensor monitors room temperature throughout the house. The sensors use wireless technology to send information to a base station near the telephone, and the information is transmitted over the phone line to Living Independently. After a baseline of normal behavior is developed, the computers in the monitoring center can chart daily activities such as a client’s ordinary waking time, number of kitchen visits, and time spent in the bathroom.

After the first week, the system can issue an alert if there is any change in the pattern that may indicate a problem. For example, if a senior fails to visit the medicine cabinet during the day, or goes to the bathroom and doesn’t come out within an hour, an alert will be activated through ADT’s customer service center. In response to the alert, an ADT representative calls the home to check on the client, and if necessary, then calls the family and finally emergency medical services. It may seem like this kind of close monitoring is an invasion of privacy, but according to Mark Cross, team manager for Quietcare Plus, people are usually happy to hear from them. "The customer has a sense of not being alone—that's the feedback we get. But it can be challenging at times," he added. "Every single alarm we get can be a medical emergency. Thirty percent of them are." One surprising advantage to the close monitoring is that it gives family members more things to talk about when they share the caregiving responsibilities.

ADT isn't the only company developing technology to keep seniors out of nursing homes. The Rhode Island School of Design, EDS, and MIT are working together to develop Pill Pet, which is reminiscent of the virtual Tamagotchi pet of the 1990s that was designed to teach children responsibility. If the owner of the small toy didn’t care for the pet appropriately, they had to suffer the consequences. With the Pill Pet, a fuzzy palm-sized toy animal, if the senior "owner" takes his or her medications regularly and on time, the toy lives. If not, the pet must be taken to a pharmacy for attention. The MIT Media Lab is currently testing the reactions of seniors to see if they like the idea of adopting a computerized pet to let it help them manage their health. Proctor & Gamble is working on a smart personal adviser, invented at MIT, that is a combination of Palm Pilot technology and a medical smart card. When a shopper goes to the grocery store with the personal advisor, he would scan a card containing his medical record into a Palm Pilot and it would record his current health condition. As his groceries are scanned, the adviser would note items that are not recommended for his medical condition, and suggest more appropriate alternative choices.

The system that is perhaps the most scientifically advanced is the Motiva television set-top box, created by Philips Medical System. The box is linked to medical devices and a remote control in the patient’s home to keep daily track of their blood pressure and weight. The information is sent wirelessly through the set-top box to doctors, and patients fill out on-screen questionnaires using a specially designed remote control. Doctors on the receiving end review the information and send out personalized responses to televisions, thereby giving patients daily feedback about their health status. A recent trial by 30 congestive heart failure patients was a resounding success, and both patients and doctors were pleased with the results of the study.

These new products and others in development will help to improve the quality of life for millions of seniors in the United States while allowing them to maintain their independence. With the rapidly expanding pace of computer technology, these new products are probably just the tip of the iceberg.

By: Linda Orlando

Sunday, February 21, 2010

Survey reveals India’s gaping generation gap

New Delhi: Are your children talking to you? Perhaps not.

Fathers appear to be worse off when it comes to communicating with their children. Only 7% boys and 4% girls aged 15-24 discuss “growing up” issues with their fathers, according to a recently-concluded youth survey.

Mothers were equally bad when it came to their sons, with only 6% boys confiding and “discussing life” with them. In comparison, 77% of girls spoke more freely to their mothers, mostly about issues relating to menstruation. The survey, conducted by the International Institute for Population Sciences and Population Council and endorsed by the Union health ministry, spoke to nearly 51,000 married and unmarried young males and females from six states — Andhra Pradesh, Bihar, Jharkhand, Maharashtra, Rajasthan and Tamil Nadu.

The survey found that school performance, which is not a sensitive topic, was the most common subject of conversation between children and their parents. In contrast, embarrassing topics, such as romance, relationships and reproduction, were rarely discussed with either parent (only 2% of young men and 6% of young women did so).

When it came to reproductive issues, children were equally secretive with both parents. The findings also suggest that parents controlled their children’s social interaction, particularly if it it involved members of the opposite sex. For example, 69% of young men and 84% of young women expected parental disapproval if theybrought a friend of the opposite sex home. In contrast, just 9% of men and 5% of women reported that their mother and father would be angry if they brought home friends of the same gender.

But there were some differences in perception on this matter. Among young men, for example, 64% of those from Maharashtra and the southern states perceived disapproval from both parents, but 71-80% of those from northern states said the same. For young women it was 74-85% and 82-97% respectively.

Papa Don’t Preach
Just 7% boys and 4% girls aged 15-24 discussed “growing up” issues with their fathers Only 6% boys confided and “discussed life” with their mothers but 77% girls spoke freely particularly about menstruation Embarrassing topics, such as romance and reproduction were rarely discussed with either parent School performance, a topic that isn’t sensitive was the most common subject of discussion Kids prefer relationship talk with peers: Survey

New Delhi: A government endorsed survey conducted by the International Institute for Population Sciences and Population Council found that Indian parents were most likely to disapprove of love marriages for their children, as reported by 84% of young men and 94% of young women.

With regard to perceived parental reactions to a love marriage, state-wise differences were evident for young men, with those from southern states considerably less likely than those from other states to perceive disapproval (67-78% versus 85-94%). Among young women, in contrast, state-wise differences were negligible; over 90% of young women in all the states reported parental disapproval of a love marriage.

Almost all those who were interviewed had an arranged marriage. This led to only 30% of young men and 22% of young women being aware of what to expect from their married life. Friends rather than family were found to be the major confidants for both young men and women. Only 1% men were found to confide in their family members while 85% did so in their friends. In case of women, 20% confided in family and 46% in friends.

Persons with whom youth would most likely discuss personal matters varied considerably by the sex of the respondent and the type of topic. Young women tended to consider their mother as their leading confidante on two matters: those relating to taking a job (38%) and menstrual problems (72%); fewer young women (28%) considered their father in the same role on matters relating to tak
ing a job and hardly did so on menstrual problems. Matters pertaining to boy-girl relationships, in contrast, were rarely confided in parents, the most likely confidants being peers (46%). Patterns among young men were different. As far as non-sensitive issue of taking a job, the leading confidant was their father, cited by 39% of young men.

Courtesy:The Times of India

Friday, February 19, 2010

Unique exhibition teaches some people TECH TRICKS TO SURVIVE

From an ATM that talks to an indicator that tells whether enough water has been poured for a cup of tea, a tech exhibition gives hope to the differently-abled of a better, easier life NGOs, students and companies come together with a wide array of assistive, adaptive and rehabilitative devices to help those less fortunate.

The two-day Techshare India exhibition, held earlier this week, was put together by several companies, NGOs and students at India Habitat Centre on Lodhi Road. From nailclippers with magnifying glasses for those with poor vision to foldable keyboards and talking ATMs to power wheelchairs, there was on display a huge range of devices to help people with different kinds of disabilities. Some of the devices are already in commercial use, while others have not yet hit the market.

Vinod Kumar Bharti, who runs an association called Astha for the differently-abled in Lal Kuan and Govindpuri, said: ‘‘Nauhar left school because of his disability. We hope to find some way to help him complete his computer lessons. The power wheelchair is another thing which will allow him to move around without help.’’

The wheelchair was part of an experimental laboratory set up at the exhibition. It ran on batteries and had a joystick for navigation. A user simply required to move it with a finger in whichever direction he/she wanted to go. Made in Germany, the wheelchair, however, costs over Rs 2 lakh, taking it beyond the reach of the common man.

There were, however, simpler and affordable assistives for the visually-impaired. The choice started with a beeper and a liquid level indicator — both developed by Vispy Mirza, who runs an assistive devices workshop in Mumbai.

‘‘The beeper makes a sound whenever it faces a an electronic device that has been left on. So, somebody who is visually impaired will know what he or she has to switch off. The liquid level indicator can be used to help make tea, for a visually-impaired person cannot check the level of hot liquid with his/her hands,’’ explained a volunteer.
Other affordable devices included GoTalk which was like a portable board with several picture cards. Each picture represented activities like eating, sleeping, need to visit the toilet etc. A disabled person would need to record what he wants by pressing the picture card relating to the activity.

‘‘A child who cannot speak simply needs to press a picture card denoting his requirement and the device will play the recorded voice. This way the parents will know whatever their child wants,’’ the volunteer said. There was also a colourful keyboard with big keys which would allow dyslexic children to remember alphabets through the colour scheme, while also benefiting those with poor vision.

According to the organisers, the exhibition was visited by hundreds of differently-abled people. ‘‘The idea was to showcase assistive technologies on a single platform,’’ said Shilpi Kapoor, managing director, Breaking Barriers technology that put up the show along with Royal National Institute of Blind People, UK and National Centre for Promotion of Employment for Disabled People, Delhi.

Thursday, February 18, 2010

How to Manage Difficult Conversations with Elders

Advice and Help: How to Manage Difficult Conversations with Elders

You have taken the first steps to become involved as a caregiver for an elderly family member or friend. One of the first things on your To Do list is to have a conversation with the person to find out their concerns, plans and dreams for their final years.

Surprise – the senior doesn’t want to talk. Their immediate response is that “everything is fine” and that they are taking care of themselves and their spouse (if there is one). Elderly men may be especially resistant to sharing decision-making for themselves and their spouse with children or other younger family members. This period of their life is an entirely unfamiliar situation for someone who for 60 or 70 years has been the family leader. Sharing responsibility and decision-making is emotionally difficult for both the senior and their family members.

When is the right time for family and friends to directly address the resistance? First, is anyone’s safety in jeopardy? Jack and Ann, a couple in their mid-80’s, have been living in the same home for 60 years. Their two daughters and one son all live in other parts of the country. The nearest daughter is a six hour drive away from them. Jack is still driving and has a regular routine of playing cards with friends during the week. This activity is his major social outing and very important to him.

Ann’s cognitive functioning has been slowly slipping to where she needs help dressing in the morning as well as reminders to take regular baths and to eat. Neither her physician nor her family have talked about a possible Alzheimer’s diagnosis. Jack has been taking care of her but she is left alone for several hours when he is out. One day she leaves a kettle on the stove that burns dry and sets off the fire alarm. Her daughters and son hear about it and are worried for her safety. They also see the changes in her when they visit. But Jack is resistant to hearing that his care-giving is no longer enough.

How do Ann’s children help protect her safety while honoring their father’s role in the family? It is not unusual that for some period of time the adult children continue to be reassured that the cognitively intact parent is handling things. But then there comes a time when either they too clearly see the changes or there is a safety or health crisis. The care-giving spouse may have health crisis, which results in the children having to take over direct care of the elder still in the home. Rarely does the situation return exactly to the previous status.

Here are tips for managing difficult conversations. If at all possible, hold a face-to-face conversation. The quandary for many families is that visiting happens during holidays when everyone wants to keep a calm and happy face. But, remember, that it is rarely a one-time conversation and it is better to open the dialogue face-to-face.

Have the conversation in private. If this is difficult to do in the home, suggest going for a walk or having a cup of coffee somewhere.

Focus on one or two items per conversation. Take a deep breath and remember that not everything can get resolved with one conversation.

Ask pointed and open ended questions (that don’t allow a “yes” or “no” answer). For example, ask “how do you go shopping?” or “what does mother do when she is alone at home?” It may be easier to start with questions about activities of daily living than decisions about money or legal issues.

Keep your voice tone neutral, without accusations.

Listen carefully and repeat back what you have heard. This will be especially necessary if the elder is confused about what he/she is trying to say.

Listen between the lines – be alert to facial expression, tone of voice, level of attention. In some situations it can be helpful to have a second person with you just to listen and look for these clues.

Be patient – it may take your relative some time to express a thought.

Be prepared for negativity – the changes of aging can be difficult for people to accept. Watch out for your negative reactions to what is being said by your relative. You will be carrying into the conversation all of the “baggage” from your relationship with the relative.

• Talk about your own feelings. Use “I” statements rather than telling the relative what he/she “should” do.

Be mindful that your relative may fear that admitting a need in one area will cause the family to over-react. So agree upon whom you will share information from the conversation.

In some situations the parent-child/children relationship is burdened by past behaviors and conflicts. Children, who nevertheless are committed to being involved in elder caregiving, would be wise to seek a deeper level of knowledge and support to help them through this process. To find a caregiver support group in your area contact your local Agency on Aging (which are federally supported everywhere in the United States), United Way or religious organization. The tips on managing difficult conversations are drawn from Avoiding An Eldercare Crisis from VNA Community Healthcare. Another helpful book is Coping With Your Difficult Older Parent: A Guide for Stressed-Out Children by Grace Lebow and Barbara Kane. Remember, you can act responsibly and feel good about your efforts even if you are not doing it out of love.

Maureen Lopes
VNA Community Healthcare, Guilford, CT
For more information,
Healthcare News and Resources at

Tuesday, February 16, 2010

Vitamin D May Reduce Falls in Elderly Nursing Home Residents

Laurie Barclay, MD

January 29, 2010 — Vitamin D supplementation and pharmacist review of medications may help reduce falls in elderly nursing home residents, according to the results of a systematic review reported online January 20 in the Cochrane Database of Systematic Reviews.

"Falls in nursing care facilities and hospitals are common events that cause considerable morbidity and mortality for older people," write Ian D. Cameron, from Sydney Medical School, the University of Sydney in Ryde, Australia, and colleagues.

The goal of this review was to determine the efficacy of interventions aiming to reduce falls by older people in nursing care facilities and hospitals. The reviewers searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2009); the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 2); MEDLINE, EMBASE, and CINAHL (all to November 2008); trial registers; and bibliographies of retrieved articles.

Criteria for inclusion in the review were randomized controlled trials of interventions designed to reduce falls in older people in nursing care facilities or hospitals, with main study endpoints of fall rate and the risk of falling. Methodologic quality of the trials was independently evaluated by 2 reviewers, who also extracted and pooled data where appropriate.

There were 41 trials, enrolling a total of 25,422 participants, meeting selection criteria. Findings from 7 trials testing supervised exercise interventions in nursing care facilities were inconsistent. Overall, multifactorial interventions were not associated with a significantly lower rate of falls in 7 trials enrolling a total of 2997 participants or with a lower risk of falling in 8 trials enrolling a total of 3271 participants.

However, multifactorial interventions provided by a multidisciplinary team were associated with lower rate of falls in nursing home residents (rate ratio [RaR], 0.60; 95% confidence interval [CI], 0.51 - 0.72; 4 trials, n = 1651) and risk of falling (risk ratio [RR], 0.85; 95% CI, 0.77 - 0.95; 5 trials, n = 1925), based on a post hoc subgroup analysis.

Vitamin D supplementation in nursing home residents was associated with a lower rate of falls (RaR, 0.72; 95% CI, 0.55 - 0.95; 4 trials, n = 4512) but not with the risk of falling (RR, 0.98; 95% CI, 0.89 - 1.09; 5 trials, n = 5095).

Multifactorial interventions in hospitals for patients with a length of stay of 3 weeks or more were associated with a lower rate of falls (RaR, 0.69; 95% CI, 0.49 - 0.96; 4 trials, n = 6478) and the risk of falling (RR, 0.73; 95% CI, 0.56 - 0.96; 3 trials, n = 4824). In addition, supervised exercise interventions were associated with a significant decrease in the risk of falling (RR, 0.44; 95% CI, 0.20 - 0.97; 3 trials, n = 131).

"There is evidence that multifactorial interventions reduce falls and risk of falling in hospitals and may do so in nursing care facilities," the review authors write. "Vitamin D supplementation is effective in reducing the rate of falls in nursing care facilities. Exercise in subacute hospital settings appears effective but its effectiveness in nursing care facilities remains uncertain."

Limitations of this review include those inherent in the selected studies, such as lack of blinding, confounding because of differences in treatment and control groups at entry, differences in underlying care programs, poorly defined inclusion and exclusion criteria and falling events, and differences in ascertainment of falls.

"Falls prevention programmes that include exercises for frail nursing care facility residents should carefully assess each individual's suitability, as there is the possibility that exercise programmes may increase their risk of falls," the review authors conclude. "The choice of type of exercises may be important in avoiding an increase in falls. The rate of falls and number of fallers should be monitored before and after adopting an intervention because it might increase falls."


Monday, February 15, 2010


Palliative care

Palliative care was defined by the World Health Organization in 2002, as: “an approach that improves the quality of life of patients and their families facing the problems 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, and intends neither to hasten nor to prolong death. Palliative care integrates the psychological and spiritual aspects of patient care, and offers a support system to help patients live as actively as possible until death. It also offers a support system to help the family cope during the patient’s illness and in their own bereavement. Using a team approach, palliative care addresses the needs of patients and their families, including bereavement counselling if necessary. It enhances quality of life, and may positively influence the course of the illness. It is applicable early in the course of the illness 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.

Palliative care should be offered as needs develop and before they become unmanageable. Palliative care must not be something that only specialized palliative care teams, palliative care services or hospices offer when other treatment has been withdrawn. It should be an integral part of care and take place in any setting.

The needs of older people at the end of life

It is no surprise that most deaths in European and other developed countries occur in people aged over 65. None the less, comparatively little research has been carried out on their needs for palliative care. Older people very clearly have special needs, because their problems are different and often more complex than those of younger people.

Older people are more commonly affected by multiple medical problems of varying severity.

The cumulative effect of these may be much greater than any individual disease, and typically lead to greater impairment and needs for care.

Older people are at greater risk of adverse drug reactions and of iatrogenic illness.

Minor problems may have a greater cumulative psychological impact in older people.

Problems of acute illness may be superimposed on physical or mental impairment, economic hardship and social isolation.

The complexity of the problems that older people have to suffer is revealed by epidemiological studies in which relatives or key informants are asked about the last year of the patient’s life. These show, in particular, that mental confusion, problems with bladder and bowel control, sight and hearing difficulties and dizziness all greatly increase with age.

The problems that many older people experience in the last year of life are therefore those of great age and its troubles as well as those caused by their final illness. All areas of health care that seek to provide continuity of care for older people, including general practice, geriatric medicine and rehabilitation, have recognized these wider needs for many years. Because it is more difficult to predict the course of many chronic diseases affecting older people, palliative care should be based on patient and family needs and not on prognosis. The examples of cancer, heart failure and dementia illustrate this point.


The term cancer includes many illnesses that cause varying problems depending on the site of the body affected. The disease is more common with increasing age, and three quarters of deaths from cancer occur in people aged over 65. The most common cancers affecting women are breast, lung and colorectal cancer, while those most commonly affecting men are lung, prostate and colorectal cancer. Breast and prostate cancer have the best prognoses, followed by colorectal cancer and lung cancer. The prognosis for any individual depends on the extent of the growth at presentation and the response of the tumour to treatment, which may include surgery, radiotherapy and/or chemotherapy. People are not usually severely restricted in their activity until the final stages of the illness when the disease stops responding to treatment, but they have many psychological needs and require information and support from the time of diagnosis. In general, studies show that patients with cancer want more information, would like to be involved in decision-making, and experience better psychosocial adjustment if palliative care and good communication are part of their care from the time of diagnosis.

Heart failure

Heart failure affects more than one in ten people aged over 70, and the five-year mortality of 80% is worse than for many cancers. The course is often one of intermittent exacerbation of the symptoms of breathlessness and pain, causing great distress, followed by a gradual return to, or near to, the previous level of function. Death may follow a gradual decline or may be sudden during a crisis. Although there has been considerable progress in treating symptoms and crises well, patients and their families often have difficulty understanding and managing the complex drug regimes required. People with heart failure seem to have less formal knowledge of their diagnosis and prognosis. There appears to be a lack of open communication from health professionals about this, probably owing in part to the difficulty of prediction and an unwillingness to raise the subject. Families also report poor coordination of care and difficulties in forming a relationship with any single professional. These aspects of care therefore compare unfavourably to the information and support available to people with cancer.


Dementia affects 4% of people over the age of 70, increasing to 13% of those over the age of 80. The median length of survival from diagnosis to death is eight years, and during this time there is a progressive deterioration in ability and awareness. Common symptoms include mental confusion, urinary incontinence, pain, low mood, constipation and loss of appetite. The physical and emotional burden on family members is well documented, as is their grief as they slowly lose the person they knew. Many ethical issues are also raised by the care of people with dementia who are unable to communicate their wishes. Current issues include the best use of antibiotics in the treatment of pneumonia and of feeding tubes for hydration and nutrition. However, less than 1% of patients in inpatient hospices have dementia as their primary diagnosis.

The needs of caregivers

Only relatively recently has the role of people caring for older seriously ill people been fully appreciated. There is relatively little formal knowledge about their needs, although their role varies considerably. It may include carrying out intimate tasks such as washing, helping people to dress and go to the toilet, or heavy tasks such as lifting. This kind of caring is usually performed by people with close kinship ties, often living in the same house and motivated by love and a desire to keep an older person out of an institution. However, the burden of care may lead in time to conflicting emotions, dealing with changes in personality and behaviour, restrictions on the carer’s own life, and the drain on financial resources. Long-term care for seriously ill relatives is unpaid and unsupported work that may damage the health, wellbeing and financial security of caregivers themselves.

A new way of looking at palliative care

As ageing populations develop new needs, health care systems need to be equally flexible in their response and perceptions about palliative care need to change. Traditionally, palliative care has been offered most often to people suffering from cancer, partly because the course of this illness is more predictable and it is thus easier to recognize and plan for the needs of patients and their families. One consequence of this has been the perception that palliative care is relevant only to the last few weeks of life and can be delivered only by specialized services. In fact, people and their families experience many problems throughout the many years of an illness and need help at the time and not at an easily definable point just before death. The idea that palliative support and care should be offered alongside potentially curative treatment, although obvious to patients and families, appears a radical idea for some health professionals. In addition to supporting people with a clearly terminal illness, health care systems must find ways of supporting people with serious chronic illness or multiple chronic problems over many years and allow for an unpredictable time of death.

Autonomy and choice

“Everyone has the right to … security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his [or her] control”.

Article 25, United Nations Universal Declaration of Human Rights, 2001

However complex a person’s problems or uncertain their future may be, autonomy is a key human right and maintaining this must be a core ethical value for society and health services. This has recently been incorporated into the concept of “patient-centred care” that many health care systems are now attempting to implement, which emphasizes the need to structure health care in response to people’s values and preferences.

“Patient-centred care is care that incorporates respect for patients’ values and preferences, provides information in clear and understandable terms, promotes autonomy in decision-making and attends to the need for physical comfort and emotional support”.

Preferences for place of care and death

There is increasing research evidence concerning the decisions that people would prefer to make about care at the end of their life. Most studies have found that around 75% of respondents would prefer to die at home. Those recently bereaved of a relative or friend are slightly more likely to prefer inpatient hospice care. A range of studies have found that between 50% and 70% of people receiving care for a serious illness also say they would prefer home care at the end of life (although as they approach death, part of this group may come to prefer inpatient care. A core value for palliative care from its inception has been in enabling people to make genuine choices about their care.

Source: Better Palliative Care for Older People

Edited By: Elizabeth Davies & Irene J Higginson


As the hospice and palliative care movement has expanded, evidence has grown for the effectiveness of aspects of the treatment and care it has promoted. Systematic reviews of the evidence, including studies on people with cancer from many different countries, now report consistently the importance of certain key areas of care. The evidence is currently strongest for simple measures such as pain relief, good communication and coordinated teamwork to satisfy preferences for place of care. There is also preliminary evidence for the application of models of palliative care for people with other illnesses.

Palliative care skills of individual health professionals

Pain and symptom control

The effectiveness of pain control methods has been established for over 30 years, and a wide variety of drugs is available to control pain associated with cancer and other illnesses. Observational studies show that, when clinical guidelines on pain control are followed, 70–97% of patients with advanced cancer gain adequate pain relief. Research on implementation has been relatively neglected, but education can improve the knowledge and attitudes of staff about pain (though not necessarily the levels of pain suffered by patients). There is most evidence for brief interventions, whereby nurses encourage patients to complete pain diaries and doctors use explicit strategies to ensure that pain is assessed daily and that drug dosages are adjusted accordingly. By comparison, the study of pain using standardized measures in older people with other illnesses has been relatively neglected.

Communication skills

Effective communication between doctors and patients is associated with a range of health outcomes including, most commonly, improvements in psychological health, symptoms and function and better control of pain, blood pressure and blood glucose level. The ability of health professionals to communicate effectively with families and involve them in decision making consistently emerges as an important contributor to their satisfaction with care at the end of life. The communication skills of health professionals can be improved by using feedback from videotaped consultations and discussion, but they nevertheless need further help to sustain these new skills in everyday practice.

Giving information

Recordings or summaries of key consultations are of benefit to most cancer patients. They lead to improved knowledge and recall of information without causing psychological problems and to greater satisfaction. Nevertheless, these must be used sensitively with patients whose prognosis is poor, and account must be taken of whether or not they wish to know the full facts. In general, decision- making aids can help professionals deal with the concerns of patients, explain their treatment and improve their satisfaction.

Providing holistic care

Spiritual support

Spiritual and religious needs are highly personal and salient to many people at the end of life, and therefore need to be part of palliative care services. There is some preliminary evidence that spiritual belief can affect the way in which patients cope, and even the outcome of the disease. It can also affect the way in which relatives cope with bereavement.

Psychological support

A wide range of psychological interventions has been tested in over 150 randomized trials over 40 years. The results were mixed and tended to vary by site of disease and follow-up period, with positive outcomes not being sustained over time. Most evidence exists for adjuvant psychological therapy, but more work is required to identify specific needs and how to target patients for intervention.

Complementary therapy

In the general population, complementary therapies tend to be used by younger women who perceive them as natural and allowing greater control. Despite interest in their use in palliative care, studies have so far been hampered by a lack of standard definitions, small sample sizes, poor response rates and inadequate measurement, and thus no adequate conclusions have been drawn.

Coordinating care across different settings

Transferring information

An important issue in the care of older people is the transfer of information between settings, and between those with responsibility for medical care and those providing medical and social support services in the community. Current mechanisms are often inadequate and – although there is little empirical research in the area – a “key worker”, “case manager” or “case coordinator” seems the most effective way of transferring information.

Meeting preferences for home care

A second issue is whether improved coordination of care can allow more patients to die at home if they so desire. Trials of different approaches to coordinating hospital and community services are now finding that a higher proportion of people can be helped to die at home if they wish. There is also evidence that the quality of life of their caregivers can be improved if support is provided and well coordinated.

Supporting families and caregivers

A range of services has been developed, including home care, respite and “sitting” services, activities within social networks, support groups and individual psychotherapy or education. Carers generally report satisfaction with home care and, if they are willing to leave the patient, value respite and sitting services. The few who take up group activities or support groups value the chance to talk openly with others, but formal evaluation of their benefit is weak. Further work is needed to explore the priorities of caregivers and what it is realistic for services to achieve for them. Here it is important to remember that giving caregivers the impression of being listened to and appreciated is in itself an important goal of care.

Anxiety and depression are normal responses to loss and the threat of loss in lifelong relationships. Health professionals who meet people at the very end of these relationships may not be able to influence these basic responses. Nevertheless, they can avoid adding a sense of isolation or confusion by providing care that appears coherent and coordinated and that relieves the patient’s suffering.

Specialist palliative care

Specialist palliative care teams

Expressed by patients and their families (combined odds ratio 0.38, 95% CI 0.33– A common model for delivering palliative care has been to concentrate expertise in multi professional teams that work in hospitals, inpatient units such as hospices or within the community. These teams usually deal with a selected group of patients, referred to them by other teams of professionals, who have the most complex needs for symptom control, communication and coordination of care. Despite conflicting findings in initial reviews, meta-analysis now reveals benefits for both patients and families in terms of the control of pain and other symptoms and the satisfaction 0.44).

Specialist palliative day care

There is evidence that patients value attending palliative day care units, where they can meet other patients, talk to staff and become involved in activities. There is no evidence as yet, however, that such attendance affects other outcomes such as quality or life or symptom control.

Bereavement support

In several studies, the relatives of patients dying in the care of specialist palliative care services reported fewer psychological symptoms and unmet needs than those of patients receiving standard care. Assessing the need for support and counselling after bereavement is regarded as an important part of palliative care. There is relatively little evidence, however, for the predictive power of assessments, the targeting of individuals or the benefit of individual therapy, although these aspects are very difficult to evaluate.

Developing palliative care services for non-cancer patients

Multidisciplinary teams

Multidisciplinary teams are one way of caring for people with complex problems, and already have an established role in geriatric medicine and the care of people with specific disorders. For example, team management of people with cardiac failure can reduce their hospital admissions and prolong survival.

Specialist nurses

On balance, studies so far show that specialist nurse support can also help patients with heart failure and improve continuity of care. Patients in the care of respiratory nurses live longer but do not have a better quality of life; they none the less place value on home visits from nurses.

Hospice services for patients with dementia

Pilot studies on the provision of palliative care and hospice services for patients in the end stages of dementia suggest they can make patients more comfortable and help carers.

Advanced care planning

There has recently been considerable interest in advanced care planning, whereby people can decide the care they would wish to have if they were to be diagnosed with a life-threatening illness. Such plans provide a written record of people’s desires and preferences for health professionals and their relatives to follow if they become unable to make these decisions for themselves. Despite hopes that these might reduce the number of unwanted interventions at the very end of life, there is no evidence that such plans are always followed or that they influence the use of resources or costs. More comprehensive methods are now being explored. Equally, there is little evidence for the effectiveness of intensive care in meeting the palliative care needs of older people.

Generalizability of findings

Research on meeting the needs of people experiencing and dying from diseases other than cancer is less well advanced. There is little specific information on effective methods for nursing or residential homes to meet palliative care needs, or of the needs of people aged over 80 in any setting. In general, there is also a lack of evidence from implementation research on how to get established evidence translated into practice. The comparatively uncertain prognoses of non-cancer illnesses make it more difficult to plan services. Nevertheless, simple measures such as good pain relief, communication, information and coordinated care from skilled professionals are effective in reducing symptoms and suffering. It is unlikely that these experiences differ widely by disease or across countries. This strongly suggests that it is time to make a more active and concerted effort to improve palliative care, concentrating on the implementation of simple effective measures based on the complexity and seriousness of the illness and on the needs of patient and family.

Source: Better Palliative Care for Older People

Edited by:Elizabeth Davies & Irene J Higginson