Consedration in caring for old Patient

1. Illness, Aging,
Grief & social
class
OSAMA AL HAWAJRI
PSYCHIATRIC NURSING SUPERVISOR

2. Aging

3. Functional changes
Physiological functions decline at varying rates: notably – vision,
hearing, new learning, decision making.
However, some cognitive functions may improve (e.g. memory) through
practice or experience.

4. Psychosocial changes
Psychosocial changes are less predictable.
Stigma attached to ageing (particularly in Western societies).
More likely to be lonely.
Social isolation (sensory decline/
deficits→less likely to socialize; fewer friends).
Sexual drive and enjoyment may remain intact but socially not
accepted.
Individuals become less neurotic and more able to contain emotionality.

5. Screening:
the 2 main areas of screening are cancer and abdominal aortic
aneurysm.
Breast cancer: women age >40
Colorectal cancer: men and women age >50
Abdominal aortic aneurysm screening: men age 65–75
Psychiatric
• Depression screening
–– Age >65 is a risk factor for suicide.
–– Screening appropriate especially when patients have a terminal or
debilitating illness.

6. Death & dying
The realization of imminent or impending death may lead to the
following phases ( Kübler-Ross):
• denial: disbelief; refusal to accept reality; reject diagnosis
• anger: ‘why me’; blaming
• bargaining: attempt to negotiate a better outcome
• depression: outpouring of feelings; may become clinically depressed
• acceptance: resolution of above phases; calm and understanding.

7. It is increasingly recognized that these phases do not necessarily resolve
in rigid sequence.
Adjustment to death involves both the dying individual and their family
and friends.
Communication and compassion help both the patient and those
around them to adapt.

8. Bereavement & Grief
The process following the death of a loved person or chronic illness.
Stages of bereavement:
Denial: initially in a state of shock: stunned and feeling numbed, denial
Protest & Bargaining : refusal and negotiation with the
God to change the condition
Preoccupation: involves yearning for subject of loss – illusions and
hallucinations; some symptoms of depression
Disorganization: disruption of routine, irritability
Resolution: eventually come to terms with loss; accept and adjust to reality.
NB bereaved more likely to consult their family doctor and at increased risk
of dying during first 6 months.

9. Predictors of poor resolution or adjustment:
loss of child/spouse
loss is unexpected
occurs at time of additional stresses
from poorer socio-economic background
ambivalent/dependent relationship with deceased.
Typically grief resolves within 6–12 months.

10. PSYCHIATRIC
DISORDER AND
SOCIAL CLASS

11. Socio-economic status is a very strong predictor of
morbidity. The reasons for this may be:
social causation theory: the greater the environmental
stress experienced by the lower social classes in some way
contributes to the development of psychological ill-health

12. social selection/drift theory: those with psychiatric illness
are not equipped to remain in the higher social classes
and so either remain in the lower social classes or
gravitate towards them
differential treatment/labelling: race and social class bias
the management of those with psychiatric illnesses,
producing a misrepresentation in the lower classes.

13. SOCIAL CLASS AND
PSYCHIATRIC HEALTHCARE
The utilization of psychiatric healthcare services
has been described by Goldberg and Huxley as a
series of five levels.
Movement from one level to the next entails
successfully negotiating through a filter:

14. Level I: The community
– Filter 1: Illness behavior prompting decision to seek help
Level II: GP attenders
– Filter 2: Detection of disorder by GP
Level III: Diagnosed as ill
Filter 3: Decision as to whether specialist help is needed
Level IV: Specialist service attendees
Filter 4: Decision to hospitalize
Level V: Specialist service inpatient.

15. Decisions as to when and how individuals move through
a healthcare system are based on:
characteristics of the service: funding, waiting lists,
geographical convenience etc.
nature of the disorder: severity, risk to patient and
others etc.
social aspects of the individual: age, gender, race, status
etc.

16. Psychiatric patients from poorer socio-economic
backgrounds are more likely to:
become psychiatric inpatients
remain as inpatients for longer periods of time
be subjected to physical treatments such as
electro-convulsive therapy (ECT).

17. THE DOCTOR–
PATIENT
RELATIONSHIP

18. DOCTOR’S ROLE
An individual’s expected pattern of social behavior is their
social role.
For doctors and patients Parsons put forward a model
incorporating their rights and obligations.
A doctor’s social role is to:
diagnose and define illness
offer support and treatment
legitimize illness and patient sick role.

19. Doctors therefore confer the sick role, which gives the
patient certain rights and obligations:
rights: exempt from blame, i.e. not responsible for having
illness; excused from usual/normal duties, e.g. household
activities or work.
obligations: to desire recovery and to seek necessary help;
to cooperate in the assessment and management of their
illness.

20. Acute illness is a common stressor, prompting concern about socio-
economic future.
Likelihood of illness and coping strategies change with age.
Chronic illness leads to adjustment in stages:
• shock: sense of disbelief
• encounter: react by grieving and possibly becoming depressed

21. • retreat: use denial to avoid dealing with illness or its consequences
• intrusion: gradual adaptation and acceptance of fate.

22. ILLNESS BEHAVIOUR
Mechanic defined illness behavior as ‘the ways in which
given symptoms may be differentially perceived, evaluated
and acted upon’.
Abnormal illness behavior has been defined by Pilowsky as
‘the persistence of a maladaptive mode of experiencing,
perceiving, evaluating and responding to one’s own health
status’.
The illness behavior is disproportionate to the underlying
disease (real or not).

23. Maslow’s (1908–
1970) hierarchy of
needs

24. Maslow’s (1908–1970) hierarchy of needs combines
extrinsic and intrinsic elements.
Ordered according to survival value.
Those that are lower in the hierarchy must be at least
partially satisfied before subsequent (higher) needs can
be addressed:

25. 7 Self-actualization
intrinsic motivations, altruism
6 Aesthetic
symmetry, beauty, order
5 Cognitive
understanding, exploration, knowledge
4 Esteem
social approval, competence, recognition
3 Belonging and love
affiliations, relationships
2 Safety
protection, security
1 Biological
air, food, water, shelter