Dr Wan Zafidah Wan Nawawi Pakar Psikiatri Hospital Permai Bayu

Aging with Dignity
Dr Wan Zafidah Wan Nawawi
Pakar Psikiatri
Hospital Permai
Bayu Marina Resort
08th Oct 2015
Dignity
a basic human right
“Human rights rests on human dignity.”
Human rights represent all the things that are
important to us as human beings, such as being
abler to choose how to live our life and being
treated with dignity & respect.
Defining Dignity
• I think of myself, wanting care, preferably in my
own home. A carer who listens and does not try
to persuade me to do things I do not want to
do.
• I prefer a carer who has had some training and
respects my home and my independence
and has a sense of humour…
• Elderly Female
Defining Dignity
Care, gentleness of carers when
handling / and respect
on touching the body.
Real effort to communicate – taken
time listening and talking.
Defining Dignity
Not pigeon-holing people,
not treating them as all the same;
asking them what is important for them
and how they would like to be cared for
Patient- Acute setting
Barriers to Dignity in Care
There is a constant staff shortage.
We often stay over and take our hours back
another time.
Team spirit is unbelievable
and
it can get very stressful because we do a lot of
bed baths
Assistance-Acute Setting
Aging with Dignity
• Aging with dignity is really about self respect
• From the day we come to this world till the
day we die we are ageing.
– How we age is important thing
– Do we do so with dignity
– When we think of aging with dignity we seem to
think of dying with dignity.
– We have thoughts dementia, nursing home,
palliative care
Aging with Dignity
( and Independence )
• Aging with dignity (and independence) is the
ability to live life to its fullest in the place you
call home, regardless of age, illness, or
disability.
• 70 percent of people over 65 will need longterm care at some point in their lives.
Erik Erikson:
The Life-Span Approach
Psychosocial Stages of Personality
Development
• 8 successive stages over the lifespan
• Addresses bio, social, situational, personal influences
• Crisis: must adaptively or maladaptively cope with
task in each developmental stage
– Respond adaptively: acquire strengths needed for next
developmental stage
– Respond maladaptively: less likely to be able to adapt to
later problems
• Basic strengths: Motivating characteristics and beliefs
that derive from successful resolution of crisis in
each stage
BASIC TRUST vs. MISTRUST
• Birth – 2yr.
– Needs being met
– Basic trust develops when needs are met
(Attachment)
– Loving relationship is formed with caregiver
– Important event: Feeding
– Q: CAN I TRUST THE WORLD?
AUTONOMY vs. SHAME AND DOUBT
• 2 – 4 years
– Learning to do things for oneself
– Development of physical activities (ex. walking)
– Important event: toilet training
–Q: Is it okay to be ME?
INITIATIVE vs. GUILT
• 4 – 5 years
– Preschoolers learn to initiate tasks
– One becomes more independent
– Q: Is it okay for ME to do, move and act?
COMPETENCE/ INDUSTRY vs. INFERIORITY
• 5 – 12 years (puberty)
– Child completes tasks themselves
– Learning on your own
– Important Event: school/learning
–Q: Can I MAKE IT in the world of
people and things?
IDENTITY vs. ROLE CONFUSION
• 13 (Teens) – 19 years
– Teens refine sense of self
– Test new roles and incorporate them into an identity
– Important events: forming relationships with friends
–Q: Who AM I? Who can I BE??
INTIMACY vs. ISOLATION
• 20s – 40s
– Young adults develop intimate relationships
– Gaining the capacity for intimate love
– Important event: forming love and/or strong
relationships
–Q: Can I LOVE?
GENERATIVITY vs. STAGNATION
• 40s – 60s
– Middle-aged discover a sense of contribution to this
world
– Family and work oftentimes satisfy this desire
– Supporting and satisfying future generation
– Important event: Parenting
– Q: Can I make my LIFE
count?
INTEGRITY vs. DESPAIR
• 60s +
– Reflection on entire life
– Did I contribute to this world?
– Sense of fulfillment
– Q: Is it okay to HABE BEEN ME?
Erik Erikson Psychosocial Stages
Evaluation/ Criticisms of Erikson’s Theory
• Theory does attempt to show development
throughout life span
• Stages are more descriptive than explanatory
• Ambiguous terms and concepts
• Lack of precision
– Some terms are not easily measured
empirically
WHY IT IS IMPORTANT TO DISCUSS
ON AGING?
Aging in Asian Societies
• Rapid aging Asian is in progress in all countries
in Asia. We look at the ratio of elderly to the
total population over 65 years old.
• Japan:
– 1970: Aging society-7% of elderly in the
population
– 1994: Aged society-14% of elderly
– 2007: Super aged society-21% of the elderly
– 2050: 40% from the population
Aging in Asian Societies
• Singapore:
– Aging Society  Aging Society: in 19 years
– Super Aged Society in 2023(another 8 years)
• South Korea
– Aging Society  Aging Society: in 15years
– Super Aged Society in 2027(another 12 years)
• Note: In Western countries: The shift takes
about hundred years
Aging in Asian Societies
• Problem arises: population of rapid aging, the
would have great impact on competing
various resources in Asian than in Western
countries
Successful Aging
vs
Unsuccessful Aging
Successful Aging.
Active Aging
Creative Aging
Successful Aging
• 4 factors
–1. Physical Health
–2.Normal Cognitive Function
–3. Life Satisfaction (well Being)
–4. Social Activities and Productivity
Unsuccessful Aging
Unsuccessful Aging
• The easy way to define unsuccessful aging is
dementia
• Dementia is in the opposite of “successful
aging”, implying the failure of various social
function
• (Cognitive function is defined by the following six domains: Attention,
Executive function, Memory and learning functions, language function,
sensory-motor activities)
Unsuccessful Aging
• The impairment in cognitive function results in
reduced satisfaction of life ( decreased quality
of life, QOL), and eventually leads to impaired
social activities and social productivity
Cognitive Reserve Hypothesis
• Alzheimer’s disease amyloid deposits.
Neurofibrillary tangle, and neuronal loss of
the brain
• Patients with those pathologic finding show
large individual differences in cognitive
function
• Thus, the hypothesis of cognitive reserve is
propose to explain such differences
Cognitive Reserve Hypothesis
• Cognitive reserve = clinical manifestations of
brain is not directly related to the degree of
brain pathology
• Therefore, an individual with high cognitive
reserve can maintain cognitive function even
if pathology of Alzheimer’s disease has been
triggered in the brain
Factors for Improving
Cognitive Reserve Cognitive Function
Social activity
Exercise
Meals/Diet
Higher Educational Hx
Aerobic Exercise
Mediterranean Diet
Exciting work
Walking
Green/Yellow
Vegetables
Hobby to activate
mental fxn
Movement of the
fingertip
Caloric Restriction
Brain Training
Taking Nap
Polyphenol
Social Interaction
Unsaturated Fatty Acid
Cognitive Reserve Cognitive Function
• Social activity (Education):
– Rotterdam Community Study (Ott et al 1995):
Higher Alzheimer’s Disease in low level of
education
– Nun study (Snowdon et al. 1996)
Study the expressive linguistic of early life in nun.
The nuns with better degree of linguistic
sophistication are not associated with low
cognitive test score in late life
Cognitive Reserve Cognitive Function
• Doing exciting work and hobby to activate
mental function, and brain training
– Tai Chi vs Stretching and toning exercise ( Lam et
al)
– Tai Chi group has lower risk of developing
dementia
– Another study, Cheng et al, 2014 Tai Chi can
improve the score of mini mental state
examination (MMSE), delayed recall
Cognitive Reserve Cognitive Function
• Doing exciting work and hobby to activate
mental function, and brain training
– Playing Mahjong also improve the MMSE score,
delayed recall and forward digit span in those
marked cognitive impairment (Cheng et al, 2014)
– To stimulate brain function, suggested activities
include to learn a new language, to brush teeth
with different hand, and to explore another kind
of new hobbies
Cognitive Reserve Cognitive Function
• Job
– Duloil et al, 2014 reported that the occurrence of
dementia of the elderly is 15% LESS with group
who retired from work at the age of 65 years than
those retired at the age of 60
– For those who have retired, to volunteer doing
something is a good substitution for work, to keep
something exciting, and not to idle their brain
Cognitive Reserve Cognitive Function
• Social Activity
– Wang et al, 2002 found that study subjects who
had frequent ( daily-weekly) engagement in
mental, social, or productive activities have
inversely been related to dementia incidence.
– Kraut et al, 1998 have found that people with
greater use of internet are associated with declined
communication with their family members in the
household, and those with greater use of internet
also has had a declined size of social circle, and
increase in their depression and loneliness
Cognitive Reserve Cognitive Function
• Aerobic Exercise
• Erikson et al, 2011, have found that aerobic exercise
increases the size of anterior hippocampal volume by
2%, reversing age related loss in volume by 1 to 2 years
Cognitive Reserve Cognitive Function
• MEALS:
• Mediterranean Diets
– Countries: Greece, Italy, Spain, Portugal, Morocco, Cyprus,
and Croatia
– Has 6 or more small serving per day
– They eat primarily plant-based foods ( such as fruits and
vegetables, whole grain, legumes and nuts). Use healthy
fats such as extra virgin olive oil, using herbs and spices
instead of salts to flavor their food, eating fish and poultry
at least twice a week, and limiting red meat to no more
than a few tines a month
Cognitive Reserve Cognitive Function
• MEALS:
• Mediterranean Diets
– Sofi et al, 2008, have found that people with good
adherence to a Mediterranean diet have reduced
risk for mortality of cardiovascular diseases,
mortality and incidences for cancer, as well as
incidence for Parkinson’s disease and Alzheimer’s
disease
Cognitive Reserve Cognitive Function
• MEALS:
• Green/Yellow Vegetables
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–
They are lack of calories
The color represents different nutritional components
Carotenoids and beta carotene
Otsuka 2000, Alzheimers’s patients have disliked fish and greenyelllow vegetables and have taken mere meats. They are also
take less vitamin C and carotene
Cognitive Reserve Cognitive Function
• MEALS:
• Calorie Restriction
– Witte et al, 2009 have found that the study subjects have
improved verbal memory scores after caloric restriction, which
correlated with decreased fasting plasma levels of insulin and
high sensitive C-reactive protein
– Mechanism underlying this improvement are thought to
include higher synaptic plasticity and stimulation of
neurofacillitatory pathways in the brain because improved
insulin sensitivity and reduced inflammatory activity
Cognitive Reserve Cognitive Function
• MEALS:
• Polyphenol
– It is the richest abundant antioxidants in the diet and
widespread constituents of fruits, vegetable, cereal, dry
legumes, chocolate, and beverages, such as tea, coffee, or wine
– Kim et al, 2005, tea polyphenol has exhibited inhibitory effect of
acetycholine activity
– Kuriyama et al, 2006 have demonstrated that subjects with
higher consumption of green tea is associate with a lower
prevalence of cognitive impairment
Cognitive Reserve Cognitive Function
• MEALS:
• Unsaturated Fatty Acids
• Kalmijn et al, 1997 the subjects with more intake of total
fat and cholesterol have high risk of becoming dementia,
that subjects with more fish consumption, an important
source of n-3 polysaturated fatty acids, is inversely
related to incident dementia, in particular Alzheimer's
disease
Cognitive Reserve Cognitive Function
• In summary, lifestyle changes in pursuit of
being physically healthy, that the elders (
and everyone) are encouraged to be
socially active, and being conscientious of
eating healthy diet, to achieve successful
aging, or to maximize cognitive reserve.
• In this way, the improvement of healthy life
span rather than only the life span
Thank You
Attention
• Common attention deficits include
• being easily distracted,
• having difficulty attending, unless input is
restricted/simplified,
• experiencing decreased informationprocessing speed-thinking/processing takes
longer than usual.
Learning and Memory
• Common learning and memory deficits include
• episodic memory deficits, including difficulty
remembering specific autobiographical events,
situations, and experiences;
• short-term/working memory deficits—rapid
forgetting of information recently seen or heard;
• difficulty acquiring and remembering new
information (e.g., appointments or events, new
routines).
Reasoning and Executive Functioning
• Common reasoning and executive functioning deficits include
• difficulty setting goals and planning, including reliance on
others to plan activities and/or make decisions;
• poor judgment and impaired reasoning and problem-solving
abilities, such as making decisions without regard to safety;
• difficulty multi-tasking and handling complex tasks—need to
focus on one task at a time;
• difficulty responding to feedback, self-monitoring, and
correcting one's own errors;
• lack of inhibition;
• lack of mental flexibility.
Perceptual Abilities
• Common perceptual deficits include
– difficulty completing previously familiar activities
or navigating in familiar environments;
– inability to recognize familiar people, common
objects, sounds, etc.;
– inability to find objects in direct view,
independent of visual acuity.
Language
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Common language deficits include
less concise (empty) discourse with fewer ideas;
economy of utterances and stereotypy of speech;
repetitious/perseverative language (e.g., asking the same question
repeatedly);
word-finding difficulties, including long latencies, paraphasias, and word
substitutions;
difficulty recalling names of family and friends;
tangential language;
circumlocution;
grammatical errors, including omission or incorrect use of articles,
prepositions, auxiliary verbs, etc.;
Language-Cont
• use of jargon and loss of meaningful speech;
• difficulty following and maintaining conversation;
• in bilingual patients, errors in selecting and maintaining
appropriate language during conversation (Friedland & Miller,
1999);
• regression to primary language in bilingual patients (Mendez,
Perryman, Pontón, Cummings, 1990);
• language comprehension deficits;
• difficulty following multi-step commands;
• impaired ability to compose meaningful written language;
• reading comprehension difficulties.
Social Cognition and Behavior
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Common social cognition and behavior deficits include
inappropriate behavior outside of socially acceptable range,
inability to read facial expressions and other social cues,
loss of empathy,
mood fluctuations, including agitation and crying,
restlessness,
depression,
negative reaction to questioning,
combativeness/hostility/aggressiveness,
compulsive or obsessive behaviors,
erratic or strange behaviors,
loss of initiative/motivation,
paranoia and delusions of persecution.