aging and death

د.وليد عزيز العميدي المرحله الثالثه
Aging, Death, and Bereavement
I. AGING
A. Demographics
1. By 2020, more than 15% of the U.S. population will be more than 65 years of age.
2. The fastest growing segment of the population is people over age 85.
3. Differences in life expectancies by gender and race have been decreasing over the past few years.
4. Gerontology, the study of aging, and geriatrics, the care of aging people, have become important new medical fields.
B. Somatic and neurologic changes
1. Strength and physical health gradually decline. This decline shows great variability but commonly includes impaired vision, hearing, and immune responses; decreased muscle mass and strength; increased fat deposits; osteoporosis; decreased renal, pulmonary, and gastrointestinal function; reduced bladder control; and decreased responsiveness to changes in ambient temperature.
2. Changes in the brain occur with aging.
a. These changes include decreased weight, enlarged ventricles and sulci, and decreased cerebral blood flow.
b. Senile plaques and neurofibrillary tangles are present in the normally aging brain but to a lesser extent than in dementia of the Alzheimer type.
c. Neurochemical changes that occur in aging include decreased availability of neurotransmitters such as norepinephrine, dopamine, ?-aminobutyric acid, and acetylcholine, and increased availability of monoamine oxidase. These changes can be associated with psychiatric symptoms such as depression and anxiety (see below).
C. Cognitive changes
1. Although learning speed may decrease, in the absence of brain disease, intelligence remains approximately the same throughout life.
2. Some memory problems may occur in normal aging (e.g., the patient may forget the name of a new acquaintance). However, these problems do not interfere with the patient s functioning or ability to live independently.
D. Psychological changes
1. In late adulthood there is either a sense of ego integrity (i.e., satisfaction and pride in one s past accomplishments) or a sense of despair and worthlessness (Erikson s stage of ego integrity versus despair). Most elderly people achieve ego integrity.
2. Psychopathology and related problems
a. Depression is the most common psychiatric disorder in the elderly. Suicide is more common in the elderly than in the general population.
(1) Factors associated with depression in the elderly include loss of spouse, other family members, and friends; decreased social status; and decline of health.
(2) Depression may mimic and thus be misdiagnosed as Alzheimer disease. This misdiagnosed disorder is referred to as pseudodementia because it is associated with memory loss and cognitive problems.
(3) Depression can be treated successfully using supportive psychotherapy in conjunction with pharmacotherapy or electroconvulsive therapy.
b. Sleep patterns change, resulting in loss of sleep, poor sleep quality, or both.
c. Anxiety and fearfulness may be associated with realistic fear-inducing situations (e.g., worries about developing a physical illness or falling and breaking a bone).
d. Alcohol-related disorders are often unidentified but are present in 10%–15% of the geriatric population.
e. Psychoactive agents may produce different effects in the elderly than in younger patients.
f. For a realistic picture of the functioning level of elderly patients, the physician should ideally evaluate patients in familiar surroundings, such as their own homes.

E. Life expectancy and longevity
1. The average life expectancy in the United States is currently about 76 years. However, this figure varies greatly by gender and race. The longest-lived group is Asian Americans, particularly the Chinese, and the shortest-lived group is African Americans. (Table 3-1)
2. Factors associated with longevity include:
a. Family history of longevity
b. Continuation of physical and occupational activity
c. Advanced education
d. Social support systems, including marriage


II. STAGES OF DYING AND DEATH
According to Elizabeth Kübler-Ross, the process of dying involves five stages: denial, anger, bargaining, depression, and acceptance (DAng BaD Act). The stages usually occur in the following order, but also may be present simultaneously or in another order.
A. Denial.
The patient refuses to believe that he or she is dying. ("The laboratory made an error.")
B. Anger.
The patient may become angry at the physician and hospital staff. ("It is your fault that I am dying. You should have checked on me weekly.") Physicians must learn not to take such comments personally.

C. Bargaining.
The patient may try to strike a bargain with God or some higher being. ("I will give half of my money to charity if I can get rid of this disease.")
D. Depression.
The patient becomes preoccupied with death and may become emotionally detached. ("I feel so distant from others and so hopeless.")
E. Acceptance.
The patient is calm and accepts his or her fate. ("I am ready to go now.")
III. BEREAVEMENT (NORMAL GRIEF) VERSUS DEPRESSION (ABNORMAL GRIEF OR COMPLICATED BEREAVEMENT)
After the loss of a loved one, there is a normal grief reaction. This reaction also occurs with other losses, such as loss of a body part, or,for younger people, with a miscarriage or abortion. A normal grief reaction must be distinguished from an abnormal grief reaction, which is
pathologic (Table 3-2).
A. Characteristics of normal grief (bereavement)
1. Grief is characterized initially by shock and denial.
2. In normal grief, the bereaved may experience an illusion that the deceased person is physically present.
3. Normal grief generally subsides after 1–2 years, although some features may continue longer. Even after they have subsided, symptoms may return on holidays or special occasions (the "anniversary reaction").
4. The mortality rate is high for close relatives (especially widowed men) in the first year of bereavement.
B. Physician s response to death
1. The major responsibility of the physician is to give support to the dying patient and the patient s family.
2. Generally, physicians make the patient completely aware of the diagnosis and prognosis. However, a physician should follow the patient s lead as to how much he or she wants to know about the condition. With the patient s permission, the physician may tell the family the diagnosis and other details of the illness.
3. Physicians often feel a sense of failure at not preventing the death of a patient. They may deal with this sense by becoming emotionally detached from the patient in order to deal with his or her imminent death. Such detachment can preclude helping the patient and family through this important transition.