2. Psychological Issues in
Advanced and Terminal
Illness
Average life expectancy in North America is
76 years.
Leading causes of death in adults are
chronic illness
What are the leading causes of death
across the life span?
3. Mortality Rates
Leading causes of death
< 1 year
congenital abnormalities;
sudden infant death syndrome (SIDS)
Children > 1 year old
Accidents (40% of all deaths)
Cancer (especially leukemia)
Adolescence
Unintentional injury
Homicide
AIDS
4. Mortality Rates
Leading causes of death
Middle age
Sudden death due to heart attack or stroke
Cancer
Elderly
Heart disease
Cancer
Stroke
6. Potential Reasons for Gender
Differences in Mortality
Females are more hardy
Males engage in riskier behaviours (factor after
birth and infancy)
Men engage in riskier sports
Males tend to hold high stress or higher risk jobs
Men tend to have poorer health habits (e.g., drink
more alcohol)
Social support may be more protective in women
7. Risk Factors
Family history
Marital status (adds 10 yrs in men; 4 yrs in
women)
Economic status
Body weight
Exercise
Alcohol (add 2 years if drink 1-3 drinks/day)
8. Risk Factors - continued
Smoking
Disposition (add 2 yrs if reasoned, practical)
Education
Environment (add 4 yrs if rural)
Sleep (more than 9 hours subtract 5 years)
Temperature (add 2 yrs if thermostat is <
68)
Health care – regular check ups add 3 yrs
10. Adapting Under Good
Circumstances
First concern upon hearing diagnosis is
fears about mortality.
Optimistic but tentative about plans
May try to normalize activities
Risk is they may over-extend
May have feelings of helplessness
Risk is to become overly dependent
11. Three Themes of Adaptation
Find meaning: why illness happened or
rethink priorities
Gain sense of control
control symptoms and treatment
Restore self-esteem
Often by comparison with worse off others
12. Adapting Under Bad
Circumstances
Relapse seen as a bad sign with poor
prognosis
Re-focuses one on the illness
Need to undergo the coping process
again but likely less hopeful than
before.
13. Heart Disease
Due to narrowing or blocking of the
coronary arteries.
Angina pectoris
painful cramp in chest, arm, neck, or back due
to brief blockage of oxygenated blood to the
heart.
More often during exercise, stress, cold
temperature, digesting large fat meal.
Little or no permanent damage
14. Heart Disease
Myocardium
Muscle tissue around the heart
Myocardium infarction (heart attack)
Prolonged blockage of blood to an area of the
heart resulting in muscle tissue damage.
Symptoms of a heart attack
Pressure in chest, fullness, squeezing pain.
Pain spreading to shoulders, neck, or arms
Lightheadedness, fainting, sweating, nausea
15. Who Is At Risk of Heart
Disease?
Prevalence increases with age, particularly
after 45 years of age
Prior to 50s, 60s, men at greater risk than
women but increases in women after
menopause.
More women than men are likely to die
from a heart attack
Blacks at higher risk, Asians at lower risk
16. Heart Disease Risk Factors
High blood pressure
Family history
Cigarette smoking
High LDL and total cholesterol levels
Physical inactivity
Diabetes
Obesity
Stress
17. Why high blood pressure a
risk factor?
Heart has to work harder.
Since heart muscle is working harder, it
can become enlarged.
Wear and tear on the arterial wall can
increase the likelihood of lipid and calcium
deposits adhering to the arterial wall. This
leads to hardening of the arteries.
18. Type A Behaviours
Hostile, cynical
Judgmental (opinionated)
Competitive
Time urgent
Uses gestures while talking
Nodding of head while others are talking
Intense
19. Physiological Reactivity
Physiological and cardiovascular reactivity
to acute stress (“hot reactors”).
Exaggerated increases in blood pressure,
heart rate, catecholamines, corticosteroids
High levels of these hormones can
damage heart and blood vessels
Presence of epinephrine (a
catecholamine) increases the formation of
clots.
21. Psychosocial Predictors
of Sudden Cardiac Death (BDI>10)
1.00
0.95
Proportion
Surviving
0.90
Placebo, BDI <10
Placebo, BDI >10
AMIO, BDI <10
AMIO, BDI >10
0.85
0 200 400 600 800
Survival in days
22. When do heart attacks occur?
Less likely during sleep.
Among the employed, more often on a
Monday between 6 and 11 am.
In part due to waking and becoming active
shortly after dreaming which increases BP.
In part because of circadian rhythm effects,
increases in arousal hormones and blood
pressure.
23. Medical Treatment
Initial treatment may involve clot-dissolving
medication and close monitoring
Balloon angioplasty
Tiny balloon is inserted into blocked vessel and
inflated to open blood vessel
Bypass surgery
Use grafted vessel (e.g., piece from leg) to
bypass blockage in artery to the heart
24. Medical Treatment
Medications (e.g., beta blockers, calcium
channel blockers) to protect heart and
improve function.
Risk management
Control of high blood pressure
Control of lipid abnormalities
25. Rehabilitation
Promote recovery and reduce risk of
another attack
Heart disease is chronic condition
requiring ongoing management.
26. Rehabilitation Includes:
Exercise
Physiological and psychological benefits
Weight management
Smoking cessation
Lipid and BP management include dietary
changes to control lipids
Reduce excessive alcohol intake
Stress management
27. Rehabilitation
Exercise is the key component but:
50% drop-out rate within first 6 months
For those who continue benefits include:
Improved self concept, perceived health,
sexual activity, involvement in social activities.
Those who stop are more likely to:
Smoke, have poorer cardiac function, have
higher body weight, be more sedentary,
experience greater anxiety and depression.
28. Symptoms of a Stroke
Sudden
weakness or numbness of the face, arm, or leg
(usually on one side of the body)
dimness or loss of vision (usually one eye)
Loss of speech or trouble talking or
understanding speech
Unexplained, severe headache
Dizziness, unsteadiness, or sudden fall
29. What is a stroke?
Tissue damage to area of the brain due to
disruption in blood supply, depriving that
area of the brain of oxygen.
30. Causes of Strokes
1. Infarction – blockage in cerebral artery
that cuts off or reduces blood supply
a) Thrombosis – blood clot
b) Embolus – piece of plaque becomes lodged
in the artery.
2. Hemorrhage – happens suddenly. Less
frequent than infarction but more
damaging and more likely to cause death.
31. Stroke Risk Factors
Rare up to age 55, than risk increases
sharply with age (doubling with each
decade).
More common in men but women more
likely to die from them.
Rates highest among blacks and lowest
among Asians.
Family history
32. Stroke Risk Factors
High blood pressure
Cigarette smoking
Heart disease, diabetes, and their risk
factors such as obesity and physical
inactivity.
High red blood cell count (making the
blood thicker and likelier to clot).
Mini-strokes – transient ischemic attacks
(TIA)
33. Effects of a Stroke
Some motor, sensory, cognitive, or speech
impairment usually occurs
Limitations may be permanent but lessen
in severity over time.
Younger patients recover better
Impairments caused by hemorrhages
more easily overcome than those caused
by infarctions.
34. Effects of Stroke
Motor impairments often due to paralysis
on one side of the body (side opposite to
brain damage).
After about 6 weeks of rehab about 50% of
patients can perform independently (many with
cane or walker).
Language, learning, memory, and
perception problems depend on location of
the injury.
35. Effects of Stroke
Left-hemisphere damage more commonly
associated with language problems called
aphasia.
Receptive aphasia – difficulty understanding
verbal information.
Expressive aphasia – difficulty producing and
using language.
Damage to right side of brain often
associated with difficulties in visual
processing and emotions.
36. Psychosocial Aspects of
Stroke
Denial is common
Unclear whether psychological or physiological
basis.
This ambiguity also applies to depression
when it occurs after a stroke.
Less than ½ of the patients return to work
following a stroke.
Notes de l'éditeur
SIDS is higher in lower class urban environments, when mother smoked during pregnancy, and when baby is put to sleep lying on his/her stomach or side. Accidents due to accidental poisoning, injuries, or falls. Later the main cause of death dues to accidents is automobile accidents. Remember that leukemia strikes the bone marrow producing an excessive amount of white blood cells, resulting in severe anemia and other complications.
When asked how they would like to die, most say sudden death. By the way, in women under the age of menopause, breast cancer remains the number one cause of premature deaths.
More fit – more males are conceived but more female fetuses are born. This trend persist in infancy so that more male babies are likely to die. Thus, females may be more hardy.
More fit – more males are conceived but more female fetuses are born. This trend persist in infancy so that more male babies are likely to die. Thus, females may be more hardy. Essentially, no one really knows why there is the female advantage. Conflicting reports on social support since marriage appears to benefit men more than women. All of these factors may operate to increase the mortality rates in men.
30%-40% of stroke victims have another stroke within five years.
High scores on the Beck Depression Inventory in the placebo group was associated with a 2-times greater risk of mortality over 2 –years follow-up. Irvine J, Basinski A, Baker B, Jandciu S, Paquette M, Cairns J, Connolly S, Gent M, Roberts R, Dorian P. Depression and risk of sudden cardiac death after acute myocardial infarction: Testing for the confounding effects of fatigue. Psychosomatic Medicine, 1999; 61: 729 -737
TIAs may occur one or more times before a stroke.
The difficulty with emotions can be either managing their own emotions or understanding those of others.