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FAMILY MEDICINE AND COMMUNITY HEALTH III

August 27, 2011


TOPICS:
Gifted child
Special child
Adolescence
Geriatrics
Dementia
MMSE
__________________________________________

GIFTED CHILD

3- 5 % of children in any of the area is gifted


while the rest can be classified as high
achievers.
HIGH ACHIEVER
- knows the answer
- interested
- good ideas
- grasps meaning
- completes assignments
- listens with interest
- absorbs info

GIFTED
- asks questions
- curious
- unexpected ideas
- draws inference
- initiates projects
- strong opinions
- manipulates info

__________________________________________
Potential or demonstrated achievement in
general intellectual ability.
Brief Summary of Giftedness
1. Extraordinary memory
2. High level of abstract thinking
3. Application of knowledge
4. Intellectual curiosity
5. Persistent goal- directed behavior
6. Facility of expression
7. Hobby interest
8. Advanced knowledge
INTELLIGENCE QUOTIENT ( IQ )
Serves as a basis for determination of
intellectual giftedness
Quotient is derived by dividing mental age
score by chronological age.
INTERPRETATION OF GIFTEDNESS
1. SUPERIOR
Markedly above average in the major aspects
of intelligence
Assume substantial positions in their
community during adulthood
2. GIFTED
3. EXTREMELY GIFTED
Small fraction of the gifted group.
Superior: > 116- 124 ( 1 in 10- 15 )
Gifted: > 132- 140 ( 1 in 49- 100 )
Extremely Gifted : > 172 ( 1 in 10,000- 100, 000 )
MULTIPLE INTELLIGENCE THEORY
Howard- .:
- Intelligence is not indicated solely
by IQ score but by having 1 or
multiple strengths in TEN
intelligences:
1. Verbal/ linguistics
2. Logical/ mathematical
3. visual/ spatial
4. bodily/ kinesthetics
5. musical
6. interpersonal
7. natural
8. intrapersonal
9. existential
10. moral/ behavioral

CHARACTERISTICS OF A GIFTED CHILD


POSITIVE CHARACTERISTICS:
1. Learn rapidly and easily
2. Retain what they learn without much drill
3. Show much curiosity
4. Have rich vocabulary
5. Ability to generalize
6. Examine, tabulate, classify, collect and keep
records
7. Know and appreciate many things
8. Interested in the nature of man and universe
9. Seek older companions among children and adults
10. Possess a good sense of humor and is cheerful
NEGATIVE CHARACTERISTICS
1. Restless, inattentive, disturbing and annoying to
those around him
2. Poor in spelling, careless in writing, inaccurate in
mathematic
3. Lacks interest in completing or handling
assignments
4. Outspokenly critical both themselves and to others
GIFTED CHILDREN AND THEIR EDUCATION
Gallagher states there are three major areas
in which modification is needed:
1. Content of material
2. Method of presentation
3. Nature of learning environment
Program Modification:
1. Need an expanded program
2. Need a stepped up program
3. Need for Grouping
RESULTS OF INADEQUATE EDUCATION
1. NON- PARTICIPATION
Finds adjustment difficult if not stimulating or
challenging enough.
Hurry tasks in slipshod manner.
Does not participate in discussions.
Feel let down when expectations are not met.
2. NON- CONFORMITY
Want to do what is right.
Develops complex concepts of justice and
morality.
High standards in behavior and performance.

3. IMAGE OF MEDIOCRITY
Learn early to conceal their ability from
teachers in order to avoid additional work.
In order to win friend or avoid the stigma of
being called a nerd.
4. REVOLT AGAINST ROLE
Early success fails to help child develop good
working habits.
Difficulty or failure is due to unmet needs.

Subjects and activities requiring


memory does not arouse his interest.
Response may range from passive
acceptance to active revolt.
5. MECHANICS OF SELF- EXPRESSION
Difficulty of writing due to rapid thought
processes occurring in their mind that they
could not abide in the slowness of writing
down their ideas.
Ease to master ideas and verbal concepts
causes them to be fearful of attempting new
ideas.
6. AVOIDANCE OF FAILURE
Timid in trying new physical skills due to
possibility of failure.
7. OUTSPOKENNESS
Strong feeling for truth and justice
Often being considered rude, impatient,
unruly, self- centered, undisciplined.
Needs guidance to get along with people.
MODIFICATIONS OF PROVISION
1. ACCELERATION
Grade skipping
Advantage: reduce the time to reach high
school or college where the curriculum may
be more challenging.
Skipping is effective if accompanied by wise
guidance and follow- up tutoring if gaps in
learning have occurred.
Disadvantage: basic tools may be missed
and gaps undiscovered.
2. CONTINUOS INDIVIDUAL PROGRESS
Advance at his own pace.
Advantage: Continuous progress at his own
best rate.
Disadvantage: When he is the sole
accelerant, he must work alone.
3. EARLY SCHOOL ENTRANTS
4. ADVANCING THE CURRICULUM
5. EXTENDED CURRICULUM
Extended activities in a regular classroom if
other procedures are not feasible.
Teacher must have specific curricular
modification.

__________________________________________

SPECIAL CHILD

__________________________________________
Impairment, disability, and handicapped
CAUSES:
1. Inadequate nutrition
2. Abnormal prenatal conditions
3. Abnormal perinatal events
4. Infectious diseases
5. Accidents
6. Unknown
CONSEQUENCES OF DISABILITY
A. IMPACT ON THE CHILD
Loss of vision
( cataract: exposure of mother to German
measles )
Loss of hearing
Mental retardation
Loss or paralysis of the limbs
B. IMPACT ON THE FAMILY
Feeling of guilt
Time management
Family relationship
C. IMPACT ON SOCIETY
Rehabilitation measures
ROLE OF PHYSICIAN
1. Presentation of the diagnosis
2. Education of the family
3. Management of complications
4. Emotional; support
5. Define goals and objectives
6. Formulate strategy for future management
7. Assure routine health maintenance
SPECIAL EDUCATION PROGRAM
Designed to give educational opportunities to
commensurate with the abilities and needs of
special children.
Features:
1. Modified curriculum
2. Professionally trained teachers
3. Special methods and techniques
4. Special class site
5. Special facilities
Help Children through:
1. Socialization and skills development of the
mentally retarded.
2. Acceleration program to the fast learner.
3. Academic and vocational preparation of
the physically- impaired.
4. Skills training and rehabilitation of youth
5. Hospital- based for chronically ill patients.

___________________________________
ADOLESCENCE
_______________________________________
THREE LEVELS OF DEVELOPMENT:
A. BIOLOGICAL
Physical growth and personality formation.
B. PSYCHOLOGICAL
Sexual characteristics, identity establishment,
moving from dependent to independent
person
C. SOCIAL
Preparation for the forthcoming role of an
adult
FEATURES:
Tends to be a time:
1. of seeking status as an individual
2. when peer group relationship become of
major importance
3. when physical maturity is attained
4. of intellectual expansion and academic
experience
5. of development and evaluation of values
HEALTH SERVICES
1. DELIVERY OF HEALTH SERVICE
Between ages 11- 21 should have annual
preventive health visits
Should be developmentally appropriate and
sensitive to individual and socio- cultural
differences.
Health care providers should establish office
policies concerning confidential cases for
adolescents and should be made clear to the
youth and their parents.
2. HEALTH GUIDANCE
At least once during early, middle and late
adolescence.
To better understand physical, psychosocial
and psychosexual development.
To be actively involved in health care
decisions
Promote prevention of injuries
3. SCREENING
Annual hypertension, dyslipidemia and
coronary heart disease
Eating disorders
Tobacco use, alcohol, substance abuse,
misuse of over- the- counter and prescription
drugs
STD, Confidential HIV testing
4. IMMUNIZATION
Receive immune prophylactic immunizations
in accordance with the guidelines of the
Advisory Committee on Immunization
Practices

__________________________________________

GERIATRICS

__________________________________________
Subspecialty of medicine that focuses on
health care of elderly.
Aims to promote health and prevent
diseases.
GERONTOLOGY: Study of aging process.
EPIDEMIOLOGY OF AGING
1992: > 65 years old- 342 million
1996: 540 million
2020: projected to be > 1 billion
ANATOMICAL AND PHYSIOLOGICAL CHANGES
IN AGING
1. CHANGES IN HEIGHT
Loss in trunk length----changes in posture,
growth of vertebrae, forward bending of
spine, compression of disc between
vertebrae.
2. CHANGES IN BODY WEIGHT
FEMale: increase until mid- 50s
Weight loss in late 60s and 70s
Male: increase until late 60s, decline
thereafter at a rate slower than female.
3. CHANGES IN BODY SYSTEM
a. SKIN
o Aging skin requires > 30 days to
renew epithelium
o Loss of elasticity, wrinkles, lines, age
spots, dry and thin fragile skin
o Lowered activity of the sweat glands
b. HAIR
o Hair graying: loss of pigment cells
from hair bulbs
o Decrease number of hair follicles in
scalp
o Growth of hair in scalp, pubic and
armpit declines
o Increased growth of hair in the
eyebrows and nostrils
c. NAILS
o Develop longitudinal striations
o Slower rate of growth
o Toenails grow at 15 % slower than
fingernails
d. MUSCLES
o Decrease in strength, endurance,
size and weight relative to total body
weight due to inactivity nutritional
deficiency, diseases and long
standing conditions.
e. SENSORY
o SIGHT: most common: presbyopia
- harder to focus on nearby
objects due to decrease in

elasticity of lens and atrophy


of the muscles that control
the lens shape.
- Cataract: lens losses its
transparency due to
accumulation of insoluble
protein.
- Loss of focusing power f
the lens.
o HEARING
- atrophy of ear canal
resulting in thin walls and
decrease production of
earwax.
- eardrum thickens
appearing dull and white
- degenerative changes in
small joints connecting the
bones in the inner ear
- pitch discrimination
decreases
o TASTE
- tongue atrophied with age
- diminished taste sensation:
loss of circumvallate papillae
o SMELL
- declines rapidly after age
50 for both men and women.
o TOUCH
- response to painful stimuli
diminisheddecrease in the
no. of pacinian and
meissners corpuscles.
f. CARDIOVASCULAR
o CO falls by 1 % per year after the
age of 30 causing heart to lose
elasticity, increase PVR--- increase
BP, atherosclerosis leading to
aneurysms and rupture of BVs,
diminished arterial circulation and all
organs.
o Immobility: increase risk of
thrombosis and thromboembolism
g. RESPIRATORY
o Lung function decreases with age.
o Progressive loss of elastic recoil
within lung tissue
o Stiffness of chest wall
o Decrease in alveolar -----------h. GASTROINTESTINAL
o Dental changes: teeth becomes
brittle, drier and darker in color,
wearing out of enamel and dentin on
chewing surfaces; increase amount
of cavities
o Gum recession: loss of periodontal
tissue and atrophy of alveolar bone
o Esophagus: decrease muscle mass
volume
o Gastric mucosa: atrophied, absence
of chief and parietal cells----prone to
indigestion
o Small Intestine: atrophy of the
intestinal wall
o Large Intestine: atrophic changes in
muscle
i. GENITO- URINARY TRACT
o Loss of nephrons about 3040 %
o Decrease kidney mass by 25-30
%
o GFR decreases by 40 %

Renal plasma volume by 50 %


Incontinence and urinary
frequency- loss of sphincter tone
and bladder reflex
o Decrease muscle tone in female
o Enlarged prostate male and
decrease in sperm count and
viscosity of seminal fluid
j. HEMATOPOEITIC SYSTEM
o Normal RBC count
k. REPRODUCTIVE SYSTEM
o Female: diminished breast tissue,
decrease in size of the uterus,
atrophy of the vaginal epithelial
lining, narrow and shortened canal.
l. ENDOCRINE
o
o

PREVENTIVE GERIATRICS
HEALTH MAINTENANCE
Most effective interventions that a physician
should undertake to increase not only the
lifespan but more of improving the quality of
life.
A. DISEASE SCREENING
Recommended by US Preventive Services
Task Force
Primary Prevention
o Preventive strategy
1. BP Screening: yearly
2. Influenza Immunization: yearly
3. Obesity screening: yearly
4. Pneumonia Immunization: once at
age 65 every 2 years
5. Smoking cessation: every visit
6. Tetanus Immunization: every 10
years
7. Aspirin to prevent MI: daily
8. Cholesterol Screening: every 5
years
9. Diabetes Screening: yearly
10. Hormone Replacement: yearly
Secondary Prevention
1. Sigmoidoscopy: yearly/ every 3- 5
years
2. Hearing impairment screening: yearly
3. Mammography: every 1- 2 years
4. Pap Smear: every 3 years
5. Visual impairment screening: yearly
6. Skin exam: yearly
7. BSE: monthly
8. Cognitive impairment screening: yearly
9. PSA: yearly
10. TSH: yearly
B. NUTRITION
o Calorie intake should be balanced
against the expenditure of energy
requirements
o Daily energy expenditure decreased
by:
- 17 kcal between ages 5664 years old
- 24 kcal between ages 7584 years old
o

WHO suggests that:


1. CHON: 75 grams/ kg/ day

2. Fat: 20 % of total calorie intake


3. Ca: 9- 11 mg/ day
4. Iron: < 1 mg/ day
-boiling decreases iron
content of vegetables by
70%
-milling decreases iron by
70- 80 %
5. Vitamin D: skin makes less
Vitamin D from sunshine as
one grows older
6. Thiamine: Female: 1.96 mg
Male: 1.90 mg
7. Riboflavin: increased
requirement due to
decreased IF secreted by the
gastric mucosa
8. Folic acid: protective against
cancer
9. B- carotene:
10. Vitamin E
11. Vitamin C
Female: 150 mg/ day
Male: 75- 80 mg/ day
12. Water: 55- 65 years old- 30
ml/ kg/
> 65- 25 ml/ kg
13. Exercise: sedentary lifestyle
APPLIED GERIATRICS
Comprehensive Geriatrics Assessment
A. History taking should include:
1. Reason for visit
2. Detailed account of patients daily
activities
3. Complete medication history
4. Social history
5. Personal and past habits
6. Financial resources
7. Family history
B. Hospice Care
o Attempt to improve the quality of the
patients last days of life by offering
comfort and dignity in the form of
palliative care---physical, emotional,
spiritual support
o Embraces death as a natural part of
life.
Hospice Team:
o MD
o Nurse
o Health Aide
o Social worker
o Chaplain
o Volunteers
C. Home Care:
o Means more than doing home visits.
It means being prepared to become
a part of the team, caring for the
chronically ill or terminally ill patients
at home.
o Provision of comprehensive health
services.
o People- oriented: requiring a shift in
focus from disease alone to the
complete context od disease, patient,
family and environment.

COMPONENTS OF HOME CARE


1. Preventive
2.
3.
4.Rehabilitative
5. Long term maintenance
HOME CARE SERVICES:
1. Medical
2. Rehabilitative
3. Counselling
4. Health Care
5. Health Education
6. Wellness Program
7. Diagnostic Procedures
8. Nursing Care
9. Spiritual Care
10. Support Group
11. Transportation Services
12. Berteavement
13. Environmental Assessment
ORGANIZING A HOME CARE PROGRAM
1. Get manpower
2. Train staff
3. Prepare a home care program
4. Do networking and linkages
5. Implement the program
6. Evaluate the program
__________________________________________

DEMENTIA

__________________________________________
Syndrome of cognitive decline and variable
non- cognitive features of behavioral and
psychiatric symptoms and disturbances.
ALZHEIMERS DISEASE
Progressive neurologic disorder that results
in memory loss.
CHARACTERISTICS:
1. PREDEMENTIA
o Mild cognitive impairment
o Memory loss
o Difficulty in remembering recently learned
facts
o Inability to acquire new information
o Apathy: most persistent neuropsychiatric
symptom
2. EARLY DEMENTIA
o Difficulties with language, executing
functions, perceptions and movements
o Episodic memories ( older memories )
o Semantic memories ( facts learned )
o Implicit memory ( memory of the body on
how to do things )
o Language problem: shrinking vocabulary,
decreased word fluency
3. MODERATE DEMENTIA
o Progressive deterioration hinders
independence
o Unable to perform activities of daily living

Speech difficulties: unable to recall


vocabulary
o Loss of reading and writing skills
o Complex motor functions becomes less
coordinated: risk of falling increases
o Memory problem worsens: fails to recognize
close relatives
o Long term memory impaired
o Behavioral and neuropsychiatric changes:
wandering, irritability, labile affect leading to
crying, aggression, resistance to care- giving
4. ADVANCED DEMENTIA
o Completely dependent upon caregivers
o Language reduced to simple phrases or
single words, complete loss of speech
o Can understand and return emotional signals
o Simplest task cannot be performed without
assistance
o Muscle mass and mobility deteriorate
o Later become bedridden and lose the ability
to feed themselves
o Behavioral and neuropsychiatric changesextreme apathy and exhaustion
o

CAUSES:
1. CHOLINERGIC HYPOTHESIS
o Decrease synthesis of acetylcholine
o Oldest
2. AMYLOID HYPOTHESIS
o Amyloid B deposit
o 1991
3. TAU HYPOTHESIS
o Tau protein abnormality initiate cascade

4. DEMYELINIZATION
DIAGNOSIS
Patients history from relatives clinical
observation
Medical Imaging: CT, MRI, SPECT, PET
MMSE
Pharmacologic Management: Donepezil,
Rivastigmine, Galantamine
MINI- MENTAL STATUS EXAM
Quick and simple cognitive exam: cognitive
function
Includes:
o Personal information
o Orientation
o Word registration
o Attention
o Recall
Total Score: 30
CLASSIFICATION OF ALZHEIMERS DISEASE
TYPE
Score

MMSE

Mild, cognitive impairment


Mild AZ
Moderate AZ
Severe AZ

24- 26
21- 23
10-20
< 10