Communication WITH The elderly patient

Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat the University of Pécs and at the University of DebrecenIdentification number: TÁMOP-4.1.2-08/1/A-2009-0011

COMMUNICATION WITH THE ELDERLY PATIENT

Gyula Bakó and Miklós SzékelyMolecular and Clinical Basics of Gerontology – Lecture 19

Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat the University of Pécs and at the University of DebrecenIdentification number: TÁMOP-4.1.2-08/1/A-2009-0011

TÁMOP-4.1.2-08/1/A-2009-0011

Outline

• Difficulties of the history-taking and determination of diagnosis in the elderly

• Communication with the elderly patient

TÁMOP-4.1.2-08/1/A-2009-0011

History-taking in the elderly:polymorbidityElderlies have survived more diseases and have more ongoing chronic abnormalities (cumulation). Poly(multi)morbidity:• cumulation of damaging effects during aging• predisposition due to physiological weakening

of functions during aging• with the advancement of health care,

potentially lethal diseases become treatable, therefore more and more elderly people survive to acquire multiple diseases typically affecting the young and the middle-aged

TÁMOP-4.1.2-08/1/A-2009-0011

History-taking in the elderly:atypical symptomsAging of different organ systems and functions proceed in different rates, and a very delicate balance exists among them. Apparently, disruption of homeostasis is likely to be expressed in the most vulnerable, most delicately balanced systems (weakest link of the chain). A disease in older persons manifests itself first as functional loss, often in organ systems unrelated to the locus of primary illness. In the background of the atypical complaints the presence of complex problems, processes, diseases, syndromes suffered during a long life, can be considered.

TÁMOP-4.1.2-08/1/A-2009-0011

History-taking in the elderly:complex assessmentThe accuracy of the anamnestic data and the judgment of the diseases are influenced by the scene: does it take place at home, in a nursery home, outpatient service or in a hospital.Assessment of • mental,• physical, functional• socioeconomicconditions of the patient are also essential.

TÁMOP-4.1.2-08/1/A-2009-0011Multiple problems require complex assessment in the elderlyOrgan damage• Pain, rigidity of joints

and muscles • Impaired renal function• Associated chronic

diseases• Multiple medications ,

higher risk for side effects• Impaired fluid and food

intake• Failing memory,

deterioration of cognitive function

Functional disorders• Gait disturbances• Impaired self-reliance • Impaired ability to carry

out household duties • Limited leisure activities

Social difficulties• Financial problems• Inappropriate housing • Death of

spouse/caretaker • Social isolation

(scattered family)

TÁMOP-4.1.2-08/1/A-2009-0011

Geriatric assessment/management• Standard and/or systemic structured

geriatric assessment;• Decision making involving the

evaluation of the interdisciplinary team, executing interventions;• Based on comprehensive geriatric

assessment, when it is needed, recommendation for long-term senior housing may be issued;

TÁMOP-4.1.2-08/1/A-2009-0011

History-taking in the elderly:special considerations Family members of the old patient are allowed to be present with permission of the patient only.We have to take into consideration the impaired vision, hearing, reduced motor skills of the elderly. More patience and longer time are usually needed.Limiting factors of the history taking:• depression• fear of invasive examinations• impaired cognitive functions • atypical manifestations of diseases.

TÁMOP-4.1.2-08/1/A-2009-0011

History-taking in the elderly:special considerations Patients might not recognize the importance of some problems, that they assume to be associated with their age. Therefore, they may not reveal important complaints which can lead to misdiagnoses (repeated interviews). Written records (kept by the patient or a family member) may be very useful concerning• main complaints, symptoms, earlier diseases• list of drugs taken by the patient. Logorrhea should be prevented by asking straightforward questions.

TÁMOP-4.1.2-08/1/A-2009-0011

History-taking in the elderly IHistory-taking should include in general:• previous illnesses,• surgery,• current medications,• allergies,• vaccinations, • preventive medical examinations (screening

tests),• family history,• evaluation of self-reliance.

TÁMOP-4.1.2-08/1/A-2009-0011

History-taking in the elderly IISpecific features of history-taking in the

elderly:• social conditions (i.e. does the patient live

alone or in a family or with caregivers?)• economic conditions (e.g. quality of heating,

bathroom).• functional status (e.g. ablity to walk, self-

reliance, quantity and quality of diet).- ADL (activities of daily living)- IADL (instrumental activities of daily living)

TÁMOP-4.1.2-08/1/A-2009-0011

History-taking in the elderly IIIWe need to list complaints systematically by

organs:• cardiovascular system• respiratory tract• gastrointestinal tract• urogenital system• neurologic, psychiatric, locomotor system• skin• “general” complaints: fever, weight loss,

appetite and othersand by order of appearance.

TÁMOP-4.1.2-08/1/A-2009-0011

Communication withthe elderly patientIn general, basic methods of history-taking and physical examination are not different from that performed by general medicine (e.g. by internists). Main differences:1 Dealing with elderly patients usually takes

longer because• during a longer life more diseases are

developed• due to impaired cognitive functions recalling

information is more difficult and slower• lack of proper medical records makes the

evaluation of past medical history including diagnoses and surgical interventions more difficult

TÁMOP-4.1.2-08/1/A-2009-0011

Communication withthe elderly patient2 Patients do not consider certain information

important, such as non-prescription drugs, dietary supplements.

3 They regard certain, and often important, symptoms as age-related phenomena i.e. normal part of the aging process.

4 Diseases often present in an atypical manner which makes their assessments even harder.

5 Due to attention deficit and memory loss reporting data related to the actual complaints can be inaccurate.

TÁMOP-4.1.2-08/1/A-2009-0011

Communication withthe elderly patientFurther basic differences (history taker’s view):The thorough history-taking is especially important to avoid diagnostic errors and unnecessary examinations. (Even repeated sessions involving especially important parts of history taking may be useful.)The presence of impaired perception or hearing loss often makes further data gathering necessary, including heteroanamnesis.Due to altered pain perception in the elderly, pain assessment also has a special role in geriatric medicine.

TÁMOP-4.1.2-08/1/A-2009-0011

Communication withthe elderly patientTypical causes of impaired perception in

elderly:• Vision abnormalities (presbiopy, cataract,

retinopathy, etc.)• Hearing abnormalities (presbiacusis, loss of

certain frequencies)• Peripheral neuropathies (loss of correlation

between damage and severity of symptoms, e.g. no pain in appendicitis)

• Cognitive disorders (vascular or other dementia, depression, anxiety)

TÁMOP-4.1.2-08/1/A-2009-0011

Communication withthe elderly patientMedical history cannot be gained from an unconscious patient or patient with dementia.The acute management of the patient has priority while heteroanamnesis can be obtained from the relatives of the patient.It can be important for the patient to see the doctor’s face since mimic motions and lip reading can help to understand the questions asked by the health professional.

TÁMOP-4.1.2-08/1/A-2009-0011

Communication withthe elderly patientData must be recorded in an appropriate manner:• Social history should be assessed (i.e.

heating, bathroom and the like).• Does the patient live alone or in a family or

with other caregivers?• Is one able to walk, is one self-sufficient, what

does one’s diet consist of and so on.

TÁMOP-4.1.2-08/1/A-2009-0011

Example for tests of assessment:The Barthel ADL* indexACTIVITY SCORE

FeedingUnableNeeds cutting, spreading butter, etc., or requires modified dietIndependent

05

10

BathingDependentIndependent (or in shower)

05

GroomingNeeds help with personal careIndependent face/hair/teeth/shaving (implements provided)

05

DressingDependentNeeds help but can do about half unaidedIndependent (including buttons, zips, laces, etc.)

05

10

BowelsIncontinent (or needs to be given enemas)Occasional accidentContinent

05

10

* activities of daily living

TÁMOP-4.1.2-08/1/A-2009-0011

Example for tests of assessment:The Barthel ADL* indexACTIVITY SCORE

BladderIncontinent, or catheterised and unable to manage aloneOccasional accidentContinent

05

10

Toilet useDependentNeeds some help, but can do something aloneIndependent (on and off, dressing,wiping)

05

10

Transfers (bed to chair and back)

Unable, no sitting balanceMajor help (one or two people physical), can sitMinor help (verbal or physical)Independent

05

1015

Mobility (on level surfaces)

Immobile or <50 yardsWheelchair independent, including corners, >50 yardsWalks with help of one person (verbal or physical) >50 yardsIndependent (but may use any aid, eg. stick) >50 yards

05

1015

StairsUnableNeeds help (verbal, physical, carrying aid)Independent

05

10

* activities of daily living

TÁMOP-4.1.2-08/1/A-2009-0011

Interpretation of scoring on the Barthel index

Score Level of independence80-100 Independent in the daily activities60-79 Needs minimal help with ADL40-59 Partially dependent20-39 Very dependent0-19 Totally dependent