Health Issues and the Pediatric Visit - 204.39 KB
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Transcript Health Issues and the Pediatric Visit - 204.39 KB
Grandparent Caregivers:
Health Issues and the Pediatric
Visit
Amanda D. Soong, MD
Assistant Professor of Pediatrics
University of Alabama at Birmingham
Objectives
Identify key health issues for:
Grandparent Caregivers
Discuss ways for the pediatrician to assist in the
evaluation of Grandparent’s health during a
pediatric visit
Discuss resources available in the community for
grandparents in need of medical evaluation
Definitions
For the purposes of this talk, Grandparent
Caregivers are defined as grandparents that
provide the majority of care for their grandchildren
under the age of 18.
This may include grandparents with formal or
informal custodial arrangements, or grandparents
that provide childcare for working parents.
Also included are other older relatives that may
have custody/provide care.
The Issue
According to 2011 American Community Survey
Estimates:
2,870,639 Grandparents are primary caregivers to
one or more grandchildren.
Some estimate that in the inner city, 30-50% of
children are in the care of grandparents.
Grandparent Health
Grandparents who care for grandchildren often
neglect their own health for a myriad of reasons
We may be the only health care providers a
grandparent sees if they have been overlooking
their own health in the process of caring for their
grandchild.
At Well Child Checks…..
You should already be asking about the Family
Medical History during your well child checks.
When dealing with grandparents, ask specifically
about their health instead of just asking what runs in
the family.
At Well Child Checks..
After asking about the child’s medications, ask
about other medications in the home and how the
medications are stored.
This may offer you more insight into the
grandparent’s health, and also provide invaluable
information in the case of an ingestion of an
unknown substance.
Health of Grandparent Caregivers
Multiple studies have examined the health of Grandparent
Caregivers.
Almost all of the studies have concluded that Grandparent
Caregivers have worse health than their peers not raising
children.
Health of Grandparent Caregivers
Besides worsening of adult illnesses like DM2, hypertension and arthritis, grandparent
caregivers may face other challenges.
Multiple studies have documented that
grandparent caregivers have greater
difficulty than their non-caregiving peers with
performing activities of daily living such as
performing day to day tasks, climbing a flight
of stairs, and moving around the house.
Health of Grandparent Caregivers
The caregivers are also more likely to report
depression than their non-caregiving peers.
Depression is known to have a significant
impact on overall health.
Health of Grandparent Caregivers
Your interaction with the grandparent
caregiver can also give you valuable insight
into their health.
Observe how well the caregivers seems able
to walk when going in or out of the exam
room.
Do they appear to have hearing or sight
issues?
Health of Grandparent Caregivers
While talking with the caregiver, do they
appear forgetful or confused?
As the child’s pediatrician you should
consider if you feel as if the child would be
safe with the caregiver.
If you have concerns for the safety of the
child, social work should be contacted.
Dementia or Cognitive Impairment
There is a continuum that exists between
mild cognitive impairment and dementia.
Early dementia may also be difficult to
differentiate from just a disorganized or
overwhelmed caregiver.
Signs of Dementia
Cognitive Changes:
New forgetfulness, increasing trouble understanding
written and spoken communication, work finding
difficulty, disorientation.
Psychiatric Symptoms:
Withdrawal or apathy, depression, suspiciousness,
anxiety, paranoia, hallucinations
Personality Changes:
Excessive friendliness, flirting; frustration, disinterest,
explosive outbursts.
Signs of Dementia
Problem behaviors:
Wandering, agitation, noisiness, restlessness
Changes in day-to-day Functioning:
Trouble driving, getting lost; neglecting self care
or chores, trouble shopping, cooking and paying
bills.
Diagnosis
There are 3 main categories to think of in the
continuum of dementia.
Age Related Cognitive Decline- memory loss without other cognitive
issues. Within normal limits given a person’s age.
Mild Cognitive Impairment- patient with some cognitive impairment,
but not to the degree found in dementia.
Dementia- according to the DSM-IV, cognitive impairment to the
degree that social or occupational function is reduced, with the
functional impairment representing a decrease in the patient’s normal
ability.
What should you do if you suspect a caregiver has
dementia or signs of cognitive decline?
If during the visit you are concerned by what you
observe, ask the child if they are old enough, if they
have noted any changes.
Are there any other relatives you could talk to?
You could ask the grandparent open ended
questions like, “Do you find you have more trouble
doing X than you used to?” If they say yes, probe
further.
If you are concerned for the child’s safety, social
services and DHR should be contacted.
Identifying dementia
As stated before, you may be the only contact with a
medical professional for the grandparent caregiver.
If you suspect dementia, there is an easy, quick
screen you could perform in the clinic to help guide
your decision making called the Mini-Cog exam, or
clock drawing test.
http://www.alz.org/documents_custom/minicog.pdf
The Mini-Cog
The test consist of 3 steps:
1) Instruct the caregiver to listen carefully to and
remember 3 unrelated words and then repeat the
words back.
2) Have the caregiver draw a clock face, and once
the face is drawn, ask them to add clock hands to
read a specific time like 10:20. You can repeat
instructions, but give no other instructions. This is
called the Clock Drawing Test (CDT)
3) Ask the patient to repeat back the 3 words
previously presented.
Scoring the Mini-Cog
Give 1 point for each recalled word at the end (1-3
points)
A score of 0 is a positive screen for dementia.
A score of 1 or 2 with an abnormal CDT indicates a
positive screen.
A score of 1 or 2 with a normal CDT is a negative
screen.
A score of 3 indicates a negative screen.
The Mini-Cog
As with any screen, further evaluation is needed for
a positive screen.
If concerns persist despite a normal screen, further
evaluation is also warranted.
Health Resources for Grandparent
Caregivers
Be aware of resources for geriatric patients in your
community. If concerns regarding cognitive
impairment arise, a physician specializing in
Geriatric Medicine may be able to assess the
patient and offer recommendations.
Social Support
Studies have indicated that Grandparent Caregivers
can benefit from taking part in support groups with
their peers.
Information regarding groups in your area may be
found at: http://www.aarp.org/relationships/friendsfamily/grandfacts-sheets/
Conclusions
Remember to ask about who is the primary
caregiver in the home.
Always ask about family history, but in the case of a
grandparent caregiver, try to get a complete history
and assess their access to care.
Consider screening for dementia if indicated.
Encourage the caregiver to seek medical care.
Advise caregivers of available community support
groups.
Sources
Minkler, M, Driver, D, et al. Community Interventions To Support Grandparent Caregivers.
The Gerontologist, 33( 6). 807-811.
Kelley, S., Whitley,D. Psychological Distress in Grandmother Kinship Care Providers: The
Role of Resources, Social Support, and Physical Health. Child Abuse & Neglect. 24(3) 311321.
Minkler, M., Fuller-Thomson, E. The Health of Grandparents Raising Grandchildren: Results
of a National Study. American Journal of Public Health. 89(9) 1384-1388.
Clinical Toolbox for Geriatric Carehttp://www.hospitalmedicine.org/geriresource/toolbox/mini_cog.htm
Grandfacts: A State Fact Sheet for Grandparents and Other Relatives Raising Children.
AARP. Alabama, August 2007
Santacruz, Karen, and D. Swagerty. Early Diagnosis of Dementia; American Family
Physician. Vol63, No 4; pages 703-713.
Personal communication with Dr. Marsha Crowther, Associate Professor of Psychology at
the University of Alabama