Transcript Communication WITH The elderly patient

Manifestation of Novel Social Challenges of the
European Union
in the Teaching Material of
Medical Biotechnology Master’s Programmes
at the University of Pécs and at the University
of Debrecen
Identification number: TÁMOP-4.1.2-08/1/A-2009-0011
Manifestation of Novel Social Challenges of the
European Union
in the Teaching Material of
Medical Biotechnology Master’s Programmes
at the University of Pécs and at the University
of Debrecen
Identification number: TÁMOP-4.1.2-08/1/A-2009-0011
Gyula Bakó and Miklós Székely
Molecular and Clinical Basics of Gerontology – Lecture
19
COMMUNICATION WITH
THE ELDERLY PATIENT
TÁMOP-4.1.2-08/1/A-2009-0011
Outline
• Difficulties of the historytaking and determination of
diagnosis in the elderly
• Communication with the
elderly patient
History-taking in the
elderly:
polymorbidity
TÁMOP-4.1.2-08/1/A-2009-0011
Elderlies 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
History-taking in the
elderly:
atypical symptoms
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Aging 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
History-taking in the
elderly:
complex assessment
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The 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
• socioeconomic
conditions of the patient are also
essential.
Multiple problems require
complex assessment in the
elderly
TÁMOP-4.1.2-08/1/A-2009-0011
Organ 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
• Gait disturbances
• Impaired self•
•
reliance
Impaired ability to
carry out household
duties
Limited leisure
activities
Social difficulties
• Financial problems
• Inappropriate
housing
• Death of
Geriatric
assessment/management
TÁMOP-4.1.2-08/1/A-2009-0011
• 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;
History-taking in the
elderly:
special considerations
TÁMOP-4.1.2-08/1/A-2009-0011
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
History-taking in the
elderly:
special considerations
TÁMOP-4.1.2-08/1/A-2009-0011
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.
History-taking in the
elderly I
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History-taking should include in
general:
• previous illnesses,
• surgery,
• current medications,
• allergies,
• vaccinations,
• preventive medical examinations
(screening tests),
• family history,
• evaluation of self-reliance.
History-taking in the
elderly II
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Specific 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)
History-taking in the
elderly III
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We 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 others
Communication with
the elderly patient
TÁMOP-4.1.2-08/1/A-2009-0011
In general, basic methods of historytaking 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
Communication with
the elderly patient
TÁMOP-4.1.2-08/1/A-2009-0011
2 Patients do not consider certain
information important, such as nonprescription 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.
Communication with
the elderly patient
TÁMOP-4.1.2-08/1/A-2009-0011
Further 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.
Communication with
the elderly patient
TÁMOP-4.1.2-08/1/A-2009-0011
Typical 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
Communication with
the elderly patient
TÁMOP-4.1.2-08/1/A-2009-0011
Medical 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.
Communication with
the elderly patient
TÁMOP-4.1.2-08/1/A-2009-0011
Data 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 selfsufficient, what does one’s diet
consist of and so on.
Example for tests of
assessment:
The Barthel ADL* index
TÁMOP-4.1.2-08/1/A-2009-0011
ACTIVITY
SCORE
Feeding
Unable
Needs cutting, spreading butter, etc., or requires modified diet
Independent
0
5
10
Bathing
Dependent
Independent (or in shower)
0
5
Grooming
Needs help with personal care
Independent face/hair/teeth/shaving (implements provided)
0
5
Dressing
Dependent
Needs help but can do about half unaided
Independent (including buttons, zips, laces, etc.)
0
5
10
Bowels
Incontinent (or needs to be given enemas)
Occasional accident
Continent
0
5
10
* activities of daily living
Example for tests of
assessment:
The Barthel ADL* index
TÁMOP-4.1.2-08/1/A-2009-0011
ACTIVITY
SCORE
Bladder
Incontinent, or catheterised and unable to manage alone
Occasional accident
Continent
0
5
10
Toilet use
Dependent
Needs some help, but can do something alone
Independent (on and off, dressing,wiping)
0
5
10
Transfers
(bed to chair
and back)
Unable, no sitting balance
Major help (one or two people physical), can sit
Minor help (verbal or physical)
Independent
0
5
10
15
Mobility (on
level
surfaces)
Immobile or <50 yards
Wheelchair independent, including corners, >50 yards
Walks with help of one person (verbal or physical) >50 yards
Independent (but may use any aid, eg. stick) >50 yards
0
5
10
15
Stairs
Unable
Needs help (verbal, physical, carrying aid)
Independent
0
5
10
* activities of daily living
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Interpretation of scoring on
the Barthel index
Score
80-100
60-79
40-59
20-39
0-19
Level of independence
Independent in the daily activities
Needs minimal help with ADL
Partially dependent
Very dependent
Totally dependent