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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
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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.
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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)
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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;
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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.
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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.
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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.
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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)
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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.
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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
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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.
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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.
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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)
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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.
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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.
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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
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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
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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