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The Geriatric Interview. Mary McDonald, MD Division of Geriatric Medicine and Palliative Care Department of Family Medicine. Learning Objectives. Every student should be able to...
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The Geriatric Interview Mary McDonald, MD Division of Geriatric Medicine and Palliative Care Department of Family Medicine
Learning Objectives • Every student should be able to... • Demonstrate an appreciation of communication barriers that may present challenges when interviewing older adults • Explain how cultural differences may affect the geriatric medical interview • Discuss the importance of setting an agenda and of reviewing the goals of therapy during an office visit • Describe methods used to improve effective communication and enhance patient adherence to the recommended plan of care • List the ten components of the comprehensive geriatric assessment • Identify components of the environmental interview • Describe screening tools used to assess mood and memory in a clinical setting • Define the activities of daily living and the instrumental activities of daily living • Describe simple screening methods for vision and hearing evaluation • Discuss the importance of serial weight evaluation as a marker of nutritional well-being and the degree of weight loss that should trigger intervention
Key Terms • Comprehensive geriatric assessment • Depression • Finger-rub test • Dementia • Sleep latency • Sexuality • Serial weights • Constipation • Urinary incontinence • Activities of daily living (ADLs) • Instrumental activities of daily living (IADLs) • Mini-mental state exam(MMSE) • Geriatric depression scale (GDS) • Insomnia • Visual impairment • Hearing impairment
Barriers to Effective Communication • Attitude/Ageism • Sensory losses • Dysarthria • Aphasia • Altered mental status
Ageism Discrimination based on age, especially prejudice against the elderly American Heritage Dictionary of the English Language, fourth Edition, 2000
Examples of Ageism • Seeing aging as a disease state • Attributing symptoms to age and not addressing suffering • Withholding medical resources from older adults (“why bother?”) • Failure to pursue uncomfortable subjects
Impaired Hearing • Increasing prevalence with increasing age • Medicare does not cover hearing aides • Associated with social isolation and depression • Finger rub testing • Clinical impression from interview very important for diagnosis
Communication with the Hearing Impaired Patient • Sit facing patient • Speak slowly and clearly • Lean in toward patient • Lower pitch of voice • Minimize background noises • Written materials • Hand held assistive devices
Vision Impairment • Increased prevalence with increasing age • Macular degeneration, glaucoma, cataracts, presbyopia, diabetic retinopathy • Corrective lenses are not covered by Medicare • Ask patient if he/she can read the newspaper print • Pocket Snellen eye chart Landon Center on Aging Photo Contest
Communication with the Vision Impaired Patient • Large print when available • More dependent on verbal instructions • Ask patients to repeat main treatment points to assure understanding • Well lit room • Heavy contrast helpful when writing
Dysarthria • Dysfunctional speaking • Common finding after stroke • Dentures may inhibit clear speech • Often worse when patient feels rushed or stressed. Taking time to allow patient to speak may help • Yes/No questions helpful
Aphasia • Inability to speak(expressive) or to understand speech(receptive) • Yes/No questioning helpful • Written interview may be helpful
Altered Mental Status • General term often encompassing delirium or dementia • May necessitate interview of family members or care staff • Insight into medical condition often poor • Understanding of medications and disease states often lacking
Setting an agenda • Open ended questioning to start the interview may lead to improved communication. • “What issues would you like to discuss today?” • May need to assist with triaging problems • “Which two issues on your list would you like us to concentrate on today?”
Agenda Follow-Up “Did we adequately address the main issues you had hoped to cover today?”
Establishing Rapport/Trust • Sit during interview • Shake hands and introduce yourself • Culturally appropriate eye contact • Use last name when addressing patient • Communicate caring/concern • Legitimize patient concerns • Allow time for reminiscing/life review
Audio/Visual Gait/Mobility/Falls Insomnia Nutrition GU GI ADL/IADL Mood/Memory Environment Sexuality The Comprehensive Geriatric ROS
Audio/Visual “Do you have any difficulty seeing the print in the newspaper?” “How is your Hearing?” Landon Center on Aging Photo Contest
Gait/Mobility/Falls • A previous fall is highly predictive of falls in the future • Ask about falls and near falls at each visit for frail older adults and at yeast yearly for all older adults • May self select to sedentary lifestyle to avoid falls • Fear of falling associated with social isolation and depression
Insomnia • Sleep architecture changes with aging • Increased sleep latency • Less time in stage III and IV (deep) sleep • Side effect of many medications, etoh • Improving sleep hygiene may be more helpful in the long term rather than sleeping medications
Nutrition • Serial weights are most useful • > 5% loss in any 1 month period • > 10% loss in any 6 month period • Poor prognostic indicator • Access to food/cooking important information • Social support services in place to assist older adults with poor access
GI • Constipation • Diarrhea • GERD • Dysphagia • Nausea • Early satiety • Dyspepsia • Gassiness Landon Center on Aging Photo Contest
GU • Urinary incontinence • Urinary hesitancy • Urinary frequency • Hematuria • Vaginal dryness/irritation
Assessment of Function Activities of Daily Living(ADLs) Instrumental Activities of Daily Living (IADLs) Landon Center on Aging Photo Contest
ADLs Dressing Eating Ambulating Toileting Hygiene* IADLs Driving Shopping Using the telephone Cooking Housekeeping Finances ADLs/IADLs *Most often the first ADL lost in dementia
Mood • Depression common in the older adult • Horridly underdiagnosed/undertreated • Often presents as functional decline: weight loss, insomnia, social isolation, fear, anxiety, poor grooming, self-neglectful behaviors • Geriatric depression scale can be a helpful screening tool but does not replace clinical impression
Memory/Cognitive Impairment • Prevalence of dementia increases with increasing age • Alzheimer’s dementia is the most common • Mini-mental state exam (MMSE) may be a helpful screening tool but limited by level of education and perhaps ethnicity
Environment • Who lives in the home? • What type of dwelling? • Daily contacts • Transportation accessibility • Home services available Landon Center on Aging Photo Contest
Sexuality • Often neglected component of the interview of the older adult • Stereotypes, perceived “off limits” topic by some medical professionals • Many patients are unaware that this is a topic appropriate to discuss with their physician • Erectile dysfunction, vaginal dryness
Advance Directives • Living Wills • Durable Power of Attorney for health care decisions Ideally, should be addressed at the first visit with all patients to become part of your routine office visit
Medication History • Older adults account for < 15% of the US population • Over 1/3 of all prescription medications • Heavy usage of OTC medications • Likelihood of adverse drug event related to number of comorbid illnesses and number of medications taken Curtis, et al Arch Intern Med/Vol 164, Aug 9/23, 2004. 1621-1625
Medication History • Asking patients to bring all medications and over the counter medications to each visit can be very helpful. • While reviewing there medication bag, state the indication for each medication. • Any medications with an unclear indication should be scrutinized and is likely unnecessary
Alternate History Sources • Family, friends, caregivers especially important for patients with altered mental status or otherwise unable to communicate. • Only with the patient’s permission or once the durable power of attorney privilege has been invoked
Alternate History Sources • Remember who the patient is. Address questions to the patient whenever possible. • Protect patient privacy during exam to highest degree possible • May receive contradictory reports from various sources. Often must consider accuracy/attitudes/knowledge of reporter
Tips for Enhanced Adherence • Decrease the complexity of the treatment regimen • Repeat instructions and/or write them down. Include indication for each med • Encourage use of pill box • With patient permission, include family or friend in care plan • Be sensitive to cost concerns • Reminder calls for appointments
What’s left? • Interview and management of chronic and acute disease states. Hypertension Diabetes Chronic obstructive pulmonary disease coronary artery disease cerebrovascular disease hyperlipidemia etc,etc,etc
How to manage? • Multidisciplinary team approach works best • Doctor • Nurse • Social worker • Physical/occupational therapist • Dietician
Questions? Questions?