Communication WITH The elderly patient

1. 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 Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011

2. 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 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 elderlypatient

3. Outline • Difficulties of thehistory-taking and determination of diagnosisintheelderly • Communication with the elderly patient

4. History-taking in the elderly:polymorbidity • Elderlieshavesurvived more diseases and have more ongoingchronicabnormalities (cumulation). • Poly(multi)morbidity: • cumulation of damagingeffectsduringaging • predispositionduetophysiologicalweakening of functionsduringaging • withtheadvancement of healthcare, potentiallylethaldiseasesbecometreatable, therefore more and more elderlypeoplesurvivetoacquiremultiplediseasestypicallyaffectingtheyoung and themiddle-aged

5. History-taking in the elderly:atypical symptoms • 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 complaints the presence of complex problems, processes, diseases, syndromes suffered during a long life, can be considered.

6. History-taking in the elderly:complexassessment • 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 patientare also essential.

7. Multiple problems require complex assessment in the elderly • 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 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)

8. 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;

9. 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.

10. 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 familymember) may bevery useful concerning • main complaints, symptoms, earlier diseases • list of drugs taken by the patient. • Logorrhea should be prevented by asking straightforward questions.

11. History-taking in the elderly I • History-taking should include in general: • previous illnesses, • surgery, • current medications, • allergies, • vaccinations, • preventive medical examinations (screening tests), • family history, • evaluation of self-reliance.

12. History-taking in the elderly II • 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) • IADL (instrumental activities of daily living)

13. History-taking in the elderly III • 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 • and by order of appearance.

14. Communication withthe elderly patient • In 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

15. Communication withthe elderly patient • 2 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. • 5Due to attention deficit and memory loss reporting data related to the actual complaints can be inaccurate.

16. Communication withthe elderly patient • 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. • Due to altered pain perception in the elderly, pain assessment also has a special role in geriatric medicine.

17. Communication withthe elderly patient • 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 dementia, depression, anxiety)

18. Communication withthe elderly patient • 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.

19. Communication withthe elderly patient • 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 self-sufficient, what does one’s diet consist of and so on.

20. Examplefortests of assessment:The Barthel ADL* index * activities of dailyliving

21. Examplefortests of assessment:The Barthel ADL* index * activities of dailyliving

22. Interpretation of scoring on the Barthel index