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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 TÁMOP-4.1.2-08/1/A-2009-0011 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 TÁMOP-4.1.2-08/1/A-2009-0011 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 TÁMOP-4.1.2-08/1/A-2009-0011 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 TÁMOP-4.1.2-08/1/A-2009-0011 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 TÁMOP-4.1.2-08/1/A-2009-0011 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 TÁMOP-4.1.2-08/1/A-2009-0011 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