What are some common communication barriers between clinicians and geriatric partients?
- Inadequate description of chief complaint could be due to:
- Memory loss
- Depression
- Hearing impairment
- Cultural issues
- An age gap between patient and physician could make it difficult to establish rapport:
- Clinicians may infantilize older ill patients which can jeopardise the therapeutic relationship.
- Be aware of patients own preconceived notions about ageing and could assume that their symptoms are a normal part of ageing and not seek help.
- Family members can present both a challenge and an opportunity: reinforce information about the patient’s illness, provide corroboration of subjective history, aid with treatment plan and help set/achieve management goals. Allow some private patient-doctor time in each visit.
What are some ways a clincian can overcome communication barriers with their geriatric patients?
Hearing Loss:
- Quiet rooms that reduce extraneous noise (music and machinery).
- Speak distinctly and where the person can see your lips.
- Don’t shout: age-related stiffening of the tympanic membrane and ear ossicles distorts high volume sound. (lower tones better)
Dress Code:
- The majority did not like sandals, open necked shirts in males, or low cut or tight fitting clothes in female doctors.
- Also, patients did not like earrings in males, or non-traditional hair styles.
- Liked dress pants in males and females, or dark business skirts in females + white coat.
List and describe the components of a functional assessment in a geriatric patient
They must be addressed in both the history and physical examination:
. Vision
. Hearing
. Mentation
. Depression
. Nutritional Status
. Mobility
. Physical disability
. Urinary Incontinence
Why would geriatric patients be more vulnerable/at risk of inadequate nutrition?
- Issues with dentition or ill-fitting dentures.
- Diminished appetite due to depression, loneliness, or appetite-supressing drugs.
- Conditions prevalent in elderly include constipation, congestive heart failure, cancer, dementia.
- Lack of financial resources.
- Disabilities resulting in limited access to food&/or inability to prepare meals.
What issues should be routinely considered in geriatric social history?
gives cinitian better idea of who person is
- Living arrangement - alone? death of spouse? disconnected from society?
- Vocation? volunteer?- past occupation? duration of retirement? highest level of education?
- Habits/lifestyle
- exercise -type
- sleep - duration, quality
- smoker: pack/years
- alcohol: standard per day/week
- recreational activities
- Transportation
- Social network
What aspects of Pts. Social Hx help form a nutritional assessment?
- Occupation, retirement and income
- Participation in economic assistance programs
- Living arrangements
- Availability of transportation and shopping
- Educational reading level
- Motivation and adherence to health recommendations
What screening tool can help identify elderly patients who are malnourished or at risk of malnutrition?
MNA-SF
Mini Nutritional Assessment - Short Form
What are some aspects of physical examination that may indicate nutritional tratus?
- General appearance (muscle wasting, pitting oedema, mood).
- Height and body weight
- Skin (dermatitis, echymosis)
- Hair (thinning, brittle)
- Nails
- Oral cavity (gums, glossitis)
- Vision and upper extremity (ability to prepare or consume food).
- Peripheral neuropathy and dementia could also be a sign of nutritional deficiency.
What are some common deficiencies in the elderly population?
B2 (riboflavin) deficiency:
- cheilosis, glossitis, angular stomatitis, seborrhoeic dermatitis, and a magenta tongue.
B6 (pyridoxine) deficiency:
- anaemia.
B12 deficiency (Up to 5% of persons over 80)
- can lead to dementia, anaemia, incontinence, posterior column disease, and orthostatic hypotension.
zinc deficiency
- weight loss, glucose intolerance, and diabetic neuropathy
copper deficiency
- goiters
chromium deficiency
- anaemia and leukopenia
iron deficiency
- diarrhea, dermatitis, hair loss, poor wound healing, alteration in the senses of taste and smell
iodine deficiency
- Anaemia
High levels of alcohol consumption over a long time => thiamine deficiency, resulting in Wernicke-Korsakoff syndrome (Australia has one of the highest prevalence of this in the world).
What OM would you use to assess ALCOHOL DEPENDENCE?
CAGE questionnaire13
C - Have you ever felt you should Cut down on your
drinking?
A - Have people Annoyed you by criticizing your drinking?
G - Have you ever felt bad or Guilty about your drinking?
E - Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (“hair of the dog” or “eye-opener”)?
Scores of > or = 2 are clinically significant and may indicate alcohol dependence
How important is emotional adaptability with regards to an elderly patients health?
- Emotional adaptability + fortitude provide considerable protection against declining health in elderly patients.
- A patient’s resilience in the face of adversity is often a better predictor of health outcomes than the specific nature of that adversity.
- do they look foreward to the future, its prospects?
A review of VISUAL AQUITY in an elderly Pt should include what specific questions?
-DDX
(specifically Macula Degeneration + Test)
- “Do you have any difficulty reading, watching TV or driving because of your vision?”
- “Have you had an loss of central/peripheral vision?”,
- “Are you bothered by glare from lights at night, especially when driving?”,
DDx:
A. Cataracts
B. Glaucoma
C. Macula Degeneration
D. Stroke
E. Temporal Arteritis
F. Presbyopia
Macula Degeneration
- 1 in 7 Australians >50yo and the incidence increases with age
- It is hereditary 50% chance of inheriting with Family Hx
- Etiology = genetic and environmental factors. Risk factors include age, family history, smoking and diet and lifestyle factors.
- Screening = Amsler Grid (There is a dot in the centre of a grid; +tve = wavy, broken, distorted, blurred lines “black hole”)
How can you assess COGNITION include OM
Before testing cognition, it is important to vision and hearing are intact.
Deficits in primary sensation could lead to a false conclusion about the patient being cognitively impaired.
Mini Mental State Exam (MMSE):
- The best validated and most widely used
- Covers the cognitive domains of orientation, memory, attention, calculation, language, and constructional ability.
- Mini-Cog assessment instrument:
- combines an uncued 3-item recall test with a clock-drawing test (CDT).
- can be administered in about 3 minutes
- no special equipment
- uninfluenced by level of education or language variations.
- Performance in diverse populations is comparable to MMSE..
How can you assess MOBILITY STATUS using a Timed Up and Go test (TUG)
- The patient is observed and timed while he or she rises from an arm chair, walks 3 meters, turns, walks back, and sits down again.
- score is reliable & valid, correlates with scores on the Berg Balance Scale, predicts ability to go outside alone (functional mobility)
What Questions should you ask about FALLS?
*hint SPLATT!!
Symptoms prior to fall – dizziness? New symptoms?
Previous falls or near falls – no.1 risk factor for a fall.
Location of fall – environmental factors (wet floor, furniture layout)
Activity at time of fall – sit-stand? Reaching outside BOS
Time of fall – night? After medication?
Trauma, physical and psychological – fear of falling can lead to greater levels of weakness and others performing ADLs for them => increasing risk of future fall.
Helps determine:
- cause of fall
- specific risk factors
- impairments leading to fall
What are some risk factors for URINARY INCONTINENCE in the elderly population?
- Female 2:1 - F = weakened pelvic floor; M = likely post prostate surgery
- Age
- Parity - no. childbirths
- Dementia
- Polypharmacy = 4 or greater no. meds
- Stress UI = mc (walking aerobics, sneezing, coughing)
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Week 1 Normal Aging36
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Week 2 Geriatric History16
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Week 4 Falls39
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Week 5 Dementia23
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Week 7 Trunk and Spine25
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Week 6 - Intro to Paediatric + Child Development20
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Week 8 - ITW0
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Week 9 DHD0
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Week 10 Cerebral Palsy7
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Week 10 Birth Palsy's and New Born Foot0
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Week 8 Abnormalities of the Lower Limb0
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Week 9 Torticolis0
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Week 9 Plagiocephaly0
