Mary Mc Donald MD Division of Geriatric Medicine

Mary Mc. Donald, MD Division of Geriatric Medicine and Palliative Care Department of Family Medicine

Learning Objectives n Every student should be able to. . . n Demonstrate an appreciation of communication barriers that may present challenges when interviewing older adults n 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 n n n List the ten components of the comprehensive geriatric assessment n Identify components of the environmental interview n Describe screening tools used to assess mood and memory in a clinical setting n Define the activities of daily living and the instrumental activities of daily living n Describe simple screening methods for vision and hearing evaluation Discuss the importance of serial weight evaluation as a marker of nutritional wellbeing and the degree of weight loss that should trigger intervention n

Key Terms n n n n 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 n Sensory losses n Dysarthria n Aphasia n Altered mental status n

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 n Attributing symptoms to age and not addressing suffering n Withholding medical resources from older adults (“why bother? ”) n Failure to pursue uncomfortable subjects n

Impaired Hearing Increasing prevalence with increasing age n Medicare does not cover hearing aides n Associated with social isolation and depression n Finger rub testing n Clinical impression from interview very important for diagnosis n

Communication with the Hearing Impaired Patient n n n n 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 n n n 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 n More dependent on verbal instructions n Ask patients to repeat main treatment points to assure understanding n Well lit room n Heavy contrast helpful when writing n

Dysarthria n n n 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) n Yes/No questioning helpful n Written interview may be helpful n

Altered Mental Status General term often encompassing delirium or dementia n May necessitate interview of family members or care staff n Insight into medical condition often poor n Understanding of medications and disease states often lacking n

Setting an agenda n Open ended questioning to start the interview may lead to improved communication. n n “What issues would you like to discuss today? ” May need to assist with triaging problems n “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 n n n n 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

The Comprehensive Geriatric ROS n n n Audio/Visual Gait/Mobility/Falls Insomnia Nutrition GU n n n GI ADL/IADL Mood/Memory Environment Sexuality

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 n Ask about falls and near falls at each visit for frail older adults and at yeast yearly for all older adults n May self select to sedentary lifestyle to avoid falls n Fear of falling associated with social isolation and depression n

Insomnia n Sleep architecture changes with aging n n Increased sleep latency Less time in stage III and IV (deep) sleep Side effect of many medications, etoh n Improving sleep hygiene may be more helpful in the long term rather than sleeping medications n

Nutrition n Serial weights are most useful n n > 5% loss in any 1 month period > 10% loss in any 6 month period Poor prognostic indicator n Access to food/cooking important information n Social support services in place to assist older adults with poor access n

GI Constipation n Diarrhea n GERD n Dysphagia n Nausea n Early satiety n Dyspepsia n Gassiness n Landon Center on Aging Photo Contest

GU Urinary incontinence n Urinary hesitancy n Urinary frequency n Hematuria n Vaginal dryness/irritation n

Assessment of Function Activities of Daily Living(ADLs) Instrumental Activities of Daily Living (IADLs) Landon Center on Aging Photo Contest

ADLs/IADLs n n n ADLs Dressing Eating Ambulating Toileting Hygiene* IADLs n n n Driving Shopping Using the telephone Cooking Housekeeping Finances *Most often the first ADL lost in dementia

Mood n n 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 n Alzheimer’s dementia is the most common n Mini-mental state exam (MMSE) may be a helpful screening tool but limited by level of education and perhaps ethnicity n

Environment n n n 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 n Stereotypes, perceived “off limits” topic by some medical professionals n Many patients are unaware that this is a topic appropriate to discuss with their physician n Erectile dysfunction, vaginal dryness n

Advance Directives Living Wills n Durable Power of Attorney for health care decisions n Ideally, should be addressed at the first visit with all patients to become part of your routine office visit

Medication History n n 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. n While reviewing there medication bag, state the indication for each medication. n Any medications with an unclear indication should be scrutinized and is likely unnecessary n

Alternate History Sources Family, friends, caregivers especially important for patients with altered mental status or otherwise unable to communicate. n Only with the patient’s permission or once the durable power of attorney privilege has been invoked n

Alternate History Sources Remember who the patient is. Address questions to the patient whenever possible. n Protect patient privacy during exam to highest degree possible n May receive contradictory reports from various sources. Often must consider accuracy/attitudes/knowledge of reporter n

Tips for Enhanced Adherence n n n 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? n Interview and management of chronic and acute disease states. Hypertension Diabetes Chronic obstructive pulmonary disease coronary artery disease cerebrovascular disease hyperlipidemia etc, etc

How to manage? n Multidisciplinary team approach works best n n n Doctor Nurse Social worker Physical/occupational therapist Dietician

Questions?