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APROACH TO THE GERIATRIC PATIENT

ISTI ILMIATI FUJIATI

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OBJECTIVEAt the end of session the students will be able to describe:– geriatric health care – how to assess the geriatric patient– home visit in geriatric patient– health maintenance– longterm care placement

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• CURRENTLY:15 – 20% of all visits to family physicians are made by people 65 years of age and older.

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• CURRENTLY:15 – 20% of all visits to family physicians are made by people 65 years of age and older.

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INITIAL ENCOUNTER • Foundation for a mutually satisfying

long-term relationship • A caring, professional attitude• Unhurried manner

trust and rapport MYTHS: unproductive members society, lost interest in their own sexuality, senile, and noncompliant

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ASSESSING THE GERIATRIC PATIENT

• History - General assessment:- Ability to communicate by evaluating hearing, comprehension, mental status and speech date of birth, street address - Crucial: assessment of activities of daily living (ADLs) and Instrumental activities of daily living (IADLs)

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• Clinical HistoryThe elderly may present with the single chief complaint or a general “ I don’t feel well”

The physician review of system will reveal multiple problems area and needs.

The physician should be sure to elicit the patient’s agenda and expectation.

The physician should consider evaluating the patient for dementia and depression

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Asessment of ADLs & IADLs• ADLs:

- Ambulation

- Eating

- Bathing- Dressing- Toileting

- How do you get around the house?

- Any trouble climbing stairs?- Do you eat special diet?- Do you use special

instruments?- Do you have any problems

bathing?

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• IADLs:- Transportation

- Money management

- Meal preparation

- Housework - Telephone use

- Medications

- How do you get to the office today? Do you drive? At night?

- Who pays the bills and manages the money?

- Who prepares the meals?

- Who does the work?- Who in your family would you call

for help in an emergency?- What medicines do you take each

day?

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• Evaluate patient responses to treatment by noting any changes in functional abilities

• The family history should emphasize the availability and stability of social supports rather than familial diseases clarify important family membersPatient’s experience w/ chronic diseases

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• When patient ‘s social support system is limited or fragmented watch for signs of caregiver stress may present subtle abuse or neglect (manifested as noncompliance w/ medications, treatments, or follow-up visit

• Medication history elderly 3 -7x suffer a side effect and drug interaction than younger Poly pharmacy

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ASSESSING THE GERIATRIC PATIENT: Physical Examination

• Differs from the PE of younger adults • Important: mental status, hearing,

speech, condition of teeth and gums, skin, joints, feet, gait, the presence of orthostatic (postural) hypotension, evidence of atherosclerosis: hypertension, bruits, signs of CVD, neoplastic disease

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Physical Examination…• Focuses in functional abilities:

– Mental status– Hearing– Speech– Teeth and gums– Skin– Joints– Feet – Gait

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Physical Examination…• Focuses in functional abilities:

– Mental status– Hearing– Speech– Teeth and gums– Skin– Joints– Feet – Gait

The presence of orthostatic (postural) hypotension Evidence of atherosclerosis, hypertension, bruits, signs of congestive failure, reduced or absent pulses, sign of neoplastic disease, sign of other disease unique to the elderly, such of temporal arthritis, polymyalgia rheumatic and benign prostatic hypertrophy.

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Vital sign• Changes in systemic blood pressure with

aging deserve special attention• The man systolic pressure rises

progressively with age, whereas diastolic blood pressure level off or even falls beyond age 55 to 60

• Combined systolic-diastolic hypertension (systolic>160 mmHg, diastolic>95 mmHg)

• Pure systolic hypertension increase the risk of stroke and heart disease

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Mental StatusAlzheimer's disease and related

degenerative brain disease with advancing age screening for early dementia

Memory, orientation, intellectual function, judgment and affect cognitive dysfunction

Family physician are encourage to choose simple mental status screening instrument (mini-mental state) and become familiar with it and use it consistently in encounters with elderly patients

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Laboratory and Other Special Studies

• Laboratory studies should be chosen carefully

• The result of many laboratory test perform on elderly patient can be evaluated according to the standard set of younger patient

• However, several notable exception with which you should be familiar

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Laboratory and Other Special Studies…These include :• Creatinine clearance must be

considered in dosing medications correctly for the elderly patient

• Total iron binding capacity (TIBC) decrease with age, therefore a serum ferritin level or a bone marrow analysis are better ways to diagnose iron deficiency anemia in elderly

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• 10-20% healthy elderly adults demonstrate autoimmune phenomena, such as antinuclear antibodies, positive nuclear antibodies, thyroid antibodies, positive rheumatoid factor, positive VDRL

• Glucose intolerance (use 140 mg/ml as the upper limit of normal)

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ADDRESSING THE PROBLEMS OF THE GERIATRIC PATIENT

The problem list identify 3 category:1. Medical (diagnosis and unexplained

findings)2. Functional, such as aphasia,

incontinence or impaired gait3. Psychosocial, such as isolation, poverty

or caregiver stress

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• Once the patient' problem and needs have been identified, it may be necessary to negotiate with the patient the order in which they should be addressed

• Considerable time and expertise Reasonable management plans

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• A complex patient will be better managed when the physicians work as a part of a team that include :

1. Other health professional2. Family members or caregivers3. Neighbors or friends4. Other community resource

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Home Visit• Home visit are an essential part of

geriatric medicine• Many patient can be benefit from home

visit, especially those with multiple medical problems, behavioral problems, chronic disease and debilitating disease.

• A home visit allows the physicians to see and understand the realities with which the patient live.

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• In conducting a home visit, it is important to clarify with the patient and family what can be accomplished

• The physician need observation and communication skill and limited equipment in his bag (stethoscope and sphygmomanometer)

• Home visit can be very rewarding beneficial to both of physicians and patient

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HEALTH MAINTENANCE ISSUES• Discussion about the risk and benefit of any

intervention with the patient essential • Screening for increased serum cholesterol

usefulness for person over the age 70 • Pap smear and pelvic examination

women over 65 y.o• Breast examination by physical and

mammography indicated yearly for all women over the age of 65 y.o

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• Flexible sigmoidoscopy is recommended for screening for colon cancer every 3 to 5 years (beginning at age 50 y.o)

• Discuss and document how the patient would like to be treated if they incompetent to participate in therapeutic decision

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Long-Term Care Placement• When the patient’s everyday can no

longer be provided in the home, families and patients generally appreciate having their family physicians continue provide primary care service in the rest home, home for the aged, or nursing home

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Conclusion• Health in elderly is defined as the

ability to live and function autonomously in society, not the absent of the disease

• Improving and maintaining function not diagnosing and caring disease is the primary role of the physician in geriatric care

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• Providing quality care for elderly patients can be both rewarding and frustrating, comfort may be the most important goal

• The physician need work with health care team to provide the best care possible to elderly patients.

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Thank You