Communication Strategies for Older Adult Patients

1. Chapter 13Assessment of Older Adult Patients

2. Learning Objectives After reading this chapter you will be able to: Describe several techniques for reducing communication barriers with older adult patients Describe how loss of vision and hearing affect geriatric assessment efforts Identify techniques health care providers can use to compensate for hearing or vision loss in patients

3. Learning Objectives (cont’d) Identify age-related structural and physiologic changes in the cardiovascular and pulmonary systems Describe why older adults have a depressed immune system Describe pulmonary and cardiac assessment techniques

4. Learning Objectives (cont’d) List specific diagnostic tests that have altered age-related normal values Describe how functional ability relates to level of health, both actual and perceived

5. Introduction This chapter introduces age-related changes Gradual decline and chronic illness characterize aging Communicating with the aged can be challenging but if successful can lead to better outcomes

6. Introduction (cont’d) Older adults have depressed immune systems and often present with atypical signs and symptoms Systematic inventory of functional ability is necessary The “graying of America” increases the importance of understanding the special needs of this population

7. The Importance ofPatient-Clinician Interaction Principles of communication Avoid ageism: discrimination against the aged Treat the aged with compassion

8. Reduce communication barriers Sensory deficits of hearing or visual impairment Speech may be impaired by poor fitting dentures, stroke, head injury, or Alzheimer’s disease Emotional barriers such as depression Bridging these barriers facilitates communication The Importance of Patient-Clinician Interaction (cont’d)

9. The Importance of Patient-Clinician Interaction (cont’d) Reduce communication barriers Always approach patient in a caring manner Address by last name and appropriate title Avoid condescending terms: “sweetie,” “dear” Adjust heat, lights, etc. for patient comfort Introduce yourself and explain your purpose Eliminate background noise and interruptions Do not rush the patient

10. Age-Related Sensory Deficit Hearing impairment Presbycusis is age-related, progressive hearing loss often causing diminished functional independence Tinnitus, ringing, or buzzing in the ear is more prevalent, often caused by ototoxicity Assess hearing impairment by whispering a simple question while out of view but close to the patient

11. Age-Related Sensory Deficit (cont’d) Hearing impairment Compensating for hearing impairment Ask the patient if he or she can hear you Discuss possibility of ototoxicity or earwax with nurse Adjust hearing aid if available Enunciate words clearly May place stethoscope earpieces in the patient’s ears and speak into the bell

12. Age-Related Sensory Deficit (cont’d) Vision impairment Presbyopia: age-related change to eye’s lens Typically results in correctable farsightedness More serious disorders include cataracts, glaucoma, diabetic retinopathy, macular degeneration Places patients at high risk for falls Assessing for vision impairment Done by optometrists or ophthalmologists Not crucial for RTs to assess

13. Age-Related Sensory Deficit (cont’d) Compensating for vision loss/impairment Leave everything where patient wants it Patients memorize where items are If eyeglasses are used, make sure they are clean and properly positioned Label medicines with large letters or puff paint Use halogen lighting if available Verbal communication more important Speak clearly and explain procedure thoroughly If patient must move, offer an arm of support

14. Aging of Organ Systems Cardiovascular system Cardiovascular diseases common in elderly Normal CV changes include: Increased systolic pressure Increased LV afterload results in LV wall thickening Arterial walls stiffen LV filling slows; by age 80 may be reduced by 50% Up to 90% loss of SA node cells numbers, results in increased cardiac arrhythmias, particularly atrial fib The occurrence of CHF doubles for each decade of life between 45 and 75 years

15. Aging of Organ Systems (cont’d) Pulmonary system Trachea and bronchi become more rigid Smooth muscle progressively replaced with fibrous connective tissue Alveolar septa gradually deteriorate reducing surface area for gas exchange A/C membranes thicken reducing diffusion Lungs have less elastic recoil; chest wall more rigid: result is increased FRC and RV

16. Pulmonary system At ~55 years respiratory muscles begin to weaken Diaphragm strength may weaken by 75% Central responses to decreased O2 and increased CO2 diminish The age-related changes are not significant until combined with disease Together these result in increased morbidity and mortality Aging of Organ Systems (cont’d)

17. Pulmonary defense mechanisms Epithelial lining of tracheobronchial tree degenerates, ciliary action slows, and phagocytic activity decreases Cough becomes less effective This reduces mucociliary clearance; makes patient susceptible to pulmonary infections Institutionalized adults even more susceptible Conditions leading to decreased LOC Use of narcotics or sedatives GERD, dysphasia, etc, increase risk of aspiration and decreased cough mechanism Aging of Organ Systems (cont’d)

18. Immunity Aged have a reduced cell-mediated immunity May impair ability to fight infections placing them at greater risk for pneumonia, sepsis, etc. Increased frequency of reactivation tuberculosis Aging of Organ Systems (cont’d)

19. Unusual Presentation of Illness Presentation of older person with specific illness often different from younger person Could be due to a number of reasons Patients may just consider it “old age” Peripheral sensitivity decreases, diminishes pain Tachycardic response to hypoxia/sepsis reduced Aging organ systems may lose their ability to compensate for other systems Diminished inflammatory response

20. Unusual Presentation of Illness (cont’d) Pneumonia may present with: Reduced appetite, fatigue, decreased ability to perform daily activities, weakness Nausea, vomiting, diarrhea, myalgia, arthralgia Most sensitive sign of pneumonia is increased respiratory rate (>28 beats/min) Chest radiograph may not show infiltrate if patient dehydrated (detectable 24-48 hr after rehydrate) Consider bronchoscopy to identify cause

21. Unusual Presentation of Illness (cont’d) Heart failure: leading cause for hospitalization in adults >65 50% of people older than 75 years die of an MI They often have atypical presentation of MI Complaints of shoulder, throat, or abdominal pain Bilateral elbow pain Syncope, acute confusion, weakness, and fatigue Dyspnea or dizziness may be only complaints Cough, wheezing and hemoptysis

22. Unusual Presentation of Illness (cont’d) Asthma often misdiagnosed Should be considered in elderly patients with wheezing or dyspnea even if they do not have: Nocturnal or early morning symptoms History of allergies Immediate response to bronchodilators Underdiagnosis may relate to underuse of objective measurement by spirometers and peak flowmeters

23. Patient Assessment Vital signs in the elderly Temperature Tends to be lower, >90 years may be 96˚ to 97˚ F Obtaining a temperature may be difficult Aged may not be able to keep mouth closed Axillary method may not be accurate due to wasting Rectal method is accurate but not tolerated well Tympanic method, expensive but accurate and fast

24. Patient Assessment (cont’d) Vital signs in the elderly Pulse Active older adults may have normal resting pulse Inactive ones may have resting pulse of 50 to 55 beats/min Arrhythmias with rapid pulse are poorly tolerated Any changes in pulse should be immediately investigated

25. Patient Assessment (cont’d) Vital signs in the elderly Blood pressure (BP) Generally rises with age, particularly systole Risk of CV disease doubles with every 20/10 increment Thus it is key to control HTN BP may be falsely high due to arterial stiffness Procedure Have patient rest quietly 3 to 5 minutes Use a cuff that covers third of upper arm Measure on both arms; note differences Measure supine and sitting

26. Patient Assessment (cont’d) Vital signs in the elderly Respiratory rate (RR) Normal RR is 18 to 25 breaths/min Tachypnea may be due to: Ambulation Anxiety or midbrain lesions Hypoxemia, acidemia, or pneumonia Bradypnea may be due to: Medication or being asleep Alkalosis or hypothermia

27. Patient Assessment (cont’d) Inspection of the elderly Breathing pattern Cheyne-Stokes is noted with CHF, uremia, respiratory depression and brain damage Biot’s seen with elevated ICPs and brain damage Note length of apneas for both of the above Cyanosis Elderly may have small vessel syndrome with local areas of cyanosis or necrosis May experience pallor and cyanosis at room temp

28. Patient Assessment (cont’d) Inspection of the elderly Skin turgor (assess hydration) Tenting cannot be used because wasting provides a false positive Condition of tongue better indicates dehydration Clubbing Elderly have higher incidence of chronic diseases thus also have higher incidence of clubbing May indicate connective tissue disease

29. Patient Assessment (cont’d) Inspection of the elderly Edema Often peripheral edema indicates CHF or DVTs Not always a reliable indicator of CHF, so be careful Jugular venous distention (JVD) JVD is indicative of right heart failure Hepatojugular reflex is a reliable indicator of heart failure in the elderly

30. Patient Assessment (cont’d) Palpation in the elderly May be a scouting maneuver for skin condition, scars, signs of infection, and presence of bumps or bruises For those on ventilators or with trauma or post-thoracic surgery, check for subcutaneous emphysema Evaluating vocal fremitus requires cooperation Elderly may not be able to physically cooperate

31. Patient Assessment (cont’d) Pulmonary auscultation May not be able to sustain deep breathing Best effort may produce 3 or 4 breaths followed by rest Start posterior basal portions first Breath sounds (B/S) may be reduced even if healthy making vesicular sounds hard to hear Adventitious B/S will be just as with other patient groups

32. Diagnostic Tests Gas exchange in the elderly Reduced VC and PEF Increased closing volume reduces ventilation to bases while increases ventilation of upper lung fields Results in an increased V/Q ratio Slight reduction in PaO2 secondary to loss of alveolar surface area and increased V/Q mismatch

33. Arterial blood gases PaO2 decreases with age, roughly –0.245 mm Hg/year (see Table 13-2) Blood gas drawn from supine patient has PaO2 of 5 mm Hg less than if patient sitting After age 75 PaO2 tends to be higher in males PaO2 should be adequate in absence of disease Hypercapnia occasional in healthy aged Not predictable and usually mild Diagnostic Tests (cont’d)

34. Diagnostic Tests (cont’d) Pulse oximetry (SpO2) The lower PaO2 common in elderly results in a slightly lower SpO2 (93% to 94%) If the PaO2 stays at 60 mm Hg or greater the fall in SpO2 will not be clinically significant A good, measurable pulse is essential to measure SpO2 Some older patients have poor circulation, so obtaining a reading can be a problem

35. Diagnostic Tests (cont’d) Pulmonary function studies (PFTs) After age 25, pulmonary function declines Residual volume almost doubles with older age Important to use age-appropriate norms (Box 13-2) FVC and FEV1 diminish by approximately 30 ml/yr for men and 23 ml/yr for women DLCO decline not linear but worse after age 40 PFTs may require extra time Talk to the pulmonologist about the patient’s level of comprehension and performance

36. Comprehensive Geriatric Assessment Important goal: improve functional ability Quantified by activities of daily living (ADL) Personal hygiene, feed self, use toilet, dress self Instrumental activities of daily living (IADL) A way of quantifying the complex ADL Money management, telephone use, writing skills, ability to shop Deterioration of functional ability: early sign of illness; noting this may maintain quality of life

37. Summary Effective communication will improve patient care Taking extra time with older adults is worth the effort Disease presentation is often atypical in the elderly

38. Summary (cont’d) Vital signs and functional anatomy are often altered in the aged Preventive interventions to keep older patients healthy and functional and at home is the best medical care we can offer