Older persons as a patient

1. Olderpersons as a patient Specialization in Health Management forOlderAdults MODULE IV UNIT 2

2. Whatisgeriatrics? • Geriatric medicine is a sub-specialty of family medicine that focuses on health care of elderly people. It aims to promote health by preventing and treating diseases and disabilities in older adults. • Primary care doctors and geriatricians need to know the medical aspects of aging, which include the atypical presentation of diseases, demanding a different approach and the integral evaluation and management of health.

3. Variables that affect the presentation of diseases in geriatrics • Comorbidity is frequent in the elderly patient, and no disease dominates the clinical picture. • Multi-Organ Failure • The presentation of a social problem can obscure an underlying disease or complicate health management. • The use of multiple medications can complicate health management. • Some medications can cure health problems while causing other health problems. This can be critical in older adults.

4. Different presentation of disease compared with younger adults • For a given symptom, diagnosis may vary greatly between older and younger adults. For example, symptoms that habitually correspond to gastro esophageal reflux in the young adult can correspond to carcinoma in the older adult. • What can appear to be the same disease in different age groups can in reality have very diverse etiologies.

5. Aging and disease • There exists epidemiological evidence of a relationship between aging and disease; this by no means implies that all diseases increase with age. Therefore we should distinguish 2 disease groups: 1) Diseases dependent on age: those whose incidences increase exponentially as age increases and 2) Diseases relating to age: those which are associated more frequently with a specific age. • There are certain disorders associated with the intrinsic changes which accompany aging of which older adults are particularly prone. Oesophagic motor disorders and osteoarthritis are examples. • Some complications of common diseases only occur decades after the process starts and are therefore more frequently observed in older adults. For example, the complications of arterial hypertension or the late manifestation of diabetes.

6. Delayed presentation of disease • The principal complaint at the time of consultation may not directly reflect the main problem. In reality the chief complaint corresponds more frequently with the symptoms that are most easily recognized by the patient or caregiver. • Conditions frequently associated with old age such as falls, incontinence and cerebral accidents don’t always constitute the patients principal complain even through they are frequently present. • The main health problem may be hidden by a facilitating complaint which corresponds with what the patient thinks will evoke the most favorable response from the doctor.

7. Geriatrics in the context of primary care • One of the pillars of primary care is prevention; to avoid the development of health problems that are hard to reverse. • Quality primary care is recognized by its capacity to prevent, detect, anticipate and intervene early in the following key conditions: • Immobility • Instability • Incontinence • Intellectual Deterioration • Iatrogenesis

8. immobility • Immobility is a risk to functional independence and has negative repercussions on health and quality of life. In its highest level where the patient is confined to a bed, immobility causes problems inherent in itself, independent of the disease or condition which initially caused immobility. • Stasis ulcers and muscle contractures are examples of frequent complications in bed ridden patients. • Doctors and geriatric teams must prioritize motivation, activity and functional recuperation to address immobility.

9. instability • Postural instability and falls are problems common to older adults. In addition to causing an increased risk of fractures and being associated with increased mortality, the principal complications of falls are the functional and psychological limitations which result from fear of falling. This may lead to decreased social activities and immobility.

10. incontinence • Fecal and urinary incontinence, in addition to their own medical significance, have a profound impact on the wellbeing of elderly adults, compromising their self-esteem. Incontinence does not routinely attract the attention of doctors. • In the independent elderly adult, incontinence constitutes a motive for the abandonment of social activities and the initiation of his/her restriction to the home environment. • In the immobilized and dependent patient, incontinence can be the sign of deficient care; patients may urinate in bed as they are not able to seek help or because they are not attended to when they ask for help in going to the bathroom.

11. Intellectual deterioration • Cognitive problems are highly prevalent among older adults and constitute one of the principal causes of incapacity and loss of autonomy and independence. • Dementia is progressive and irreversible, and it is estimated that at least 10% of the population 65 years and older have at least one form of dementia. • While Alzheimer’s disease is the most frequent cause of dementia, the importance of vascular dementias should not be underscored. These afflictions have a great impact on the life of patients and their families. The presence of non-cognitive disturbances, such as personality changes, aggressiveness, sleep changes, and others increase the necessity of permanent care and the need for admittance to geriatric institutions or homes.

12. iatrogenesis • Iatrogenesis is an inadvertent adverse effect or complication oftentimes resulting from complex drug interactions. • In addressing itatrogenesis, doctors and caregivers should avoid the excessive use of medication and work to prevent self-prescribing. • Other forms of iatrogenesis include doctors giving the wrong advice to patients due to lack of knowledge or prejudice.

13. Doctor-patient relationship • An older patient’s physician must always be diligent in the diagnosis and treatment of diseases. • It has been found that visits between older adults and health personnel do not result in an appropriate therapeutic response in a significant number of cases. • Many diseases and conditions that are commonly perceived as an inevitable part of aging actually can be cured or limited. The existence of specific models of disease presentation allows you to improve detection of common problems among the elderly.

14. Comprehensive assessment of the elderly • Both the aging of organs and systems and the atypical and simultaneous presentation of disease made necessary the implementation of a special system of assessment for older adults. • A comprehensive health assessment is a clinical approach tool focused on the predominant health problems in the elderly. It is a structured and dynamic diagnostic that allows you to detect the problems, needs and capabilities of the elderly in the clinical, functional, mental and social spheres to develop an interdisciplinary strategy of intervention and long-term follow-up in order to optimize resources, achieve the highest degree of independence and quality of life.

15. Clinical evaluation of older adults • A clinical evaluation should include: • Medical history of the patient • A clinical interview that includes a personal history of: • Falls • Previous surgeries and hospitalizations • History of delirium • Prevention of infectious disease • Skills, hobbies, caregiver details, daily activity routine, etc. • Physical examination • Functional assessment • Evaluation of the mental and emotional status • Nutritional assessment • Social assessment

16. bibliography • Chodosh J, McCann RM, Frankel RM, et al. Geritric Assessment and the Twenty Minute Visit. Rochester, New York: Division of Geriatrics, Universitiy of Rochester, School of Medicine and Dentistry; 1997. • Detsky AS, Abrams, HB, McLaughlin JR, et al. Predicting cardiac complications in patients undergoing non-cardiac surgery. J Gen Intern Med. 1986;1:211-219 • Edelberg HK, Wei JY. Primary-care guidelines for community-living older persons. Clin Geriatrics. 1999; 7: 42-55. • Goldberg TH, Chaving SI. Preventive medicine and screening in older adults. J Am Geriatric Society. 1997; 45(3):344-354. • Lubin MF. Is age a risk factor for surgery? Med Clin North Am 1993; 77:327-333. • Moore AA, Su Al, “Screening for common problems in ambulatory elderly: clinical confirmation of a screen instrument.” Am J Med 1996, 100:440-5 • Reuben, D et al. Geriatrics At Your Fingertips, 1998/99 Edition, American Geriatrics Society, Belle Mead, NJ: Medical Expert, Inc., 1998. • Rowe JW, Kahn RL. Succesful Aging. New York: Pantheon Press; 1998. • Thomas DR, Ritchie CS. Preoperataive assessment of older adults. JAGS 1995; 43:811-821 • . Bo M, Martini B, Ruatta C, Massaia M, Ricauda NA, Varetto A, Astengo M, Torta R. Geriatric ward hospitalization reduced incidence delirium among older medical inpatients. Am J Geriatr Psychiatry. 2009 Sep;17(9):760-8 • Siddiqi N, Stockdale R, Britton AM, Holmes J. Interventions for preventing delirium in hospitalised patients. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD005563. • Avila-Beltrán R, García-Mayo E, Gutiérrez-Robledo LM, Avila-Funes JA. Geriatric medical consultation is associated with less prescription of potentially inappropriate medications. J Am Geriatr Soc. 2008 Sep;56(9):1778.

17. Bibliography • HermushV, Daliot D, Weiss A, Brill S, Beloosesky Y. The impact of geriatric consultation on the care of the elders in community clinics. Arch GerontolGeriatr. 2009 Sep-Oct;49(2):260-2. • Reuben DB, Frank JC, Hirsch SH, McGuigan KA, Maly RC. A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations. J Am Geriatr Soc. 1999 Mar;47(3):269-76. • Bachmann S, Finger C, Huss A, Egger M, Stuck AE, Clough-Gorr KM. Inpatient rehabilitation specifically • San Joaquín Romero AC, Fernández Arin E, Mesa Lampré MP, García-Arilla Calvo E. Valoración Geriátrica integral en: Sociedad Española de Geriatría y Gerontología. Tratado de Geriatríapararesidentes. Madrid 2006. p. 59-68. • Strauss SE, Tinetti ME. Evaluation, Management, and Decision Making with the Older Patient. In Halter JB, Ouslander JG, Tinetti ME et al. ed. Hazzard´s Geriatric Medicine and Gerontology New York. McGraw-Hill Companies, Inc 2009. p. 133-140. • Rubenstein LZ. Geriatric assessment: an overview of its impacts. ClinGeriatr Med. 1987 Feb;3(1):1-15. • Baztán JJ, Suárez-García FM, López-Arrieta J, Rodríguez-Mañas L, Rodríguez-Artalejo F. Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis. BMJ. 2010 Apr 20;340:c1718. • Li CM, Chen CY, Li CY, Wang WD, Wu SC.The effectiveness of a comprehensive geriatric assessment intervention program for frailty in community-dwelling older people: a randomized, controlled trial. Arch GerontolGeriatr. 2010 Feb;50 Suppl 1:S39-42. • Cruz Jentoft AJ, Serra Rexach JA, Lázaro del Nogal M, Gil Gregorio P, Ribera Casado JM. The effectiveness of geriatric interconsultation in elderly patients admitted to traumatology. An Med Interna. 1994 Jun;11(6):273-7.

18. bibliography • Reyes Guerrero J. Evaluación geriátrica integral en: d’Hyver de las Deses C, Gutiérrez • Robledo LM. Geriatría. Manual moderno Méxicon 2006. p.33-44. • Doubova SV, Torres-ArreolaLdel P, Rosas-Carrasco O, Pérez-Cuevas R. Quality of medication prescribing for elderly patients with non-malignant pain syndrome attending family medicine clinics. Rev Invest Clin. 2007 Nov-Dec;59(6):428-36. • DoubovaDubova SV, Reyes-Morales H, Torres-ArreolaLdel P, Suárez-Ortega M. Potential drug-drug and drug-disease interactions in prescriptions for ambulatory patients over 50 years of age in family medicine clinics in Mexico City. BMC Health Serv Res. 2007 Sep 19;7:147. • Reyes-Morales H, Espinosa-Aguilar A, Jiménez-Uribe R, Peña-Valdovinos A, Doubova SV, García-González JJ, Mendoza-Núñez VM. Guideline for integrated geriatric assessment. Rev Med InstMexSeguro Soc. 2009 May-Jun;47(3):291-306. • SurósBatllo A, SurosBatllo J. Semiología médica y técnica exploratoria. Barcelona. Masson. 2001. • Kaya G, Saurat JH. Dermatoporosis: a chronic cutaneous insufficiency/fragility syndrome. Clinicopathological features, mechanisms, prevention and potential treatments. Dermatology. 2007;215(4):284-94. • Pirozzo S, Papinczak T, Glasziou P. Whispered voice test for screening for hearing impairment in adults and children: systematic review. BMJ. 2003 Oct 25;327(7421):967. • Menéndez J, Guevara A, Arcia N, León Díaz EM, Marín C, Alfonso JC. Chronic diseases and functional limitation in older adults: a comparative study in seven cities of Latin America and the Caribbean. Rev Panam Salud Publica. 2005 May-Jun;17(5-6):353-61.

19. bibliography • de León-Arcila R, Milián-Suazo F, Camacho-Calderón N, Arévalo-Cedano RE, Escartín-Chávez M. Risk factors for cognitive and functional impairment in the elderly. Rev Med InstMexSeguro Soc. 2009 May-Jun;47(3):277-84. • Espinosa-Aguilar, A, Caraveo-Anduaga, J, Zamora-Olvera, M, Arronte-Rosoles, A, Krug-Llamas, E, Olivares-Santos, R, et al. Clinical guideline for diagnosis and treatment of depression in eldery. Salud Mental 2007;30(6):69-80. • Albert MS, Blacker D. Mild cognitive impairment and dementia. Annu Rev Clin Psychol. 2006;2:379-88. • World Health Organization: Expert Committee on Physical Status: The use and interpretation of anthropometric physical status. WHO; 1995. • Douketis JD, Paradis G, Keller H, Martineau C. Canadian guidelines for body weight classification in adults: application in clinical practice to screen for overweight and obesity and to assess disease risk. CMAJ 2005;172(8):995-998. • Sánchez-García S, García-Peña C, Duque-López MX, Juárez-Cedillo T, Cortés-Núñez AR, Reyes-Beaman S. Anthropometric measures and