Specialization in Health Management for Older

Adults

MODULE IVUNIT 2

OLDER PERSONS AS A PATIENT

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 diff erent approach and the integral evaluation and management of health.

WHAT IS 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.

VARIABLES THAT AFFECT THE PRESENTATION OF DISEASES IN

GERIATRICS

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 diff erent age groups can in reality have very diverse etiologies.

DIFFERENT PRESENTATION OF DISEASE COMPARED WITH

YOUNGER ADULTS

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 specifi c 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.

AGING AND 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.

DELAYED PRESENTATION OF DISEASE

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:1. Immobility2. Instability3. Incontinence4. Intellectual Deterioration5. Iatrogenesis

GERIATRICS IN THE CONTEXT OF PRIMARY CARE

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.

IMMOBILITY

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.

INSTABILITY

Fecal and urinary incontinence, in addition to their own medical signifi cance, 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 defi cient 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.

INCONTINENCE

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 affl ictions 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.

INTELLECTUAL DETERIORATION

Iatrogenesis is an inadvertent adverse eff ect 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.

IATROGENESIS

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.

DOCTOR-PATIENT RELATIONSHIP

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.

COMPREHENSIVE ASSESSMENT OF THE ELDERLY

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

CLINICAL EVALUATION OF OLDER ADULTS

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