Twelve principles to assess in clinical approach to the older person

Introduction

Ageing is a physiological process and not pathological. Hence any symptoms that interferes in the activities of the elderly should be evaluated and treated.

In older person the diseases can present with typical and atypical symptoms. There is a huge list of disease process presenting with atypical symptoms. One common example is reduced appetite, generalised weakness, increased thirst can be presenting feature of Fever. The elderly usually blame all the symptoms on the age.

This discussion intends to empower the clinician to approach to an elderly patient and help treat in a better way within time framework.

A clinician must know what is and what is not part of Ageing and what are the modalities of care that are available for the terminal diseases, so they can refer to a required care centre.

The older persons are unique blend of patients where we come across new onset of diseases, complications of existing diseases, iatrogenic disease and diseases of old age.

Multiple comorbidities, disabilities, impairments and psychological distress are major challenges faced by a clinician in an older patient.

Keeping such various issues in mind, it is imperative for a clinician to face challenges. This discussion shares twelve principles of clinical approach in an older patient which may ease the challenges. These principles when applied will help clinician in better understanding the older person, will not miss important aspects in assessment and likely to take a quick and needed decision.

Approach

The older persons are classified as Young old (60 -74 years), Old -Old (75 -84) and Very Old. (> 85 years). For the clinicians it is important to know that majority of elderly in young old group are independent and while very old are dependent on others. The syndromes like frailty and sarcopenia affects those in old-old group and reduces the functional capacity as they reach very-old stage.

The clinician must enquire these two things before proceeding for the detail examination.

The older person when stops certain regular activities it usually heralds onset of the disease process. Clinician should always give preference to the symptoms that bothers them most like constipation, nocturia or reduced sleep.

The assessment involves physical, mental, social, economic and spiritual wellbeing in a given older patient.

Certain signs like missed beats, absent deep tendon reflex at ankle, lost vibratory sensation, diminished arm swing and delayed response are common in older person and are considered as age related changes.1

The functional and cognition assessment has to be given priority during assessment and treatment should aim to bring them back to near independent functional life following recovery.

The approach should also aim at improving Quality of life and provide Dignified death with due respect to the decisions of older person and their caregivers.

It is equally important to know the caregiver as well. We should address burnout in them as well the doubts they are having regarding disease process. We can suggest Respite care for them if they are having symptoms of burnout.

Communication

Among all the communication skills, Listening is found to be the best skill. We need to give time for elderly to reveal the history without interruption.

Effective communication with the elderly has practical benefits.2

While having an encounter with the them, avoid interrupting when they narrate the history. Once interrupted, a patient is less likely to reveal all of his or her concerns.

Listening is the best communication skill. Use active listening skills. Face the patient, maintain eye contact, and when he or she is talking, use frequent, brief responses, such as "okay," "I see," and "uh-huh." Active listening keeps the discussion focused and lets patients know you understand their concerns.

Always demonstrate empathy. Watch for opportunities to respond to patients’ emotions, using phrases such as "That sounds difficult," or "I'm sorry you're facing this problem; I think we can work on it together." Studies show that clinical empathy can be learned and practiced and that it adds less than a minute to the patient interview. It also has rewards in terms of patient satisfaction, understanding, and adherence to treatment.

Ensure hearing aid, dentures and spectacles are in use in them before the conversation. This makes communication smooth and effective. Always face the person while talking and do not use distractors like mobile phone. Speak slowly, clearly, and loudly, and short words or sentences. Do not shout.

Non -Verbal Communication lies in your Attitude, Facial expression, Posture and gesture (nodding, appropriate movements, appropriate positioning of chairs), and Touch (holding hands, patting the hand) and use of flip charts.

Lastly, allow them to ask questions and express themselves. At the end of the conversation, a clinician must ensure that they have understood what has been informed to him by telling him to say what he has understood.

Geriatric Giants

In 1965, Bernard Isaacs coined the term “geriatric giants.” And he named the geriatric giants as immobility, instability, incontinence, and impaired intellect/memory.3

Recently the giants have been given different dimension in form of 5M.4 The five M’s are Mind, Mobility, Medication, Multi-complex and Matters Most.

Any of these giants can be presenting features of the disease. E.g. A Fall can be presenting feature of an Acute Cardiac Event, an acute confusion state (Delirium) can be presenting feature of Pneumonia, and Incontinence can be a feature of a Urinary Tract Infection.

The clinician needs to evaluate the elderly presenting with the giants in detail and try to find the cause. These giants, or 5M's, are challenges for the clinician.

Polypharmacy

While prescribing medicines for the older people ensure following points are followed 5

Vital Signs

In all the older patients Blood pressure measurement to ruleout orthostatic hypotension should be carried out. Assessment of Pain and Delirium should be carried out apart from four vital signs. Recording of weight during every visit should be done to identify significant weight loss.

Functional Assessment

The most important assessment in the elderly patients is their functional status. In includes assessment of Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) and Advanced Activities of Daily Living (AADL). Various tools like Katz index,6 Lawton scale7 are available to assess functional status.

Cognitive Status

The cognitive status is assessed by various scales like Three item recall test, Mini Mental Status Examination (MMSE),8 Montreal Cognitive Assessment (MoCA)9 and recently ICMR launched Neuro Cognitive Tool Box (ICMR – NCTB).10 These tools help us to identify minimal cognitive impairment and Dementia. MoCA and ICMR scales are also available in five Indian Languages making it easy to use in our clinical practice.

Immunization status

The Centre for Disease Control and Geriatric Society of India have recommended the following vaccines for all older people irrespective of disease status.

The vaccines recommended are for the prevention of Influenza and Pneumococcal pneumonia, Hepatitis B, Tetanus, COVID-19 and Herpes Zoster.10

Elder Abuse

Elder abuse, is a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person. This type of violence constitutes a violation of human rights. The five types of abuse are physical, sexual, psychological and emotional abuse, financial and neglect. There is a serious loss of dignity and respect among the elderly who are victims of abuse. Abuse in older people can lead to serious physical injuries and long-term psychological consequences.11 The clinician has to keep in mind abuse and try to identify and provide appropriate management strategies. Abuse of older people can have serious physical and mental health, financial, and social consequences, including, for instance, physical injuries, premature mortality, depression, cognitive decline, financial devastation and placement in nursing homes.12 The law to protect older people against abuse is Maintenance and welfare of parents and senior citizens act 2007.13

Mental Health

The common mental health issues that we come across among older patients are depression, loneliness, fear of losing friends, anxiety and suicidal thoughts. Depression should be assessed using Geriatric Depression scale.14 This scale is also available in few Indian languages.

Ageism

It is defined as how we think (stereotypes), feel (prejudice), and act (discrimination) towards others or ourselves based on age–has serious and far-reaching consequences for people's health, well-being, and human rights.15

When the physician denies treatment or surgical interventions merely based on age constitute ageism, unless the health status does not permit for the intervention.

Giving negative remarks on prognosis or saying what is left now in your life to do? considering them as less worthy and why you wish to live long? are few statements the clinician does in their consultation which constitute ageism. One should not practice Ageism.

Clinicians sometimes underestimate the physical strength and will power of the older people. They fear the older person will not sustain the stress of surgical procedure or intervention and may lead to complications, such assumptions should be avoided and thoroughly assessment and come to a conclusion rather than on your assumptions and age.

Modalities of care

The older person when develops terminal illness, for them various modalities like Day Care, Palliative care, Rehabilitation care, Hospice care and End of Life care need to be implemented as and when the situation demands. Respite care for the care giver is also equally important. The clinician should be aware when to seek these modalities.

Conclusion

The older people are most experienced persons of the society and full of wisdom. They have multiple diseases and hence need multidimensional approach. They have long past medical history and has met many clinicians before meeting you. He can judge a clinician by his attitude, behaviour, body language and communication skills. A systemic approach should help a clinician to identify a core health issue and find solutions for them meanwhile improving quality of life in older patients. The role of clinician is to identify health issues, prevent or delay complications and avoid ageism. The author recommends the readers to join TAPAS online Course on Geriatric Care and Dementia Care to gain additional knowledge. The Government of India has recently launched National Senior Citizen Helpline -14567 which can be shared to the needy elderly people.

“You do not heal old age, you promote it, you protect it and you extend it”.

Sir James sterling Ross

Source of Funding

None.

Conflict of Interest

None.