The joys of geriatrics

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The joys of geriatrics

• Yes, its more fun than you imagined!

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Outline

• Your concerns Attitudes
• who are older patient and why are they
  interesting
• general suggestions
• specific circumstances
• hearing
• cognition
• bad news

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Imagine your first day as a clerk!!!
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What are your concerns about elderly patients?

• they know better
• theyve been through a lot
• they have difficulty understanding me
• they take too long
• vague historian
• their relatives!

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UCLA Geriatric Attitude Survey

• Most older people pleasant to be with
• if I have choice, rather see younger pts
• medical care for elderly use resources
• elderly more appreciative
• I pay more attention have sympathy
• tx of chronically ill is hopeless
• interesting to listen to accounts of past

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What problems do we see at SMOL

• Falls
• urinary fecal incontinence
• chronic pain
• functional impairment
• depression
• dementia/delirium

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Problems at SMOL

• Elder abuse
• placement issues
• polypharmacy
• elder abuse
• strokes
• Parkinsons disease

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What cheers us up?

• Humour
• historical perspective
• appreciation
• feeling of achievement
• we celebrate complexity!
• Christmas gifts!!!

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Are Older people different?

• Who are the elderly
• 11 of Canadians are over 65
• young old 65-74
• middle old 75-84
• old-old over 85
• a heterogeneous bunch

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Clinical encounters with the elderly

• Complexity
• atypical presentation of illness
• time constraints
• multiple medications compliance
• functional limitations
• sensory impairments

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Older people and MD interactions

• Less time
• less concordance on major topics goals
• less joint decision-making
• less egalitarian, respectful, optimistic
• patients less assertive
• more likely to have third person present

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What do older patients think of us?

• Loyalty to their physician
• attitude and personality important
• ?more comfortable providing information based on
  MD questioning
• caring and curing
• continuity of care important

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What is the outcome of good communication

• Improved medication compliance
• increased compliance with lifestyle
  recommendation
• ?? Decreased institutionalization
• patients reported satisfaction if
• physician engaged in discussion
• physician support
• shared laughter

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Improving your communication skills

• I like to be kept up to date. 96 yr old
• Make sure you inform me about my medications.
  84 year old
• Listen to what I am telling you. 93 yr. Old
• No, my brother never said that. 78 year old
  with hearing troubles

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General points for older patients

• Patience
• talk to the patient not to the family
• get down to their level (physically!)
• make yourself heard
• watch your terminology
• be aware of subtle deficits barriers
• may have to get repeated histories

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The Importance of Good History Taking

• The Mahoney rule
• Ask the same question 3 times and the answer you
  hear twice is the closest to the truth
• History taking requires several ways to clarify
  the meaning
• Patients do not always provide unsolicited
  information about significant symptoms

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The Importance of Good History Taking

• Pain may be described differently
• Depression may not be dysphoria
• Less emphasis on open-ended questions
• And
• Dont forget to get the corroborating history!

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Dealing with cognitive impairment

• Is it dementia or delirium?
• Dementia
• insight, memory, language disturbance
• paranoia, ?? reality reorientation
• caregiver support

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Remember the vague presentations of dementia

• Head turning sign
• Eye rolling of family members!
• wt loss in the patient living alone
• Stress related illness in caregiver
• Catastrophe when caregiver hospitalized
• New non-compliance
• Change in hygiene

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Talking with a demented patient

• Shorter sentences with pauses between
• avoid jargon and figurative speech
• caution with humour
• attention to nonverbal communication
• be aware of language changes of dementia

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Talking to a Delirious patient

• More paranoia, agitation, hallucinations
• greater benefit of reality reorientation
• think of safety of patient and you
• can be frustrating

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Dealing with the daughter from California

• Geriatrics and pediatrics have similarities
• Remember confidentiality
• try to keep patient as the focus
• remember value of family conference
• caregiver stress and guilt can play role

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An easier first day
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Tell Your grandad to Take His Photo to Hospital

• The athlete versus the GOMER !

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Labeling geriatric patients

• Pain under-treated in hip patients with
  diagnosis of dementia
• Dx of dementia affects stroke prophylaxis

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Use Teams Battling complexity

• Time is of the essence for FPs
• RGPs
• Outreach, Inpatient, Day Hospitals
• Geriatric psychiatry programs
• Hospital consultation services
• Physical medicine rehab programs
• Day Centres

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Were all getting older!
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You and the older patient

• Relax
• take time when possible
• Keep patient the focus
• dont forget the role of family
• awareness of barriers to communication