ATrain Education

 

Continuing Education for Health Professionals

Elders and Their Care

Module 5

Assessing the Older Adult

[The following information is taken largely from NIA, 2011b.]

Studies find that effective communication with patients has specific benefits not only for patients but also for healthcare professionals. Patients are more likely to adhere to treatment and have better outcomes, express greater satisfaction with their treatment, and are less likely to bring malpractice suits. Learning effective communication techniquesand using themmay help health professionals build more satisfying relationships with older patients and become more skilled at managing their care.

Effective communication has practical benefits. It can help prevent medical errors, strengthen the relationship with patients, make the most of limited interaction time, and lead to improved health outcomes. When communicating with older adults:

  • Address the patient by last name, using the title the patient prefers (Mr., Ms., Mrs., etc.).
  • Begin the interview with a few friendly questions not directly related to health.
  • Don’t rush, and try not to interrupt; speak slowly, and give older patients a few extra minutes to talk about their concerns.
  • Use active listening skills.
  • Avoid jargon, use common language, and ask if clarification is needed, such as writing something down.
  • Ask the patient to say what he or she understands about the problem and what needs to be done.

Obtaining a Medical History

For elder patients, obtaining a good history is crucial; it should include social circumstances, lifestyle, and both medical and family history. If feasible, gather preliminary data before the session by requesting previous medical records or having the patient and family members fill out forms at home. Try to structure questionnaires for easy reading by using large type and providing enough space between items for people to respond.

Try to have patients tell their story only once. For older patients who are ill, re-telling can be tiring. If the patient has trouble with open-ended questions, make greater use of yes-or-no or simple choice questions. During the interview, sit and face the patient at eye level. Use active listening skills, responding with brief comments such as “I see” and “Okay.” Remember that the interview itself can be beneficial. Giving your patient a chance to express concerns to an interested person can be therapeutic.

Older adults often have sensory impairments that affect communication. Vision and hearing deficits are common and need to be addressed in communication.

Compensating for Hearing Deficits

Age-related hearing loss is common: about one-third of people between the ages of 65 and 75, and nearly half of those over the age of 75, have a hearing impairment. It is not always obvious to healthcare providers when a patient is hard of hearing. The first step is to make sure your patient can hear you. If the patient uses a hearing aid, make sure it is working. Check for the presence of excess earwax. Healthcare providers can improve communication by using the following strategies:

  • Talk slowly and clearly in a normal tone.
  • Avoid shouting or speaking in a raised voice, which distorts sound and can give the impression of anger.
  • Avoid using a high-pitched voice, which is hard to hear.

If a patient is able to read lips, face the person directly at eye level to enable lip-reading and picking up visual clues. Keep your hands away from your face while talking so that your speaking is visualized.

Background noises (computers, traffic noise, other people talking, office equipment) can mask or distort your voice so be alert for signs that these ambient noises are adversely affecting communication.

If your patient has difficulty with letters and numbers, give a context for them. For example say, “m as in Mary, two as in twins, or b as in boy.” Say each number separately, for example, “five, six” instead of “fifty-six.” Be aware that certain letters sound alike for example m and n, and b, c, d, e, t, and v.

Keep a note pad handy so, if necessary, you can write what you are saying, including diagnoses and other important terms. Let your patient know when you are changing the subject by pausing briefly, speaking a bit more loudly, gesturing toward what will be discussed, gently touching the patient, or asking a question.

Compensating for Visual Deficits

Visual disorders become more common as people age, and a person with impaired vision may experience difficulty in complex situations that demand rapid interpretation of multiple visual cues. Unfortunately, this is a common occurrence in a busy hospital or medical office. To ensure good communication for those with visual deficits:

  • Provide adequate lighting, including sufficient light on your face, and minimize glare.
  • Check that your patient has brought and is wearing eyeglasses, if needed.
  • Provide handwritten instructions that are clear and well-written.
  • Use printed materials with large type and a clear typeface.
  • Consider tape recording instructions, providing large pictures or diagrams, or using aids such as specially configured pillboxes. (NIA, 2011b)

Choosing Words Carefully

Some words may have different meanings to older patients and those unfamiliar with medical terminology. For example, a diagnosis of dementia may bring up thoughts of insanity. The word “cancer” may be considered a death sentence. A family member may be sensitive about a diagnosis of “brain damage” following a stroke and feel the healthcare provider is questioning their loved one’s intelligence.

Although we cannot anticipate every generational difference in language, be aware of the possibility and work to make communication more clear. Use simple, common language, and ask if clarification is needed. Offer to repeat or reword the information: “I know this is complexI’ll do my best to explain, but let me know if you have any questions or just want me to go over it again.”

Probing Delicately

Older patients often have multiple chronic conditions and may have vague complaints or atypical presentations. Begin the session by asking patients to talk about their major concern: “Tell me, what is bothering you the most.” Provide enough time for patients to answer your questionsgiving people uninterrupted time to express concerns enables them to be more open and complete.

Ask, “Is there anything else?” This question, which you may have to repeat several times, helps to get all of the patient’s concerns on the table at the beginning of the visit. The main concern may not be the first one mentioned, especially if it is a sensitive subject. Encourage patients and caregivers to bring a written list of concerns and questions. Ask about all medicationsincluding prescription, over-the-counter, and dietary supplements. Try to determine if the patient is using medications that have been prescribed for another family member.

Physicians and other healthcare providers typically underestimate how much patients want to know and overestimate how long they spend giving information to patients. Devoting more attention to educating a patient may seem like a luxury, but in the long run it improves adherence to treatment, increases well-being, and ultimately saves time.

Healthcare providers should provide key information and advice and encourage other team members to build on that. To explain a diagnosis, start by asking patients what they understand and how much more they want to know. When patients fail to understand their medical conditions they tend not to follow treatment plans.

After proposing a treatment plan, check with the patient on feasibility and acceptability; confirm that the patient understands the plan. Encourage patients and caregivers to take an active role in managing a chronic problem.

Assessing Sensory Function

One of the challenges of caring for older people is the atypical presentation of symptoms. Deterioration in level of functioning is often the first symptom in an older person with an acute illness. An older adult may evidence only difficulty with ambulation or mentation when they are ill, while a younger person presents with completely different symptoms. Pneumonia in an older person may present with a change in mental status and a urinary tract infection may present as a fall. Vomiting may be the only symptom of a heart attack. Changes in vision, hearing, balance and postural control, or sensory loss can affect mobility and should be thoroughly assessed in older patients.

Vision

The visual system is a key component of motor control. It allows us to determine the movement of objects in our environment; it tells us where we are in relation to parts of our own body and to other objects (Shumway-Cook and Woollacott, 2011. Blindness or low vision affects more than 3.3 million Americans aged 40 years and older and this number is predicted to double by 2030 due to diabetes, other chronic diseases, and our rapidly aging population. Early detection and timely treatment of eye conditions has been found to be efficacious and cost effective (CDC, 2009c).

The leading causes of blindness and low vision in the U. S. are primarily age-related eye diseases such as age-related macular degeneration, cataract, diabetic retinopathy, and glaucoma. Other common eye disorders include amblyopia and strabismus.

Refractive errors are the most common visual problems in the United States. They include myopia (near-sightedness), hyperopia (farsightedness), astigmatism (distorted vision at all distances), and the presbyopia that occurs between age 40 and 50 years (loss of the ability to focus up close). Refractive errors can be corrected by eyeglasses, contact lenses, or surgery. Recent studies conducted by the National Eye Institute showed that proper refractive correction could improve vision among 11 million Americans 12 years and older (CDC, 2009c).

Elders should be assessed for other eye disorders associated with aging: age-related macular degeneration (AMD), cataract, diabetic retinopathy (DR), and glaucoma.

Hearing

Hearing loss is one of the most common conditions affecting older adults. One in 3 people older than 60 and half of those older than age 85 have hearing loss. Hearing problems make it hard to understand and follow a doctor’s advice, to respond to warnings, and to hear doorbells and alarms. Hearing loss can also make it hard to enjoy talking with friends and family (NIDCD, 2011).

Hearing loss happens for many reasons. Some people lose their hearing slowly as they age (presbycusis). Another reason for hearing loss may be exposure to too much loud noiseknown as noise-induced hearing loss. Many construction workers, farmers, musicians, airport workers, tree cutters, and people in the armed forces have hearing problems because of too much exposure to loud noise. Continuous exposure to loud noises can cause tinnitus, a ringing, hissing, or roaring sound in the ears. Hearing loss can also be caused by a virus or bacteria, heart conditions or stroke, head injuries, tumors, and certain medicines (NIDCD, 2011).

Balance and Postural Control

Balance is the ability to maintain the body’s center of mass over its base of support. Balance involves multiple systems that must interact flawlessly and automatically to coordinate input from the environment and the central nervous system. Postural control is the ability to maintain the segments of our body in relation to one another and to maintain stability and orientation in space (Shumway-Cook and Woollacott, 2011).

As healthcare professionals we often see clients who have poor balance and are at high risk for falling, whether from post surgical weakness, illness, neurologic disorders, or injury. Helping a patient reduce fall risk requires assessment of medications, sensory and musculoskeletal changes, and age-related and cognitive changes. All of these factors have been shown to affect balance and falls in one way or another. Because falls are a major concern in elders, a later section is focused on them.

Assessing the Skin

The skin is our largest organ. It protects the body from infection and trauma. The skin also regulates body temperature by dilating and constricting blood vessels near the surface and releasing perspiration to cool the body.

When assessing skin color, look for cyanosis (blue-ish color), which may indicate poor oxygenation arising from respiratory or cardiac problems, or may signal low body temperature. Because skin color varies by race and ethnicity, it is important to inspect the ears, lips, inside of mouth, hands, and nail beds for signs of cyanosis.

The skin, sclera of the eyes, and mucous membranes should be inspected for jaundice, which may indicate liver disease. Skin pallor can indicate anemia. Erythema, or redness of the skin, may be due to fever, alcohol intake, or infection.

Skin should also be assessed for swelling, which can be a sign of injury or fluid retention. Bruising or bleeding of the skin should be noted, as it may indicate blood disorders or abuse.

Pressure Ulcers

A pressure ulcer is localized injury to the skin or underlying tissue (usually over a bony prominence) caused by pressure, or pressure in combination with shear and/or friction. Older adults are at high risk for the development of pressure ulcersespecially if they become less mobile due to injury or disease, or are hospitalized, bedridden, or chair ridden. Older adults in home care, during transition to a nursing home, and during long-term care may be at especially high risk for development of pressure sores (NINR, 2006).

Pressure is the foremost cause of ulcers, which can occur when a person is unable to perceive pressure or is unable to take action to relieve it. Tissue tolerance for pressureand the ability of the tissue to withstand pressureis influenced by moisture from any source, friction and shearing forces, nutrition, body temperature, hypotension, and hypoxia (NINR, 2006).

Skin becomes thinner with age, loses fat, and may take longer to heal following an injury. As physiology changes, the ability to heal following a wound is reduced by about 4% compared to younger adults.

Aging produces other changes in the structure of skin:

  • Skin turgor (elasticity) decreases.
  • Structural changes occur, such as a decreased attachment between the epidermis and dermis.
  • Skin becomes thinner as adipose tissue diminishes and slides more easily.
  • Capillaries and venules decrease, making the tissue more susceptible to injury from shear and friction.
  • Skin thus becomes fragile and subject to bruising and tearing.
  • Sebaceous glands decrease in number and size, especially in females, and the result is dry, flakey skin.
  • Tissue turnover slowsincluding the epidermal cells needed to resurface a wound.
  • Neural transmission is slowed due to decline in neurotransmitters (dopamine, serotonin, and gabapentin).
  • Pain reaction time increases so that response to pressure is delayed, allowing irreversible tissue ischemia to occur.
  • Visual changes can make it difficult for the patient to see and monitor a wound and to provide suitable wound care.

The skin of those at risk for skin breakdown should be assessed daily and should be cleansed immediately if soiled, avoiding hot water. It is important not to massage bony prominences and to use moisturizers on dry skin.

Frequent turning regimens (usually every 2 hours) should be part of the care plan for at-risk older adults. The heels of bedbound patients should be raised off the bed; do not use donut-type devices. A 30° lateral side-lying position can be used (the person should not be placed directly on the trochanter). The head of the bed should be kept at the lowest possible height and pillows can be used to prevent contact of bony prominences with each other. High-risk areas such as elbows, heels, sacrum, and the back of head should be protected from friction injury.

With high-risk patients, special mattresses, mattress overlays, and cushions can be used when frequent turning is either difficult or not possible. These devices are classified as static (nonmoving) or dynamic (movement of air currents by electrical systems). The static systems include foam, water, gel, and air-filled devices that are placed over the mattress or chair surface to provide for more even weight distribution, but these systems still require manual turning of patients. The dynamic support systems adjust weight distribution by alternating air currents and include two types: mattress overlays, such as alternating current pads, and air-fluidized beds (NINR, 2006).

Wheelchair cushions and pads frequently are used for patients confined to chairs. Sitting on a hard surface occludes blood flow to the skin at lower pressures and increases shear. These problems can be addressed by tipping the chair backward 20° (NINR, 2006).

Friction and sheer injuries to the skin can be minimized by use of protective dressings and proper lifting techniques during turning and transferring.

It is important to maintain proper nutrition in order to maximize skin health. A dietician can be consulted to correct any deficiencies of protein and calorie or vitamins. A glass of water should be offered at the time of turning to keep the person hydrated.

Pressure Ulcer Risk Assessment

The Braden Scale is one of the most often used pressure ulcer risk assessment tools. It assesses six risk factors: mobility, activity, moisture, sensation, nutrition, and shear. The Braden Scale has high validity and reliability. Scores range from 6 to 23 with a score of 15 to 18 indicating risk; 13 to 14 moderate risk; 10 to 12 high risk; and ±9 very high risk. Perform the risk assessment on admission and repeat if there is a change in the patient’s condition. This scale is valid for use with individuals of all skin tones. See www.BradenScale.com to download a copy of the Braden Scale.

Moles

During a skin assessment, moles need to be assessed for possible skin cancer. A common mole (nevus) is a small growth on the skin that is usually pink, tan, or brown and has a distinct edge. People who have more than fifty common moles have a greater chance than others of developing melanoma. Most common moles do not turn into melanoma (NCI, 2011a).

A dysplastic nevus is an unusual mole that is often large and flat and does not have a symmetric round or oval shape. The edge is often indistinct. It may have a mixture of pink, tan, or brown shades. People who have many dysplastic nevi have a greater chance than others of developing melanoma, but most dysplastic nevi do not turn into melanoma (NCI, 2011a).

If the color, size, shape, or height of a mole changes or if it starts to itch, bleed, or ooze, the physician should be notified. Similarly, report to the doctor if a new mole doesn’t look like the client’s other moles. The only way to diagnose melanoma is to remove tissue and check it for cancer cells.

Skin Signs of Elder Abuse

When assessing skin, look for signs of abuse. Healthcare providers are mandated reporters of elder abuse. While one sign does not necessarily indicate abuse, some tell-tale signs that there could be a problem:

  • Bruises, pressure marks, broken bones, abrasions, and burns may be an indication of physical abuse, neglect, or mistreatment.
  • Bruises around the breasts or genital area may indicate sexual abuse.
  • Bedsores, unattended medical needs, poor hygiene, and unusual weight loss are indicators of possible neglect.

Skin Breakdown from Urinary Incontinence

Urinary incontinence can contribute to skin breakdown and infection and also to urinary tract infections (UTIs). It is important that incontinence be managed and that skin be cleansed and dried as soon as possible to prevent these complications.

Incontinence is often seen as part of aging, but it can occur for many other reasons. For example, UTI, vaginal infection or irritation, constipation, and some medications can cause bladder control problems that last a short time. When incontinence lasts longer, it may be due to (NIA, 2011c):

  • Weak bladder muscles
  • Overactive bladder muscles
  • Damage to nerves that control the bladder from diseases (eg, multiple sclerosis, Parkinson’s disease)
  • Diseases such as arthritis that may make it difficult to get to the bathroom in time
  • In men, blockage from an enlarged prostate

During urination, muscles in the bladder tighten to move urine into the urethra. At the same time, the muscles around the urethra relax and let the urine pass out of the body. Incontinence can occur if the muscles tighten or relax without warning (NIA, 2011c).

In order to determine the cause of urinary incontinence, urine and blood tests should be done to rule out infection. Tests may also be done to determine how well the bladder is emptying. A daily diary may also be kept to track times of urination or leakage. There are different types of urinary incontinence (NIA, 2011c):

  • Stress incontinence happens when urine leaks as pressure is put on the bladder, for example, during exercise, coughing, sneezing, laughing, or lifting heavy objects. It is the most common type of bladder control problem in younger and middle-aged women. It may also begin around the time of menopause.
  • Urge incontinence happens when people have a sudden need to urinate and are not able to hold their urine long enough to get to the toilet in time. It is often, but not only, a problem for people who have diabetes, Alzheimer’s disease, Parkinson’s disease, multiple sclerosis, or stroke.
  • Overflow incontinence happens when small amounts of urine leak from a bladder that is always full. A man can have trouble emptying his bladder if an enlarged prostate is blocking the urethra. Diabetes and spinal cord injury can also cause this type of incontinence.
  • Functional incontinence happens in many older people who have normal bladder control. They may have a problem getting to the toilet because of arthritis or other disorders that make it hard to move quickly.
Bladder Control Training

There are several ways to improve bladder control (NIA, 2011c):

  • Pelvic muscle exercises (also known as Kegel exercises) work the muscles that are used to stop urinating. Making these muscles stronger helps hold urine in the bladder longer.
    • Locate the pelvic floor muscles when lying down and pretending to stop the flow of urine. Squeeze and hold these muscles for a count of 3, then relax them for a count of 3. The goal is to try to do a set of 10, rest, and then do 2 more sets each day.
  • Biofeedback uses sensors to make an individual aware of signals from the body. This may help the person regain control over the muscles in the bladder and urethra. Biofeedback can be helpful when learning pelvic muscle exercises.
  • Timed voiding has the person urinate on a set schedule, for example, every hour. The time between bathroom trips can then be slowly extended. When timed voiding is combined with biofeedback and pelvic muscle exercises, it may become easier to control urge and overflow incontinence.
  • Lifestyle changes that may help with incontinence include losing weight, quitting smoking, avoiding alcohol, drinking less caffeine (found in coffee, tea, and many sodas), preventing constipation, and not lifting heavy objects.

There are some medications that can cause or worsen urinary incontinence. Hypertension medications such as Hytrin, Minipress, and Cardura cause the bladder to relax and may cause stress incontinence with coughing or sneezing. Some antidepressants such as Tofranil and Elavil can impede bladder emptying. Diuretics cause increased urine formation, and sleeping pills may prevent waking to use the bathroom as needed (WebMD, 2009b).

Medical Management of Incontinence

Besides bladder control training, there are medications, surgeries, and devices that can help manage incontinence. Some drugs can help the bladder empty more fully during urination. Other drugs tighten muscles and can lessen leakage. Anticholinergic drugs such as Ditropan and Detrol can calm an overactive bladder. Topical estrogen can help rejuvenate the tissues in the urethral and vaginal areas. Imipramine (a tricyclic antidepressant) can help with mixed (urge and stress) incontinence. Cymbalta, another antidepressant, is sometimes used to treat stress incontinence (Mayo Clinic, 2011b).

A doctor may inject a substance that thickens the area around the urethra to help close the bladder opening. This reduces stress incontinence in women. The treatment may have to be repeated (NIA, 2011c).

Urethral inserts are small tampon-like disposable devices inserted into the urethra that act as a plug to prevent leakage. It’s usually used to prevent incontinence during a specific activity and then removed before urination. Pessaries are stiff rings inserted into the vagina and worn all day to help hold up the bladder and prevent urine leakage (Mayo Clinic, 2011b).

Surgery can sometimes improve or cure incontinence if it is caused by a change in the position of the bladder or blockage due to an enlarged prostate. In addition, absorbent underclothing can be worn under everyday clothing (NIA, 2011c).

Assessing Psychosocial Function

Isolation

The combination of an aging population and the breakdown of extended families has led to increasing social isolation of older Americans. Socially isolated older adults are frequently depressed; they often lack confiding relationships and perceive their friends as less supportive and reliable. Older adults who do not have close social ties report higher depressed mood than elders who are actively engaged in a supportive social network. The availability of a confidante was found to be the single most protective factor for four dimensions of depressiondepressed affect, low positive affect, medical complaints, and interpersonal problems (NIMH, 2003).

Cognitive theory suggests that the way elders perceive their social contact is more important than their degree of isolation. Loneliness is associated with social isolation and social support, poor or perceived health, and depressionand both depression and loneliness compromise quality of life. Older women who experience loneliness, for example, report more hopelessness, self-focus, and poor health (NIMH, 2003).

Depression and Suicide

Depression, one of the conditions most commonly associated with suicide in older adults, is a widely under-recognized and undertreated medical illness. Studies show that many older adults who die by suicide (up to 75%) visited a physician within a month before death. These findings point to the urgency of improving detection and treatment of depression to reduce suicide risk among older adults (NIMH, 2010).

Researchers have known for nearly a decade that social factors are not only related to the risk of depression but they may also influence the course of depression and play a role in suicide risk among elders. Depression is the most common risk factor for suicide among the elderly, and elders have the highest rates of suicide in the nation, with elderly males having a suicide rate 6 times the national average (NIMH, 2010).

The risk of depression in the elderly increases with other illnesses and when ability to function becomes limited. Estimates of major depression in older people living in the community range from less than 1% to about 5%, but rises to 13.5% in those who require home healthcare and to 11.5% in elderly hospital patients (NIMH, 2010).

An estimated 5 million have sub-syndromal depression, symptoms that fall short of meeting the full diagnostic criteria for a disorder. Sub-syndromal depression is especially common among older people and is associated with an increased risk of developing major depression. Depressive disorder is not a normal part of aging. Emotional experiences of sadness, grief, response to loss, and temporary “blue” moods are normal. Persistent depression that interferes significantly with ability to function is not (NIMH, 2010).

Health professionals may mistakenly think that persistent depression is an acceptable response to other serious illnesses and the social and financial hardships that often accompany agingan attitude often shared by older people themselves. This contributes to low rates of diagnosis and treatment in older adults (NIMH, 2010).

Depression can and should be treated when it occurs at the same time as other medical illnesses. Untreated depression can delay recovery or worsen the outcome of these other illnesses. Antidepressant medications or psychotherapy, or a combination of the two, can be effective treatments for late-life depression.

Older Americans are disproportionately likely to die by suicide. Although they comprise only 12% of the U.S. population, people age 65 and older accounted for 16% of suicide deaths in 2004. Non-Hispanic white men age 85 and older were most likely to die by suicide. They had a rate of 49.8 suicide deaths per 100,000 people in that age group (NIMH, 2010).

If depression is suspected, older adults should ask themselves if they are feeling:

  • Nervous
  • Empty
  • Worthless
  • No enjoyment in things previously enjoyed
  • Restless
  • Irritable
  • Unloved
  • That life isn’t worth living

Or if he or she is:

  • Sleeping more or less than usual
  • Eating more or less than usual

These may be symptoms of depression, a treatable illness. Other symptoms that may signal depression, but may also be signs of other serious illnesses, should be checked by a doctor, whatever the cause. They include:

  • Being very tired and sluggish
  • Frequent headaches
  • Frequent stomach aches
  • Chronic pain

National Suicide Prevention Hotline

If you or someone you care for are in crisis and need help right away, call this toll-free number, available 24 hours a day, every day: 1-800-273-TALK (8255). You will reach the National Suicide Prevention Lifeline, a service available to anyone. You may call for yourself or for someone you care about. All calls are confidential.

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