Managing Geriatrics

Collaborative Care for Managing the Geriatric Patient

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A collaborative relationship is central to managing geriatric patients. This involves the development of trust, as well as the ability to listen. When my patients feel that they can trust me, and believe that I am listening to and not just hearing their needs, they are more likely to be open in discussing the details of their health with me. According to Osterberg and Blaschke, studies have shown that “poor provider relationships may lead to greater medication nonadherence.”[1] By making the time to discuss their diagnoses and management of their health enhances their understanding. Then, they are more likely to cooperate with the plans we have made together.

Geriatric patients, like all of us, need to eat nutritiously, exercise regularly, and socialize with friends for a healthy, long life. Plus seeing the healthcare provider at least annually is also a major component of a healthy lifestyle. With age, changes occur throughout the body that require regular assessment and monitoring with the goal of achieving the highest level of well-being. A yearly clinical check-up identifies any deviations in the normal functioning of the body. In this way, the problem can be explored, and/or corrected. Additionally, preventative maintenance and health education can be provided, in order to reduce the risk of additional interruptions of health.

At the start, I inquire about new medications, prescription, herbal, or over the counter as well as side effects. Perhaps there are new allergies, surgeries, or diagnoses. I determine if there have been any changes in the patients’ social history, including smoking status, alcohol use, participation in exercise, and diet. Next, I discuss any new concerns with my patients’ health, including not only those that are physical, but also mental, sexual, or emotional in nature.

The physical exam is explained in terms that my geriatric patients understand and approve. I examine the whole patient, including their appearance, mental status, vital signs, weight and BMI, and assessment of all the major body systems. I obtain lab work such a CBC with platelets, a comprehensive metabolic panel, hemoccult, and any other necessary tests, as these are important to monitor on at least a yearly basis. Immunizations, such as Pneumovax or tetanus, if not up to date, I make sure to have administered, at this time. Additionally, if not previously done, I will order screening tests, such as mammograms, eye exams, and DEXA scans during the visit.

At the end of the visit, I ensure that my patients are informed of and give consent for any further evaluation that may be necessary. This includes new medications, why they are needed, and potential side effects. Geriatric patients may be resistant to new medications even though they may appear to be compliant in the office. According to a study by Turner, et al., “the lowest medication adherence level was significantly associated with a greater number of medications being consumed and lower objective physical function levels.”[2]

As geriatric patients commonly consume multiple medications together, polypharmacy can become problematic, for other reasons as well. Renal and hepatic functions tend to decline, as people age. In fact, function of the kidneys is reduced by one percent per year, beginning in the thirties and forties.[3] For example, these small changes in the way that the renal tubules work, as well as the reduction in the glomerular filtration rate (which measures the excretory capability of the kidneys) can slow the elimination of water soluble medications.[4] On the other hand, blood flow within the liver is reduced by forty five percent beginning in the mid twenties through the mid sixties. This, in turn, can affect the serum concentrations and distribution volumes of certain medicines.[5]

Decreases in absorption and motility within the gastrointestinal system also occur as people age. For example, research has shown that calcium and Vitamin D absorption decreases within the small intestine, whereas the absorption of fat soluble vitamins is increased.[6-7] In addition, the time required for transit, within the large colon, is slightly decreased.[8] These changes, in turn, can lead to an altered ability of the aging body to metabolize nutrients and medications, producing adverse effects, contraindications, and drug toxicity. For these reasons, when prescribing medication for geriatric patients, I “start low and go slow,” particularly with medications having a narrow therapeutic index.

It is not uncommon for geriatric patients to stop taking medications, or to add new ones, to counteract side effects without consulting with their healthcare provider. Medications, office visit copays, and various labs, tests, and procedures may be too costly for geriatric patients, who are impoverished or on fixed incomes. Many times geriatric patients will be lost to follow-up, cut pills in half, skip doses, or simply fail to obtain a prescribed medication, if they cannot afford the medication.

Lack of access to care can be an issue, too, when geriatric patients do not drive or have no one to accompany them to their appointments. To ensure that these issues do not become problematic, it often is necessary, to speak to or fill out forms with insurance or pharmaceutical companies to obtain free or discounted meds or to discuss why patients require such care. Additionally, I will ask for assistance of social workers and case managers, who are most helpful in obtaining the resources for geriatric patients.

When the geriatric patient is incapable of informed consent to a healthcare plan, such as in cases involving dementia, depression, or sensory challenges, the patients’ family, caregivers, or medical power of attorney must become involved. These individuals are not only a source of information regarding health issues but they are also responsible in ensuring that the patients’ health needs are met. In fact, according to Ye, et al. based on a systematic review and research by Katzen et al., “on-line messaging” has been used as a “powerful clinical tool that is transforming the relationships between patients, families, and providers.”[9] It has “improved quality of care” and “cost of care.”[10-11] Medical records and input from previous/other health care providers can be beneficial. Further, geriatric patients who are deaf, visually impaired or blind, physically disabled, or have language barriers, resources such as large print, pictures, and interpreters facilitate the collaborative relationship between patient and healthcare clinician.

In my work, as a Gerontological Nurse Practitioner, I have encountered many situations where advocating for my geriatric patients, has helped to improve not only their primary care visit experience, but also their health outcomes. In one instance, I cared for a frail elderly gentleman who was a deaf mute, as was his wife. He was an uncontrolled diabetic with whom I worked very diligently, to assist him in obtaining better control of his blood glucose levels and lowering his A1C. To accomplish this, with his permission, I included his wife and other people in the plan. His wife would help monitor what he consumed, maintain a food diary, and record his blood sugar readings, which they would then bring to me at each follow-up visit. In addition, I involved our case manager, to work with this couple, to ensure that any diabetic resources that they needed, including occasional use of an interpreter for the hearing impaired, instruction from a diabetic educator and assistance with getting supplies, such as insulin needles and test strips, were available. Also, I would always have pen and paper available at our visits (which I would have our receptionist schedule as an extended visit), by which I would communicate with this couple. I would send them home with written instructions, as well. This included any changes I made in his medications and or dosing, side effects to watch out for, and to contact me if they had any questions or concerns. Over the course of several months, this team effort was successful, as slowly the patient achieved better control over his sugars and his A1C was continuing to drop to a better percentage.

In primary care, management of geriatric patients can be challenging at times, but very rewarding. To make the primary care visit a success, and increase the chance of the patients’ adherence to plans, it is crucial to have them and/or their families involved, informed, and agreeable with all the steps discussed. Although the annual healthcare visit provides the perfect opportunity to comprehensively and holistically address these patients and their needs, these same ideas may be suitably addressed at subsequent primary care visits, when necessary, as well. As a healthcare provider, I am also an advocate for my patients by empowering them to attain and maintain health. As a partner in the therapeutic relationship, I share a sense of satisfaction and comfort with my patients. In the long run, it is the reason I entered the medical field.

 

Karen Digby, GNP-BC
Chair of Family Medicine, Northside Hospital
Atlanta, GA
Published on December 11, 2012

 

Biosketch
Karen Digby is a nurse practitioner specializing in geriatrics. She received her training from New York University and the University of Michigan in Ann Arbor. In over ten years of practice, Karen has obtained a wealth of experience in various aspects of health care including home care, outpatient/ambulatory care, dementia care, subacute care, hospice, assist living and long-term care. Due to her expertise in geriatrics, Karen was selected as an item writer, by the American Nurses Credentialing Center, for the Gerontological Nurse Practitioner Board Certification Examination. She also co-authored an article on “Falls in the Elderly” in the Plastic Surgical Nursing Journal. Additionally, Karen is certified as a Wound Care Specialist through the American Academy of Wound Management.

References

    1. Osterberg, L., Blaschke, T. Adherance to medication. NEJM. 2005;353(5):487-497.
    2. Turner A, Hochschild A, Burnett J, et al. High prevalence of medication non-adherance in a sample of community-dwelling older adults with adult protective services-validated self neglect. Drugs Aging. 2012;29(9):741-749.
    3. Miller, Carol A. Nursing care of older adults: Theory and practice. Chapter 9: Urinary elimination. Lippincott. Philadelphia. 1999:262.
    4. Miller, Carol A. Nursing care of older adults: Theory and practice. Chapter 9: Urinary elimination. Lippincott. Philadelphia. 1999:271.
    5. Miller CA. Nursing care of older adults: Theory and practice. Chapter 18: Medications and the older adult. Lippincott. Philadelphia. 1999:493,494.
    6. Miller CA. Nursing care of older adults: Theory and practice. Chapter 8: Digestion and nutrition. Lippincott. Philadelphia. 1999:232.
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    8. Meldon SW, et al. Geriatric emergency medicine. Chapter 2: The physiology of aging. McGraw-Hill. New York. 2004:10.
    9. Ye J, Rust G, Fry-Johnson Y, Strothers H. E-mail in patient-provider communications: a systematic review. Patient Education and Counseling. 2010;80:266-273.
    10. Katzen C, Solan MJ, Dicker AP. E-mail and oncology: A survey of radiation oncology patients and their attitudes to a new generation of health communication. Prostate Cancer Prostatic Disease. 2005;8:189-193.
    11. Katz SJ, Moyer CA. The emerging role of online communication between patients and their providers. J General Inter Med. 2004;19:978-983.