Chapter I. General Introduction to Home Medical Care
5. How to See the Elderly
living (ADL), motivation, and nutritional status. In this way, treatment, care, and physical function affect each other.
In addition to disease progression and decreases in physical function, the elderly are prone to psychological symptoms associated with changes in living conditions, such as bereavement and living alone. It is recommended to check whether a patient has depression actively because it may affect prognosis.
The elderly often have several geriatric syndromes. Geriatric syndromes are a series of symptoms and findings caused by various reasons. They pass into a chronic state, and make independent living of the elderly impossible. Geriatric syndromes are classified into main types:5) (1) Syndromes mainly associated with acute diseases
(2) Syndromes mainly associated with chronic diseases
(3) A series of syndromes which remarkably increase in occurrence in the elderly aged 75 or older and are closely related to decrease in ADL requiring nursing.
Most of the elderly subject to home medical care have less basic activities of daily living.
Such elderly perons have more geriatric syndromes compared to those who can have independent living. Geriatric syndromes include: Decrease in ADL, osteoporosis, vertebral fractures, dysphagia, urinary incontinence, pollakisuria, delirium, depression, pressure sore, hearing loss, anemia, undernutrition, bleeding tendency, chest pain, and arrhythmia, which remarkably increase in the elderly aged 75 or older. There is no simple treatment, therefore, care and life support are required based on comprehensive daily functional assessment in addition to medical diagnosis and treatment.
Features of the Results of Diagnostic Test in the Elderly
Reference values of blood tests for the elderly may differ from that for the young. Treatment for the young may not always appropriate for the elderly even the same level was shown by a blood test. For example, low cholesterol level is preferred for the young to prevent arteriosclerotic diseases, but if an elderly person has low cholesterol level, under nutrition or hyperthyroidism should be suspected. In addition, water intake or position may affect result. Medications such as diuretics and antihypertensives often affect results, therefore the possibility should be considered.
Furthermore, results differ substantially between individuals in the elderly in addition to differences between the elderly and the young. Therefore, it is important to know the result at normal state, and diagnose based on differences from results at normal state.
Comprehensive Geriatric Assessment in Home Medical Care
Most of the elderly subject to home medical care often have several diseases. They are also prone to have difficulty in daily functions. Therefore, care based on comprehensive functional assessment is required in addition to diagnosis and treatment. In the elderly, diseases, daily living functions, mental/psychological functions, and social status relate each other complicatedly, and may cause various problems. Hence, we need to understand whole context by comprehensive functional assessment. A physician alone cannot address such problems across several areas, therefore all members (such as nurses, pharmacists, dietitians, physical therapists, occupational therapists, speech–language–hearing therapists, certified care workers, and care managers) need to address these problems as a team in a coordinated effort.
Table. Items in Comprehensive Geriatric Assessment 1. Functions that Affect Communication
(1) Vision (2) Hearing
(3) Language functions 2. Physical Function
(1) Basic activities of daily living (2) Instrumental activities of daily living 3. Mental/psychological Function
(1) Cognitive function (2) Depressed state (3) Will/Motivation 4. Quality of Life 5. Social Status
(1) Caregiver (2) Family structure (3) Residence
(4) Contents of support 6. Nutritional Status
7. Situation of Treatment (1) Diseases
(2) Situation of treatment (3) Medication compliance
Assessment is performed for the following variables in addition to medical status (such as diseases, treatment, and medication adherence): functions (vision, hearing and language function) effecting communication; physical function such as basic ADL and instrumental ADL;
cognitive function; depression; mental/psychological functions such as motivation and a purpose in life; QOL; family structure and caregivers; house; the contents of support including formal and informal supports; and nutritional status (Table).
For physical function, assessment performed for both of the basic activities of daily living such as behavior related to personal life, and a higher life function, i.e., instrumental activities of daily living. At that time, we should focus on which ADL a patient should do or can perform in rehabilitation and care.
Hasegawa Dementia Scale and the Mini-Mental State Examination are often used to assess cognitive function. Clock Drawing Test is useful to assess medication management and self-care ability because it can assess executive function in a simple, useful in evaluating the medication management and self-care ability.
Geriatric Depression Scale -Short Version-. Japanese for 15 variables is often used for depression. Among the 15 variables, two variables for feeling low and loss of pleasure are also useful to screen depression.
For nutritional status, swallowing function including the state of oral care is assessed as well as changes in body weight and body mass index (BMI), physical measurement to estimate subcutaneous fat thickness and muscle area, and assessment by blood biochemical tests such as albumin.
To understand the living conditions of patients such as family structure, hobby activities, and interaction with society helps, treatment, rehabilitation, setting of the goal of care. Marital status, presence or absence of housemates, frequency and satisfaction to meet with children, and
frequency and satisfaction of social networks are known to relate to the risk developing dementia.6) Higher level social networks suppress the risk of developing dementia. Furthermore, having a purpose in life suppresses the risk of developing Alzheimer’s-type dementia and declining cognitive function.7) Recently, social support in the community is recognized as an important determinant of health in addition to individual determinants of health such as living habits and suffering from diseases. Social capital means the concept indicating human networks based on trust and awareness of mutual aid among local residents. It is also important factor to build integrated community care system. When we provide required life support and care, we can provide preferred support by combining informal support with formal support.
Since physical function, mental/psychological function, and social status effect each other, we should understand the whole context based on the assessment of each function. It allows us not only to understand the support necessary for the elderly who are receiving home medical care, but also to explore effective support methods multilaterally.
It takes some times to perform comprehensive geriatric assessment. Therefore, ideally speaking, treatment and care policies should be discussed based on assessments by the various professionals in each area through sharing opinions and understanding changes in the patient’s situation over time.
Assessment of Pain
Pain associated with cancer is well recognized, however, pain is frequency caused by noncancer diseases. Pain is often caused by diseases requiring home medical care, such as chronic heart failure and chronic respiratory failure. In some cases, pain is caused by underlying diseases, but most pain is caused by coexisting osteoarticular diseases. Therefore, diagnosis and assessment including that for coexisting diseases is essential. Moreover, in order to gain comfortable life and better QOL, symptom relief is required at the same time of treatment for diseases instead of separating aggressive treatment and palliative care by treatment period.
In addition to pain, the elderly also have various pain in their daily life including isolation from social activities as well as physical symptoms such as insomnia. Usually, they do not complain pain by themselves, therefore we should check main pain actively.
Approaches Based on Estimated Functional Prognosis
When the elderly are hospitalized, delirium, decline in cognitive function, decrease in physical function are prone to develop. In the elderly hospitalized with severe acute diseases, decline in cognitive function is often found during the follow-up period compared with the elderly not hospitalized. The risk of dementia is also higher in the elderly hospitalized with non-severe diseases.8) According to a survey investigated the course of physical function for 1-year before death by type, the elderly who had progressively or persistently declining physical function were more than half of the decedents, and further decline was found in their physical function associated with hospitalization.9)
Thus, in order to support more comfortable daily life we recommend palliative care instead of hospital treatment for the elderly who have such a course. Therefore, it is important to have had enough discussion on a routine basis for treatment and care plans, and understand the risk associated with hospitalization while predicting prognosis of physical function and cognitive function in addition to life prognosis. It promotes appropriate decision-making for end of life. It is difficult to treat the elderly aiming to cure at acute care hospitals alone, therefore, the role of
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