Caring For Older People
Hi, my name is Indrani, I am an IMG from India. I moved to the UK in November 2020 and am currently working in geriatrics in London as an SHO. In today’s blog, I am going to talk about caring for older people.
When working as medical practitioners, we come across an assortment of human characteristics - people from various age groups, backgrounds, having different temperaments, degrees of illness, personalities, religious beliefs, etc. We might need to be more assertive with some and with others, may be softer and gentler. We pick up on skills as we go along our careers. In this article, let me help you out with one subset of people, who might need a more tender and understanding approach- the grandparents. I use this term on purpose as it reminds us of our grandparents, our fond memories with them and the patience and care we have exercised with them, out of love. Older people may need some special considerations due to the changes brought about by advanced age. Some of them are:
It is quite embarrassing for anyone to admit that their hearing is not great, and a lot of older individuals tend to have hearing problem due to multiple reasons. Its good to be observant from the start of the consultation- is there any mention of hearing disability in the records? are there any signs of hearing aids? Sometimes they tell it to you directly. Make an effort to minimize this difficulty, both for you and the patient. Try to conduct consultation in a quiet area if you can, be louder and slower in your speech, pull down your mask (if it is safe to do so) so that they can lip read. Some people might want you to write things down. In these situations, be patient and remember that our goal is efficient patient care and communication.
Know more about them, do not impose.
As one gets older, they get set in their ways. Some people like to be very self-dependent; some might have a particular way of doing certain things and different things matter to different people. Get to know them and their preferences. Familiarizing ourselves with their daily activities, level of dependence/independence, needs and concerns, we are better able to deliver patient-centred care. It helps us to decide some of the clinical aspects of the management, whether its going ahead with a procedure or deciding a treatment escalation plan.
Memory impairment is a common age-related challenge faced by older people. There are two aspects- emotional and clinical. Clinically, one must find out their level of cognition and whether they have capacity. It is not necessary that all demented patients do not have capacity and vice versa. We should know what their baseline cognition is to be able to differentiate between delirium (acute confusion) and dementia. And as for the emotional and mental aspect, we need to be more patient and also, vigilant to ensure that they are not at risk of harm. It is very tough to lose memory, hence having familiar faces, favourite foods and gentle approach can help people with dementia be at ease.
Declining physical reserve
It is important to keep in mind that older people have multiple co-morbidities and poor physical reserve, even if they may present with a simple or single complaint. So, your treatment must be tailored accordingly. You must understand the impact of any major event like a head injury, fall, cardiac event is much more compared to a 25-year-old man. This also means we must know where to draw a line when it comes to aggressive management of a condition because what you think is for their good might hamper their quality of life. Hence, we need to establish a ceiling of care and resort to palliative care when appropriate, obviously after involving the family. In such conditions, it is even more essential to know about your patient’s wishes, to be able to deliver care aligned with their personal desire.
Having gone through so much in life, elderly people are wise but also tend to become lonely with fragile emotions at times. For example, we might fall, get up the next moment and walk away. When old people fall, it causes significant mental and emotional trauma along with plummeting confidence. Hence it must be dealt with sensitivity and compassion. Same goes for any major or not so major medical event, it does not hurt to listen to them, offer encouragement & give them some much needed TLC (tender love & care). After all, not all things can be fixed with medicines.
Cognitive slowing & capacity
With age comes wear and tear and that means things are slowing down. Older people might take longer to understand what is going on, absorb the information and express their wishes. Be patient. Try to make information as easy to receive as possible, whether it is by making physical adjustments or using slow and simple language. When it comes to any important decision, it is crucial to establish if they have capacity, not only for the patient & yourself but also because of medicolegal consequences. If patients have capacity, you cannot force them, and if they do not have capacity then you might have to make certain decisions in their best interest. And do not forget to involve family.
Miscellaneous practical tips:
Always establish a baseline -cognition, mobility & level of independence- for your patient. It helps to understand how deranged their condition is at present and how much help can be offered. Collateral history from family is very important
Pay attention to little things- are they eating well? Opening bowels regularly? Mobilizing if able? – as these things help improve their condition
Establish whether they want their family/Next of Kin to be involved or not and how much of involvement would they prefer. This is important from confidentiality standpoint as well.
Find out if any family member holds a valid LPA( Lasting power of attorney) or an advanced directive. Keep one copy in the patient’s notes.
Always have a documented treatment escalation plan after discussion with your seniors so that you know what to do in emergency situations.
Look at things holistically- therapy needed, equipment that can be helpful, any package of care that can be make their lives easy.
Ensure all medicines administered are essential and not just an addition to the long list of medicines. A statin might be useful for a 50 year old but not as much for a 95 year old.
Have realistic goals. You cannot improve their health beyond their baseline exponentially. Remember a peaceful dignified death or spending the last few weeks of life in the company of family is more valuable than futilely treating a terminal illness.
I hope you found the information in this blog helpful both in a practical way and in terms of designing a thought process. These are some of the pointers I picked up on while working with the cute old grannies and grandpas and there is much more to learn. Just remember, compassion and empathy go a long way. And if you have any questions regarding the topic, I would be happy to answer them at trewlink.com. Find me as an Expert and follow my profile -Indrani Mandal- to receive regular support and advice.