Constipation and impaction from such common causes as limited fluid intake, decreased activity, and medication side effects are also important elimination concerns to discuss, as they can lead to discomfort and decreased appetite as well as acute symptoms.4 Clarify what constipation means to the patient, and determine an appropriate follow-up plan.
Social support/environmental resources. Support from people and environmental resources becomes increasingly important with the illnesses and frailties common in advanced age. There is often a loss of these resources for the oldest old, as friends and family precede in death. Particularly for those declining in function, it is important to determine whether the individual has consistent support and a safe environment. A basic screening question asks, “Who would help you if you got sick or had an emergency?”
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Consideration of the patient’s usual living arrangements or environmental setting is part of a functional screen. While the benefits of environmental observation may be limited in primary care, ask, “Do you have trouble with stairs, lighting, bathroom, or other home hazards?” Often such simple environmental adaptations as revised room arrangements or grab bars can make a difference in functional abilities. If screening suggests problems, further evaluation can include referral to an appropriate specialist.
Visit closure
Because of the unique qualities of older adults, this patient population requires individualized treatment plans. The best plans find a balance among the older adult’s functional abilities, needs, and resources. The optimal care plan also may vary by environmental setting.2 There are some simple tips to consider as the visit concludes.
Prioritize and treat what is easily treatable. Some conditions commonly occur (e.g, UTIs). After determining care priorities, consider best treatments in light of other comorbidities and functional deficits. Gain best evidence from research, expert clinician practice, and patient preference. Focus in particular on steps that promote functional ability and quality of life.
Consider physical aging changes when prescribing medications. Whenever possible, avoid prescribing high-risk drugs to elders. Provide older patients with clear written guides for taking medications, and alert them to potential side effects.
Keep the treatment plan simple. The treatment plan should fit the patient’s abilities. Written follow-up care guides and patient reminders should contain simple bulleted information in large-font print.
Refer those who need to be referred. A team approach that includes physical, occupational, and speech therapists can enhance a function-oriented plan. The problem-oriented plan should be available to all providers.9
Guide families to needed support resources. Provide contact information for such groups as the local Area Agencies on Aging and the American Association of Retired Persons. Such specialty organizations as the Alzheimer’s Association or the Parkinson’s Disease Foundation provide educational resources and support groups that many patients and family members find beneficial.
Target the most complex cases. Once the patients that require the most involvement have been identified, determine what type of further monitoring (if any) is needed. Consider the benefits of a case manager, and include family caregivers in developing strategies for the coordination of support services.
Health promotion and disease prevention is important for people of all ages. Basic principles of improved nutrition and adequate exercise—related to functional level—apply. Health promotion diagnostic screening guides differ for those of advanced age with limited predicted longevity. Age-appropriate screening, counseling, and preventive-services guidelines can be accessed through the Agency for Healthcare Research and Quality.10
Summary
Screening for functional deficits provides the PCP with a good starting point in caring for older adults with long health histories and comorbidities. Functional screening allows for further systematic assessment and helps clarify patient strengths. Consider functional screens the first step in establishing a realistic and patient-focused care plan. By promoting optimal functional abilities, PCPs can help elders maintain independence with a focus on safety and quality of life.
Wanda Bonnel, PhD, GNP-BC, is an associate professor at the University of Kansas School of Nursing, Kansas City. The author has no relationships to disclose regarding the content of this article.
HOW TO TAKE THE POST-TEST: To obtain CME/CE credit, please click here after reading the article to take the post-test on myCME.com.
References
1. Administration on Aging. Profile of older Americans: 2010.
2. Kane RL. Ouslander JG, Abrass IB, Resnick, B. Essentials of Clinical Geriatrics, 6th ed. New York, N.Y.: McGraw-Hill Professional; 2009.
3. Leipzig RM, Granville L, Simpson D, et al. Keeping granny safe on July 1: a consensus on minimum geriatrics competencies for graduating medical students. Acad Med. 2009;84:604-10.
4. Ham RJ, Sloane PD, Warshaw GA. Primary Care Geriatrics: A Case-Based Approach. St. Louis, Mo.: Mosby; 2006.
5. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1982-1983;17:37-49.
6. National Institute of Mental Health. Older adults: Depression and suicide facts.
7. Reuben DB. Geriatrics at Your Fingertips, 13th ed. Belle Meade,N.J.: American Geriatrics Society; 2011:60-65.
8. Alzheimer’s Association. Diagnostic procedures.
9. Elsawy B, Higgins KE. The geriatric assessment. Am Fam Physician. 2011;83:48-56.
All electronic documents accessed August 15, 2011
HOW TO TAKE THE POST-TEST: To obtain CME/CE credit, please click here after reading the article to take the post-test on myCME.com.
