Challenges in Geriatric History Taking

Challenges in History Taking in Geriatric Clients

• Vision, hearing, and psychomotor performance can affect communication.
• Patients may underreport symptoms due to health beliefs, fear, depression or altered responses to disease processes.
• Cognitive impairment can also present a challenge in history taking.

Collecting Assessment Data

• Rapport is essential.
• Never address a patient by their first name unless invited.
• There are three approaches to collecting assessment data: self-report, report-by-proxy, and observational.
• Self-report is obtained through direct questioning or written responses.
• Report-by-proxy is used for cognitively impaired individuals and involves gathering information indirectly from caregivers or loved ones.
• The observational approach collects and records objective data through measurements and observations.

Health History

• The health history marks the beginning of the nurse-client relationship and assessment process.
• Verbal interviews are preferred for patients with limited vision or literacy levels.
• Written formats should be avoided if the patient has limited vision, reading comprehension, or language proficiency.
• A trained medical interpreter is required for patients with limited language proficiency.
• Additional information should be obtained from proxies for cognitively impaired patients.
• The health history includes patient profile, past medical history, review of systems, medication history and nutritional history.

Physical Assessment

• A complete head-to-toe assessment is usually done for younger patients.
• The assessment should prioritize what is most relevant to the presenting problem or major diagnoses.
• When a chief complaint is not known, a more thorough assessment is necessary.
• For well-check or health promotion purposes, focus on major preventable health problems, particularly those of cardiovascular and musculoskeletal origin.

Comprehensive Physical Assessment of the Frail and Medically Complex Elder - FANCAPES Model

• The FANCAPES model is a comprehensive and prioritized approach for assessing frail elderly individuals.
• It focuses on determining basic needs and the individuals' functional ability to meet those needs independently, aligning with Maslow's Hierarchy of Needs.
• The model includes: fluids, aeration, nutrition, communication, activity, pain, elimination, and socialization.

Fluids

• Assess hydration levels and the individual's ability to consume adequate fluids.

Aeration

• Evaluate respiratory function and the need for supplemental oxygen.
• Assess respiratory rate, depth at rest and during activity, auscultate and palpate lung sounds.
• Carefully assess lateral and apical lung fields in older adults.

Nutrition

• Evaluate factors affecting the individual's ability to obtain and benefit from adequate nutrition.
• Assess intake, eating abilities, oral health, denture fit, and understanding of special dietary needs.
• Teach aspiration prevention strategies if necessary.

Communication

• Assess communication abilities and the caregiver's understanding of those abilities.
• Evaluate hearing function, lip-reading abilities, and presence of aphasia.

Activity

• Assess ability to perform activities of daily living (ADLs) such as toileting, grooming, and meal preparation.
• Assess the need for assistance with activities and the availability of assistance.
• Evaluate participation in activities that meet higher needs like belonging and finding meaning in life.

Pain

• Identify any physical, psychological, or spiritual pain experienced by the individual.
• Assess ability to express pain and desire for relief.
• Consider any cultural barriers that may influence pain assessment or expression.
• Determine preferred methods of pain relief.

Elimination

• Assess urinary and bowel function, including any issues related to control or environmental factors.
• Evaluate the accessibility and functionality of toileting facilities.
• Assess use and availability of assistive devices.
• Determine the impact of elimination issues on social functioning.

Socialization and Social Skills

• Evaluate the individual's ability to engage in social relationships, give and receive love and friendship, and feel self-worth.

Mental Status Assessment

• Several tools can be used for mental status assessment.
• Cognitive impairment can be assessed with tools such as the Mini-Mental State Examination (MMSE), Clock Drawing Test, Mini Cog, and The Global Deterioration Scale.
• Mood can be assessed using tools like the Geriatric Depression Scale.

The Mini-Mental State Examination (MMSE)

• A 30-item instrument that screens for cognitive difficulties.
• Used to assist in the diagnosis of dementia or delirium.
• Evaluates orientation, short-term memory, attention, calculation ability, language, and construction.
• Score:
  • 30 = No impairment
  • <24 = Potential dementia

The Clock Drawing Test

• Used since 1992 to identify cognitive impairment.
• Measures severity of impairment.
• Requires manual dexterity and is not appropriate for individuals with limitations in their dominant hand.

The Mini Cog

• Provides a quicker cognitive assessment than MMSE and can be used with individuals with varying educational levels.
• Combines aspects of the MMSE with the executive function components of the Clock Drawing Test.
• Highly sensitive in detecting dementia.

The Global Deterioration Scale

• Measures the progression of cognitive changes throughout the process of dementia.
• Useful for nurses and families in developing interventions and anticipating future needs.

Mood Measures

• The Geriatric Depression Scale is used to determine the presence of depression, a prevalent yet often undetected problem in older adults.
• This tool minimizes consideration of physical complaints, sex drive, and appetite, factors that may be affected by medications.
• It is not appropriate for use with individuals with dementia or cognitive impairment.

Functional Assessment

• Identifying the specific areas where assistance is needed or not needed.
• Identifying changes in abilities over time.
• Assisting in determining service needs.
• Providing information to assess the safety of a particular living situation.

Activities of Daily Living (ADLs)

• Common assessment tools for ADLs include the Katz Index, Barthel Index, and the Functional Independence Measure (FIM).
• ADL categories include: eating, toileting, ambulation, bathing, dressing, and grooming.

Katz Index

• Developed in 1963, providing a basic framework for most ADL measures.
• Uses a 4-point scale to score performance abilities: independent, assistive, dependent, or unable to perform.
• 1 point is awarded for each ADL completed independently.
• Zero is awarded for unable to perform ADLs.
• Scores range from 6 (totally independent) to 0 (totally dependent).

Barthel Index

• The Barthel Index and the Functional Independence Measure (FIM) are also widely used assessments to evaluate ADLs and participation in daily activities.