Nursing Diagnosis For Copd

dr. christensen: good evening, and welcome to the grand finale of season 34 of doctors on call . as a say, it is not easy getting old. sometimes it is especially hard taking care of someone you love who is dealing with geriatric

medical issues. have you make the big decisions? when do you discuss no longer driving or nursing home care? i am dr. ray christensen from the department of family medicine and community health at the university of minnesota medical old duluth.

tonight we are talking about geriatric care. ready to take your questions locally at 218.788.2844. or 877.307.8762. our medical panelists this evening aren't dr. mark voice, a family medicine physician with added allocations in geriatrics

practicing at duluth clinic. dr. amy grant mentor, and internal medicine specialist with duluth clinic and dr. addie licari, a family medicine physician with st. luke's and associates. our medical students answering phones tonight are all from

minnesota. lindsay, sam, and corey. i want to also thank my host, dr. ruth west and the other hosts for all of the work they have done. at this time, i would like to thank and introduce our panelist -- would you like to tell us a

little bit about your specialty. >> mark voice. i am a family physician and for many years i have worked. medicine. i have found that even in my early practice, it included a good percentage of elders. caring for the elderly has been

newly -- has newly become a specialist -- a specialty. it still has a lot of issues of family care and communication with family but has been a very interesting area to focus on. most of my care is at facilities, both long-term care, typical nursing home, assisted

living which is in between assisting with living but not a full nursing home and then what is a very big part of medicine today which is transitional care. if i had a stroke or if an older adult had a stroke they need a recovery time.

perhaps they are not well enough because of heart or lung disease , they need to be in some sort of transitional care and that is where a lot of of our focus is and health care expenditures are. it is a good place to be practicing.

dr. christensen: thank you. dr. greminger, a little bit about yourself. dr. greminger: i initially started working in the hospital. that was not my cup of tea but i did enjoy working with geriatric patients in the community. i work primarily in nursing

homes. i have also done some work with hospice care and palliative that is a passion of mine. one thing that is really special about people at that stage in their life is a lot of times they are transitioning towards the end of their life.

to help them find their goals and their wishes and to really tailor the care they need to what kind of care that they want is a beautiful aspect of geriatric medicine and something i am passionate about. dr. christensen: wonderful. you are a frontline family

doctor. dr. licari: i spent most of my time at my mom's nursing home where she was a physical therapist assistant so i have a special place for geriatric patients. i hope to transition my practice into that.

i see a certain amount of patients in my clinic that are at the geriatric agent i also visit nursing homes as a family dr. christensen: nice review of what you guys do. dr. licari, i will start with you. this person is wondering when

parents need to stop driving, how does one convinced their mom and dad to give up their car. i don't know that the old practices work well. dr. licari: some patients tell me that they have removed a spa plug or something like that. if there is an unwillingness to

quit driving, it does take some willingness from the family and may be the help of your primary doctor to have a discussion about assisted driving and how it would not be appropriate to keep driving. a lot of patients think it is one more thing to hold on to

carry it is a right and a necessity in some areas where they need to get to the store and to some appointments and a measure of freedom. it is a hard thing for people to give up. i have had discussions with patients and family -- they

don't always think about questions such as: can we see? can they hear? i found up if you have an open discussion, there are a certain amount of people who understand that they should not drive. there is a group of people that still want to drive your i

sometimes will have the discussion with the family to do maybe a driver assessment. hospitals in town often also have a driver assessment program. if they can pass, families may feel more comfortable. dr. christensen: it reminds

become one night i got a call from my dad. she will not let me drive. and she says -- he tried to kill us. any other comments on the driving evaluations? >> a lot of times, it is a -- what if.

it -- what if there is an accident? if you play the what if game, it can be helpful. i also have found that having the most vocal opponent to losing their driver's license is often the elder son. having them drive with them,

oftentimes they will take a step back because the driving is generally horrible. my mom's was horrible. i think that helped. it is not the only thing. sometimes, doing a personal driving test, and that could be complemented i the occupational

there be test at the hospital. >> my experience with my family -- certain family members were very reticent taste on family conversations. it took someone that was not a member of the family to have that conversation. sometimes, with parents and

children, there is all sorts of role reversal. sometimes, it is helpful to bring it up with an outside person like a decision or a pa or someone who is not so deeply involved. sometimes, that helps to reserve the relationships.

dr. christensen: another problem -- sometimes you end up getting fired also. that does happen. why do you talk a little bit about visual problems in the elderly. >> i am always amazed by my patients -- when i see them,

they are so lovely and wonderful to talk to. sometimes, it is easy to forget about their very real physical limitations they have. macular degeneration is very common in the elderly and a lot of times, that distorts the finer aspects of vision a half.

they can generally see big shapes but the findings like reading or handwork can become more difficult. they are really fortunate to live in a time where there is a lot more adaptive equipment. there is better lightning, magnifiers, more equipment

through audiobooks and a lot of those kinds of things. i had a family member who does have some issues with macular degeneration and it is really amazing all of the resources that are out there. when patients do have that, it is always nice to be aware of

what resources are out there. losing vision happens, unfortunately, and sometimes, there is not a lot that can be done to fix it but there is a lot that can be done so people can live better with it. >> we forget sometimes how much it impacts your day to day life.

sometimes, especially when the vision is being affected by the medications. even the handouts we give at the clinic with instructions, if you cannot see you are less likely to follow your doctor's instructions. dr. christensen: especially if

the visual loss is concerning. >> i knew my dad's macular degeneration was changing when he, a marine marksman missed a deer. in retrospect, it became apparent that his vision loss was changing. when there is sudden vision

loss, we need to think of close migraines, strokes, or a change in the ocular degeneration. those are things that need to be brought to the attention of the medical team. dr. christensen: and the cataracts and other things. let us move over to hearing.

the questions had to do with hearing aids, hearing aids are expensive. dr. licari: it is a common complaint. even for patients above the age of 45. it interferes with their ability to have conversations.

higher frequency noises go out first. it is a common thing. the problem is the medical coverage is poor. across the board and hearing aids can cost upwards of $3000-$4000 for a pair and then you have to figure out how to

use them. dr. christensen: some of the new ones are $7,000-$8,000. i don't know the regulations but medicare does not cover any of the hearing aids or any of those types of things. you are responsible for that cost yourself.

>> when of the better coverages is from the v.a. related to military service. dr. christensen: most companies allow you a month to try them out before you make the final purchase. i am not sure. >> it is good to try them

earlier rather than later in the course of hearing lost that there is a lot of learning that goes with hearing. laura erickson from kmt talks about hearing aid helping her with bird identification. she was markedly, according to her, conversations on kmt, were

markedly appreciative of them. dr. christensen: it took my mother, two tries to realize that they really do help. a lot of my patients really like the small ones. something to try. i would encourage it. also, protect hearing for those

who have intact hearing. snowblowers. loud noises. lawnmowers. please wear hearing protection. at a young age. how do you get an at risk adult into an assisted living? from a doctor?

a court order? how does the process work? >> and older adult who is at risk to himself can be committed. yes, that can happen. you can go through a commitment process. the most common place we run

into that is maybe not in just early dementia but even moderate dementia where a score on a test, if it is -- if normal is 30, and the test score may be 18. they did pretty well and they may even have a good conversation but they are very

paranoid and very resistive to change. they don't adapt well to change either. that older adult might need a lot of encouragement to get into a facility. one of the things is making sure that the transition, if it

happens with a court order, it can come that it is a company i is much family support as possible. visits earlier in the day are better because the older adult tends to have their best time of day in the morning. that is the best time of day to

discuss things in the first place and then to visit once you have had that very difficult conversation or difficult event with commitment. once again, if you transition to a safe place when you are adaptable, that means selling your house earlier and getting

into an apartment that is accessible, that makes whole lot more sense to me than not. a means you will get more out of your house, and out of your apartment, both. that is a difficult thing.