Læknablaðið - 01.12.1973, Page 64

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LÆKNABLAÐIÐ
be revealed with skeletons falling out of
cupboards one after the other, little of re-
levant value to the present illness will
emerge. The old person and their relatives
should at least on one occasion be inter-
viewed separtely. At another and very diff-
erent interview when, after a period of hos-
pital care the time comes for the older
individual to leave hospital and to go home
as planned, then the reverse is true. There
should in fact be a three-cornered consulta-
tion between the relative, the doctor and
the patient, so that there is no misunder-
standing about the future plan or pro-
gramme for the elderly individual. This pro-
cedure avoids the ping-pong game where the
doctor is used as a ball to convey messages
between patient and relative and relat-ive
and patient. During history-taking itself
direct questioning is usually essential, and
during this time it is necessary to complete
at least one form of mental health (demen-
tia) scoring system. This will be invaluable,
not only in diagnosis but in assessing pro-
gress. Time spent during ihistory-taking
should be used to build up the mental
health of the patient by stressing any hope-
ful statements.
PAIN
Beware of t'he older person who com-
plains of a recurrence of an “old” pain.
This can mask an acute illness such as
intestinal obstruction or pneumonia. This
type of statement probably reflects a desire
on the part of the elderly person to avoid
troubling the doctor. Medical teaching has
always stressed that pain is a call for help,
and this of course is generally true. But
there is doubt about the value of t-he pain
as a sympton in the elderly. Pathy (1967)
confirmed the findings of Rodstein (1956)
in demonstrating how infrequently pain
was of diagnostic importance in coronary
thrombosis. It is well known that an elderly
woman after a fall may state that she can-
not move her leg but may make no com-
plaint of pain in hip or knee when in fact
she has fractured her femur. Intra-ab-
dominal disasters may occur in the ab-
sence of severe pain; constipation of
sudden onset and atypical in that parti-
cular individual may indicate intestinal
obstruction from one or other cause, and
acute appendicitis may be also silent
(Loe, 1969). Pain when it does occur may
be felt in the wrong place and in the wrong
organ. An elderly person may unwittingly
baffle the physician by complaining of per-
sistent pain in the back of the neck or in
the chest when in fact she is suffering
from a benign ulcer of the lesser curvature
of the stomach (Strang, 1963). The old ana-
tomical lesson that pain in the knee can
indicate a fractured neck of femur is very
often true in those elderly individuals who
do have pain following a fracture.
POSTURE
The control of posture becomes more
difficult for the elderly person and thus falls
are frequent. It is important to treat the
result of a fall in the elderly but it is even
more important to try and discover why
the old person fell in the first instance. A
fall should be considered as a rash would
be in an infant and careful attention must
be given to try and discover what has caused
the fall. Falls occur in the elderly in many
different conditions; almost any serious
illness can result in a fall and while drop
attacks were stressed by Sheldon as the
cause of about a quarter of falls in old
people, a fall may also be the result of many
illnesses, e.g., myocardial infarction, an-
aemia, heart block, latent chest infection
and neoplasm. The fall may be precipitated
by therapy as, for example, a hypotensive
agent being prescribed v/ith excessive zeal.
In individuals over 70, the value of anti-
hypertensive treatment would seem to be
in grave doubt. The very useful phenthiaz-
ine derivatives may also cause postural
hypotension and thus precipitate falls in
older people. Certainly one immediate
practice where the patient complains of
falls is to stop all drug therapy and see what
the result is. As people grow older, control
of posture is helped by changing position
slowly and the safe rule is to advise elder-
ly people to change position by numbers as
if they were in the army and to make the
endeavour to avoid sudden movements
especially of head and neck. Where no Cause
for unsteadiness on standing can be found,
it is often of value to advise a few days