Geriatric Functional History-Taking in Home Visits

1. MS-1: GATECurriculumGeriatrics and Aging through Transitional Environments GERIATRIC FUNCTIONAL HISTORY-TAKING Seema Limaye, MD Shellie Williams, MD Pritzker School of Medicine

2. Geriatrics and Aging through Transitional Environments (GATE): • Funded by University of Chicago Pritzker School of Medicine Academy of Distinguished Medical Educators: Project in Medical Education • An Integrated, Longitudinal Geriatrics Curricula within the Pritzker Initiative • MS1: Home visit • MS2: SP cases • MS3: Hospital Curriculum • MS4: Skilled Nursing Facility

3. Goals of Home Visit:How to take a geriatric functional history AAMC Geriatric Competencies on Self-Care Capacity: 9. Assess and describe baseline and current functional abilities (instrumental activities of daily living, activities of daily living, and special senses) in an older patient by collecting historical data from multiple sources and performing a confirmatory physical examination. 11. Identify and assess safety risks in the home environment, and make recommendations to mitigate these.

4. Basic Home Visit Etiquette • In pairs, you will perform a geriatric functional history at the home of a independent older adult in the community • Be courteous and respectful. • Be on time. • Address the “patient” as Mr, Ms, or Mrs. (or Dr.), and ask how he/she prefers to be addressed • Dress professionally

5. Before the visit • Review these slides on blackboard • Review the functional history-taking form • Review the evaluation forms so there are no surprises in regards to expectations.

6. Student Responsibilities • Work in pairs to: • Get to know the trained patient as a person • Complete the functional history • Complete the short post-test Leave all documents with the older adult • Complete a 250 word reflective piece on CHALK after the encounter • What was your impression of the visit? What went well with your interviewing skills? What did you feel you need to work on with history taking? What surprised you during the visit?

7. Medical Home Care Today • Provides information about patient that is otherwise not obtainable in the office • Important components of patient’s life - family, spirituality, hobbies • Unreported needs - safety issues, trouble with ADLS and IADLS • Caregiver stress - more apparent in home setting • 20% quit work to provide care (most often women) • 31% lost family savings • 40% of families became impoverished • Elder Abuse - more apparent in home setting • Financial exploitation • Physical and/or Verbal abuse

8. Medical Home Care Today • Leads to improved communication • Patients less inhibited socially and emotionally • Misunderstandings and non-compliance much easier to discern • Patients more likely to engage in discussion -> greater exchange of information

9. Indications for Home Care • Homebound: • Unable to leave home without great assistance • Terminally ill and wish to die at home • Refuse to be seen at office - behaviorally difficult • Recent hospitalization • Patients seen in office also needing at least one visit at home: • Suspect psychosocial issues interfering with care • Goals of care • Recent falls at home • Suspect caregiver burnout • Suspect elder abuse

10. Components of Home Visits • Medication Assessment • Review all MEDS • Determine system of med administration • Discuss possible drug-drug, drug-substance, drug-food interactions • Review necessity of each drug • Nutritional Assessment • Daily diet • Weight assessment • Appetite

11. Components of Home Visits • Environmental Assessment • Observe neighborhood • Lighting • Cleanliness • Assistive device barriers/ fall hazards • Security, safety • Emergency contact information

12. Components of Home Visits • Functional Assessment • Observe ambulation/mobility • Observe use of assisted device in home • Observe patient navigating through home • Observe for signs of incontinence - odors, stains, patient hygiene, skin breakdown • Ask about ADLs and IADLs

13. Physical Function • Activities of Daily Living (ADLs): Assess self-care capability Bathing Dressing Toileting Continence Transfers Gait Feeding • Instrumental ADLs (iADLs): Assess living independence Telephone use Travel Shopping Meal Preparation Housekeeping Medication management Financial management

14. Physical Function: continued • Can the patient perform ADL’s and IADL’s: • Independently • With assistance (describe the aide), or • Completely dependent • Real World Consideration: Patient reported history may not match actual abilities!

15. Interviewing Elders: A few tips • Accommodate to the patient, but don’t assume: its ok to ask patients if they have any sensory deficits! • Get closer-vision and hearing may limit interaction • Sit, don’t hover • Speak slow, don’t rush through the interview • Lower the pitch or use a Pocket amplifier • Minimize background noise

16. Interviewing Elders: continued • Normalize questions and screens. • Encourage and reassure. • Limit information to 2-3 key points. • Let them tell their story (open ended-1 min), then focus with direct questions.

17. Function and Quality of Life for Geriatric Patients Senses: Vision, Hearing, Taste (Nutrition) Falls Physical Performance Cognition and Mood Pyschosocial Support Polypharmacy

18. Falls • 30-40%/year community dwelling elders • 66% accidental deaths in elderly 2nd Falls History to take: • Any falls within last 12months? >2 abnormal • Any unsteadiness with walking? • Any fear of falling? 2nd strongest predictor of another fall

19. Injuries • Hip Fractures-1% of falls in the elderly lead to hip fx • 20-30% mortality in the year after hip fx • ¼ to ¾ of patients do not recover prior level of ADLs Rubenstein LZ, Josephson KR. Falls and Their Prevention in the Elderly: What Does the Evidence Show. Med Clin N Amer 2006;90:807-824

20. Causes of Falls • Rarely due to a single cause • At least 25 risk factors identified across 5 large cohort studies • Interaction across multiple domains: more risk-factors, increased likelihood to fall • Intrinsic to individual • Environmental challenges to postural control • Mediating factors

21. Causes: Intrinsic Patient Factors • Older Age • Female gender • Cognitive impairment • Chronic diseases • Arthritis • Parkinson’s • Use of certain medications • Psychotropics • Diuretics • History of falls

22. Falls Quick Evaluation 1. Chair Rise (without arms) abnormal=unable to perform or >10 sec to stand • Observe use of upper body for support • Observe strength legs, feet • Observe use assist devices Interventions:PT/OT assessment, assist aides, Neurologic/Musculoskeletal exam

23. Mood • Increased office and ED visits • Decreased quality of life • Higher risk for use of alcohol/drugs • Functional decline • Increased mortality • Onset of depression post-MI associated with 4-fold increase in death* • Onset of depression post-CVA associated with 3.5-fold increase in death** * Frasure-Smith N et al. Psychosom Med 1999; 61: 26. **Whyte EM et al. JAGS 2004; 52: 774.

24. Diagnosing Depression:DSM-IV Criteria • 5 or more symptoms during 2-week period • Depressed Mood • Anhedonia • Change Sleep • Change Appetite • Agitation/Retardation • Fatigue • Worthlessness/Guilt • Poor Concentration • Suicidal Thoughts • Must cause impairment in function • Not due to substance or medical condition • Not better accounted for by bereavement

25. Mood: Screens • Two Question Screen (PHQ-2): • In the past month, have you been bothered by feeling down, depressed, or hopeless? • In the past month, have you been by bothered by little interest or pleasure in doing things? • Positive screen is ‘yes’ to both • 100% sensitive, 77% specific • 5-item (GDS) Geriatric Depression Scale: • Are you basically satisfied with your life? • Do you often get bored? • Do you often feel helpless? • Do you prefer to stay at home? • Do you feel pretty worthless the way you are now? • 94% sensitive, 81% specific

26. Alzheimer’s Dementia Impact on USA Every 68 sec $200 billion 6th Lead Cause Death 5.4 million >15 mill Unpaid CG Alzheimer's Association. 2012 Alzheimer's disease facts and figures. Alzheimer's and Dementia: The Journal of the Alzheimer's Association. March 2012; 8:131–168.

27. Diagnosing Dementia:DSM-IV Criteria (2 or more features) • Impaired recent learning/retention-amnesia • Impaired reasoning ability/complex tasks-abstract • Impaired spatial ability/orientation-agnosia • Impaired language-aphasia • Impaired motor function-apraxia • Impairment interferes with work, social activity, ADL/IADL functioning • Impairment do not occur in setting of delirium & other psychiatric diagnoses don’t explain.

28. Cognition Assessment • Mini-Cog: brief <7min testing • 3 item registration (memory) and 1-3 minute recall with clock draw distraction. • Draw a clock and fill in the numbers on the face (visual spatial, planning). • 99% sensitivity; 93% specificity

29. MINI-COG Recall = 0 Recall = 3 DEMENTED Recall = 1-2 NON-DEMENTED Clock Abnormal Clock Normal DEMENTED NON-DEMENTED Mini-Cog Scoring:

30. Clock Draw: Keep it simple! • Normal: Patient places correct time and the clock appears grossly normal • Abnormal: does not meet above criteria

31. Independent Living vs. Assisted Living Facility What’s the difference?

33. Meet our patient

34. A few sample questions for guest patient • What is your typical day?  week? • What surprises you about the aging process? • What have you found as your greatest joys aging? • Do others treat you differently since you've aged?  In what way?