Geriatric Functional Assessment: The Geriatric Review of Systems

Geriatric Functional Assessment: The Geriatric Review of Systems Mary B. Preston MD FACP Associate Clinical Professor of Geriatrics University of Virginia

Objectives • Understanding of basic differences in organ systems in the elderly • Knowledge of functional geriatric assessment • With emphasis on mental status, mobility and medication

Different metabolism/function • Cells and tissues • Increased fat to lean (even in skinny people) • Heat production falls (the older, the colder) • Connective tissue has decreased elasticity • Example: lungs and skin

Cardiovascular • More sensitive to volume changes • Stroke volume, resting cardiac output decreases 1% per year • More ischemia therefore more myocardial infarction and more congestive heart failure • More problems with cardiac rhythm • Tendency to have orthostatic hypotension

Respiratory • Decreased forced expiratory volume in 1 sec (FEV1) • Decreased vital capacity • Arterial oxygen is less: the formula which adjusts for age is • PaO2 = 100.10 - 0 .323 x age • example, 60 yo average pa02 is about 82

GI • Diverticulosis occurs in over 1/2 of people over the age of 60 • Decreased esophageal motility • Decreased saliva (by 2/3) • Less ability of liver to detoxify

Renal • Nephron loss • Blood supply to kidneys decreases • Decreased creatinine clearance

Musculo-skeletal • Decreased muscle strength and mass • Cartilage deteriorates with narrowing of joint spaces • Bone mass decreased (osteoporosis)

Neurology • Parkinson’s disease seen in 10% of this population • Memory loss is NOT part of normal aging • Retention of new information decreases with aging • There is a slower processing time with aging

Sensory • Vision: trouble with glare and dim light; increased farsightedness, cataracts • Hearing: decreased universally by age 85; high frequency sounds harder to hear • Taste buds: ½ are non-functional • Smell decreased • Decreased proprioception

NOT normal aging • Fatigue is not part of normal aging • Anemia is not part of normal aging • Incontinence is not part of normal aging • Depression is not part of normal aging • DESPITE what patients themselves tell you – “I guess I am just getting old”

Interviewing skills • Speak to the patient, not the caregiver • Speak distinctly and where the person can see your lips • Take your time • Avoid age-ist remarks, EVEN if the patient themselves makes them; don’t agree • Older patients tend to be more conservative in their dress and expect you to be also

Examination skills • Deafness: speak in front of the patient, not to the side or behind them; do not shout • Attend to their comfort realizing that they may have arthritis • Warm your hands • Realize that they may respond slower; this does not indicate dementia

Covering the geriatric issues: The screening geriatric assessment • Medication, mentation, mobility • Activities of daily living • Social Support • Advance directives • Hearing and Vision • Incontinence • Nutrition • Depression

CANDY TIME • Today’s mneumonic: You will be quizzed on this at the end of the hour! MMM • MEDICATION • MENTATION • MOBILITY

Medication • The list is NOT enough • Do they need each medication ? • Are there any medications that interact? • What is their renal function? • What drugs are potentially inappropriate in the elderly? • What is the average number of medications taken by an elderly person – at home, in the nursing home?

Medications - #2 • The list: must include over the counter, doses, as needed (“prn”), how often taken • Major interactions: Software programs help • Renal function: if you are a 90 yo man with a creatinine of 1.0 (“normal”), a weight of 72 kg, your clearance is--------? • Average number of meds: 4.5 for community dwelling, 7-9 for nursing homes

Medications #3 • Clearance is 50cc/hr (nearly half normal) • Potentially inappropriate medications • Anti-cholinergics • Benzodiazepines • Tricyclics (ex: anti-depressants, muscle relaxers) • Quinolones • Meperidine • Indomethacin

Mentation • Common sense approach: look at the patient’s dress, observe way questions are answered • Need a baseline: from records or family • Tests confirm your common sense and allow you to not be fooled by the socially adept but demented patient • Prevalence of dementia is about 50% in those over the age of 85

Mentation #2 • You must distinguish between dementia, delirium and depression • Dementia: gradual onset, progressive • Delirium: acute onset, fluctuation, patient is inattentive • Depression: sad affect, sees future as no better or even worse than the present

Tests for dementia • MMSE: developed 1975; educationally dependent; poor specificity and sensitivity but extensively used for screening • Questions: Orientation, Registration, Attention, Recall, Language • How to score: no half credit for being close • Traditionally, less than 24 = cognitive impairment

Tips for doing MMSE • Use spelling WORLD backwards rather than serial 7s: easier for patient and for you • Overcoming resistance (yours and theirs) • “I do these tests on ALL over age 65” • “Some of the questions may seem silly - just bear with me” • If patient upset by not doing well, skip to the easier items

Other tests • Animal naming: Name all the animals you can in one minute • Lab: Thyroid stimulating hormone (TSH), B12, (VDRL only with appropriate history), CBC, Chemistry (renal and hepatic function). It is rare that a lab test shows you a problem that is responsible for the dementia. • X-ray: one time MRI or CT scan - especially to check for subdural hematoma

Mobility • Why might this be a problem? • Arthritis • Muscle atrophy (remember more fat than lean) • Sedentary life style • May contribute to incontinence • May contribute to depression

Exam for mobility/balance • The Get Up and Go test : person sitting in chair, gets up, walks 10 feet, turns and walks back to chair and sits down • The Functional Reach: standing, not moving legs, reach with outstretched hand about 6 inches • One leg balance: should be able to stand a few seconds on each leg independently

Activities of daily living • This is part of the geriatric history • ADLs versus IADLs • ADLs are basic, I =Independent or Instrumental like using public transportation, using a phone • Mneumonic for ADLs: DEATH • Dressing, eating, ambulating, toileting, hygeine

Social Support • This is a variation of the “social history” that you have been doing • Ask who would be able to help if the patient became sick • Ask where the children live; do not assume that if they live next door they help out

Advance Directives • ASK what the patient wants • Difference between the living will and the durable power of attorney for health care • Offer the patient some concrete scenarios • Listen • Document

Hearing/Vision • Whisper test:” Boxcar” or several numbers, or finger rubbing • 20/40 is functional vision (glasses on); it is the equivalent of newspaper print

Incontinence • There are 2 main types of incontinence • Stress: the history question here is “Do you pass urine if you cough or sneeze, or other times involuntarily?” • Urge: “Do you have to rush to get to the bathroom?”

Nutrition • Ask if they have lost more than 10 pounds in the last 6 months • The cause is likely to be not a disease, but a situation • Medications • Depression/Loneliness • Finances • If a disease, hyperthyroidism, cancer

Depression • Single question approach; • “How do you see your future?” • “Are you often sad or depressed?” • “What do you do for fun?”

Depression #2 • Distinguish between grief, minor depression and major depression • Depression in the elderly CAN be treated successfully • Grief: look at it functionally – not in terms of time • Major depression: the janitor can recognize; the excellent clinician can recognize “minor” depression and greatly benefit their patient

MMM - what are they? • Medication • Mentation • Mobility

Conclusion • You are now ready to do an excellent history and physical with your elderly patient • You know that it takes a different knowledge base, a different set of skills, and above all, a non-ageist attitude • If you remember nothing else, remember THE THREE M approach

Geriatric Functional Assessment: The Geriatric Review of Systems