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The Geriatric Assessment

The Geriatric Assessment. Dr. S Manubolu, MD PGY-2; Family Medicine Emory University Hospital. Geriatric Assessment for FPP? . The number of elderly Americans older than 65 yrs of age could increase from 34 million in 1998 to approximately 69 million in 2030.

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The Geriatric Assessment

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  1. The Geriatric Assessment Dr. S Manubolu, MD PGY-2; Family Medicine Emory University Hospital

  2. Geriatric Assessment for FPP? • The number of elderly Americans older than 65 yrs of age could increase from 34 million in 1998 to approximately 69 million in 2030. • Approximately one-half of the ambulatory primary care for adults older than 65 years is provided by family physicians. • It is estimated that older adults will comprise at least 30 percent of patients in typical family medicine outpatient practices, 60 percent in hospital practices, and 95 percent in nursing home and home care practices.

  3. Similarities and differences from standard medical evaluation ? • Incorporates all facets of a conventional medical history: The approach being more specific to older persons. • Including non-medical domains • Emphasis on functional capacity and quality of life • Incorporating a multidisciplinary team

  4. Defining Goals: • Diagnosis of medical conditions • Development of treatment and follow-up plans • Coordination of management of care • Evaluation of long-term care needs and optimal placement.

  5. Tailored practice to meet busy clinical demands! • Less comprehensive and more problem-directed. • Incorporation of various tools and survey instruments in the assessments. • Patient-driven assessment instruments which are time efficient. Is this compromising patient care ?

  6. Structured Approach Multidimensional Multidisciplinary Functional ability Physical health (pharmacy) Cognition Mental health Socio-environmental Physician Social worker Nutritionist Physical therapist Occupational therapist Family

  7. Functional Ability • Functional status refers to a person's ability to perform tasks that are required for living. • Two key divisions of functional ability: • Activities of daily living (ADL) • Instrumental activities of daily living (IADL).

  8. ADL • ADL : self-care activities that a person performs daily (e.g., eating, dressing, bathing, transferring between the bed and a chair, using the toilet, controlling bladder and bowel functions).

  9. IADL • IADL are activities that are needed to live independently • (e.g., doing housework, preparing meals, taking medications properly, managing finances, using a telephone)

  10. Lawton Instrumental Activities of Daily Living Scale 1. Can you use the telephone? Without help 3 with some help 2 Completely unable to use the telephone 1 2. Can you get to places that are out of walking distance? without help 3 With some help 2 Completely unable to travel unless special arrangements are made 1 3. Can you go shopping for groceries? Without help 3 With some help 2 Completely unable to do any shopping 1 4. Can you prepare your own meals? Without help 3 With some help 2 Completely unable to prepare any meals 1 5. Can you do your own housework? Without help 3 With some help 2 Completely unable to do any housework 1 6. Can you do your own handyman work? Without help 3 With some help 2 Completely unable to do any handyman work 1 7. Can you do your own laundry? Without help 3 With some help 2 Completely unable to do any laundry 1 8a. Do you use any medications? Yes (If “yes,” answer question 8b) 1 No (If “no,” answer question 8c) 2 8b. Do you take your own medication? Without help (right doses at right time) 3 With some help (prepare or reminds) 2 Completely unable 1 8c. If you had to take medication, could you do it? Without help (right doses at right time) 3 With some help prepare or reminds) 2 Completely unable 1 9. Can you manage your own money? Without help 3 With some help 2 Completely unable to handle money 1

  11. PHYSICAL HEALTH • Incorporates all facets of a conventional medical history: However the approach should be specific to older persons. Specific topics include: • Nutrition • Vision • Hearing • Fecal and urinary continence • Balance and fall prevention, osteoporosis • and Polypharmacy

  12. Nutrition :Four components specific to the geriatric assessment • Nutritional history performed with a nutritional health checklist • Record of a patient's usual food intake based on 24-hour dietary recall • Physical examination with particular attention to signs associated with inadequate nutrition or overconsumption and • Select laboratory tests, if applicable

  13. Nutritional Health Checklist • I have an illness or condition that made me change the kind or amount of food I eat 2 • I eat fewer than two meals per day 3 • I eat few fruits, vegetables, or milk products 2 • I have three or more drinks of beer, liquor, or wine almost every day 2 • I have tooth or mouth problems that make it hard for me to eat 2 • I don't always have enough money to buy the food I need 4 • I eat alone most of the time 1 • I take three or more different prescription or over-the-counter drugs per day 1 • Without wanting to, I have lost or gained 10 lb in the past six months 2 • I am not always physically able to shop, cook, or feed myself 2 • 0 to 2 = You have good nutrition. Recheck in 6 months. • 3 to 5 = You are at moderate nutritional risk, TLC, and recheck in 3 months. • 6 or more = You are at high nutritional risk, see dietitian, or other qualified health care professional.

  14. VISION • The U.S. Preventive Services Task Force (USPSTF) : found insufficient evidence to recommend for or against screening with ophthalmoscope in asymptomatic older patients. • Common causes of vision impairment : presbyopia, glaucoma, diabetic retinopathy, cataracts, and ARMD

  15. HEARING Updated USPSTF recommendations since 1996: • Recommends screening older patients for hearing impairment by periodically questioning them about their hearing. • (Hearing Handicap Inventory for the Elderly) • Audioscope examination, otoscopic examination, and the whispered voice test are also recommended.

  16. Hearing Handicap Inventory for the Elderly

  17. Interpretation • A raw score of 0 to 8 = 13 percent probability of hearing impairment (no handicap/no referral) • 10 to 24 = 50 percent probability of hearing impairment (mild to moderate handicap/referral) • 26 to 40 = 84 percent probability of hearing impairment (severe handicap/referral). • Potentially ototoxic drugs. • Failure of screening tests should be referred to an otolaryngologist. • Treatment of choice - Hearing aids • To minimize hearing loss and improve daily functioning.

  18. URINARY CONTINENCE • Complications: decubitus ulcers, sepsis, renal failure, urinary tract infections, and increased mortality. • Psychosocial implications : loss of self-esteem, restriction of social and sexual activities, and depression. • Key deciding factor: Nursing home placement.

  19. Questions to ask? Urge incontinence : • “Do you have a strong and sudden urge to void that makes you leak before reaching the toilet?” Stress incontinence : • “Is your incontinence caused by coughing, sneezing, lifting, walking, or running?”

  20. BALANCE AND FALL PREVENTION • Leading cause of hospitalization and injury-related death in persons 75 years and older. • Tool to assess a patient's fall risk- 16 seconds The Tinetti Balance and Gait Evaluation: • This test involves observing as a patient gets up from a chair without using his or her arms, walks 10 ft, turns around, walks back, and returns to a seated position. • Failure or difficulty to perform the test : increased risk of falling and need further evaluation.

  21. Interpretation Of Test • 7 -10 secs : Normal time • 10-19 secs : Fairly mobile • 20-29 secs : Variable mobility • 30 sec or more : Functionally dependent in balance and mobility

  22. OSTEOPOROSIS • Osteoporosis may result in low-impact or spontaneous fragility fractures, which can lead to a fall. • Dual-Energy X-ray Absorptiometry • ( Total hip, femoral neck, or lumbar spine, with a T-score of –2.5 or below) • USPSTF recommendations: • Routine screening of women 65 years and older for osteoporosis with DEXA of the femoral neck.

  23. POLYPHARMACY • Multiple medications or the administration of more medications than clinically indicated. • 30 percent of hospital admissions and many preventable problems: are 2/2 to adverse drug effects. • The Centers for Medicare and Medicaid Services encourages the use of the Beers criteria, as part of medication assessment to reduce adverse effects

  24. 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

  25. 2012 AGS Beers Criteria for Potentially Inappropriate Medications to Be Used with Caution in Older Adults

  26. Cognition and Mental Health(Depression and Dementia) • USPSTF screening recommends for Depression: Screen all adults for depression if systems of care are in place • Geriatric Depression Scale : Hamilton Depression Scale • Simple two-question screening tool (as effective as longer scales) • “During the past month, have you been bothered by feelings of sadness, depression, or hopelessness?” • “Have you often been bothered by a lack of interest or pleasure in doing things?” • Positive screening test :Responding in the affirmative to one or both of these questions , that requires further evaluation.

  27. Dementia • As few as 50 percent of dementia cases are diagnosed by physicians • Early diagnosis of dementia allows : patients timely access to medications prepares families for the future • Mini-Cognitive Assessment Instrument is the preferred test for the family physician because of its speed.

  28. Mini-Cognitive Assessment Instrument • Step 1. Ask the patient to repeat three unrelated words, such as “ball,” “dog,” and “window.” • Step 2. Ask the patient to draw a simple clock set to 10 minutes after eleven o'clock (11:10). A correct response is drawing of a circle with the numbers placed in approximately the correct positions, with the hands pointing to the 11 and 2. • Step 3. Ask the patient to recall the three words from Step 1. One point is given for each item that is recalled correctly.

  29. Mini-Cognitive Assessment Interpretation

  30. Socioenvironmental Circumstances Multidisciplinary team approach Family

  31. Assessment & Plan – Holistic approach Formulate problem list Necessary intervention Appropriate referral

  32. Question:1 • As part of assessing a 74-year-old patient's mobility, you use the "Get Up and Go" test. The patient takes 18 seconds to get up, walk 10 feet, turn around, and walk back to the chair. Which of the following best describes the patient's mobility performance? a) He is fairly mobile b) He demonstrates variable mobility c) He has normal mobility d) He has severely restricted mobility e) He is functionally dependent.

  33. Recall C – Fairly mobile 7 -10 secs : Normal time 10-19 secs : Fairly mobile 20-29 secs : Variable mobility 30 0r more : Functionally dependent in balance and mobility

  34. Question:2 • A 79-year-old patient reports eating fewer than 2 meals a day and consuming few fruits, vegetables, or milk products. Which of the following strategies should you try first to improve nutrition? Score 3-5. a)Recommend increasing fruits, vegetables, and milk products in the daily diet as long as the patient has not had weight loss. Recheck in one year. b)Refer to a nutritionist immediately. c)Recommend the patient take a multivitamin and calcium. Recheck in one year. d)Identify ways in which the patient can enhance nutrition. Rescreen in 3 months. e)Recommend nutritionally enriched supplements. Recheck in 6 months.

  35. Recall • D • The Nutrition Screening Initiative has developed a simple screening questionnaire that is suitable for grading by physicians or family members. Individuals with a score of 6 or greater are at high risk for poor nutrition and require intervention. Those with a score of 3 to 5 are at moderate risk and need to improve their eating habits and lifestyles. These individuals require reassessment in 3 months.

  36. Question:3 • A frail 83-year-old male with a 10-year history of diabetes mellitus is admitted to a nursing home. His blood glucose level, which he rarely checks, is typically over 200 mg/dL. His serum creatinine level is 1.9 mg/dL. He also has had several episodes of heart failure. His current medications include glipizide (Glucotrol), lisinopril (Prinivil, Zestril), and furosemide (Lasix). Which one of the following would be most appropriate to add to this patients regimen to treat his diabetes mellitus? (check one) • a. The American Diabetes Association 1800-calorie/day dietb. Metformin (Glucophage)c. Pioglitazone (Actos)d. Exenatide (Byetta)e. Insulin glargine (Lantus)

  37. EFor geriatric patients in long-term care facilities, the predictable glucose control of glargine is the best approach to consider initially. The American Diabetes Association does not recommend a strict diet for frail diabetic patients in nursing homes. Exenatide is not recommended for the frail elderly because of concerns about weight loss and nausea. Heart failure precludes the use of pioglitazone, and renal failure precludes the use of metformin

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