Approach to the Geriatric Patient

1. Approach to the Geriatric Patient Geriatric Assessment in a Primary Care Setting Hazards of Hospitalization

2. Learning Objectives • To understand some basic principles of geriatrics including demographics of our population • To heighten awareness about what is unique about the older patient and how these factors should impact on the approach to care • To have a working knowledge of the value and essential components of a geriatric functional assessment

3. Demographics of the US – Graying of America • By 2030 – 25% of population will be over 65 years old • Squaring of the pyramid – many more older persons living longer • Great impact on socioeconomics, health care, and long-term care issues

4. Who are these older patients? • Largest growing segment is the over 85 group • 69 men per 100 women • Most are living in the community • Overall percentage of older adults living in skilled nursing facilities – only 5% 1% - 65-74 6% - 75-84 22% - 85 and older So still 75% of those >85 are living in the community

5. Health Care Utilization • 12.5% of current population – yet older persons account for up to 40% of health care expenditures • 80% of costs incurred by approximately 20% of older age group • A large percentage of this cost is incurred in the very last days of life

6. What is different about these older patients? • Heterogeneity of population • Physiologic changes • Increased prevalence of disease – changes in patterns of illness • Under-reporting of symptoms • Atypical presentation of illness • Symptoms in one organ system often reflects abnormalities in another

7. How are elderly patients different? • Increased reliance on social supports • Increased role of adverse effects to meds and therapies • Up to 40% in older adults • Predisposing factors – advanced age, hepatic or renal insufficiency, small body size, polypharmacy

8. Cascade To Dependency

9. Falls Delirium Functional Decline Pressure Ulcers Adverse Drug Effects Transition Failure Hazards of HospitalizationHigh Risk EnvironmentHigh Risk Situation

10. Delirium – acute onset of disturbance in consciousness in which cognition or perception is altered

11. Cognitive Impairment Severe Illness High BUN/Cr Vision Impairment Low Risk (0) – 10 % risk Int Risk (1-2) – 25 % risk High Risk (3-4) – 80% risk Assessing Risk of Delirium – Medical Inpatient Prediction Rule:

12. Assessing Delirium Risk - • Mini-Cog • 3 item recall (up to 3 points) • Clock Draw (10 minutes after 11 ) all or nothing – 0 or 2 points On admission – scores of 0,1or 2 – carries a 4-5X risk for delirium True whether the pt has dementia or not

13. How Common? • Affects 20% of hospitalized elderly >65 • Up to 70-80% of older patients in ICU settings • Up to 83% of older patients at end of life • Affects about 40% of postoperative patients • Cataract 1-3% • General surgery 10-15% • Orthopedic Surgery – 30-60%

14. So what – why does it matter? • Increased length of stay – by 8 days • Increased Mortality • Double the mortality in pts with delirium • Functional Decline/NH placement • Prolonged Cognitive Defects – pts may never get back to their pre-delirium state • Newer research – 1/3 of pts d/c to SNF delirious will still be delirious 6 months later

15. Mechanism of Delirium • Imbalance of neurotransmitters • Acetylcholine • Dopamine • Hypothalamic –pituitary –adrenal axis • Inflammation • Cytokines (TNF, Interleukins) • Occult diffuse brain injury • Especially following sepsis

16. Delirium Prevention Modifiable Risk Factors Cognitive Impairment Immobility Visual Impairment Hearing Impairment Dehydration Sleep Deprivation Prospective Interventions Orienting communication Early mobilization, reduce restraints Visual Aides; adaptive equipment Amplifiers; adaptive equipment Prevent and correct dehydration Uninterrupted sleep, nonpharmacologic aides 40% relative risk reduction Inouye SK et al. A multicomponent Intervention to Prevent Delirium in Hospitalized Geriatric Patients. NEJM 1999;340:669-676 Vidan MT et al. An Intervention Integrated into Daily Clinical Practice Reduces Incidence of Delirium During Hospitalization in Elderly Patients.

17. The Hospital is a dangerous place… • Sensory deprivation – used as mechanism of torture • Sleep deprivation – many consequences – • In healthy volunteers – irritability and impaired attention • Noise, vital sign checks, lights, pain, illness, skin care, phlebotomy, medication administration at all hours …….SLEEP???

18. Elderly Patients Spend the Majority of their Hospital Time Immobile • Translation – “ad-lib” – means 97% of time immobile – one study found median amount of time standing or walking 43 minutes out of a several day hospitalization • Implications: • Schedule mobility • Culture of Unit activity • Universal Awareness that deconditioning has consequences

19. Other Important Characteristics of the Older Patient • Goals of treatment may be different – care vs. cure • Greater emphasis on function and quality of life • But – we need to be careful not to withhold treatment; look at each pt individually and analyze the morbidity/mortality of each treatment and effect of withholding – taking into account pt’s values

20. Clinical Approach to the Elderly Patient • History – needs to be tailored to address the problems and concerns prevalent in this group (discuss cognitive and sensory impairments, social history, functional status, detailed review of medications – prescribed as well as OTC • Be aware that there is rarely a chief complaint • Get history from caregivers, family members, spouses – those most likely to notice subtle changes in the patient’s status

21. Clinical Approach to the Elderly Patient • Ask the questions – patients will usually not report falls, incontinence, cognitive dysfunction, sexual dysfunction, depression – unless they are asked • Advanced Directives – discussion of the patient’s values concerning end of life care should begin in the outpatient setting while the patient is well and still able to fully express their wishes

22. Geriatric Assessment A Primary Care Approach

23. A multidimensional evaluation of older persons designed specifically for those individuals who are frail or at increased risk for functional decline Evaluation of physical and mental health as well as the determination of functional status, social and economic status, elucidation of personal values, screening for elder abuse and caregiver burnout What is Geriatric Assessment?

24. Components of the Geriatric Assessment • Functional Assessment • Evaluation of Gait • Evaluation of Cognitive Function • Evaluation of Mood • Social Assessment • Economic Assessment

25. Activities of Daily Living Bathing Feeding Transfers Toileting Dressing Continence Instrumental Activities of Daily Living Shopping Housekeeping Managing Money Food Preparation Use of Transportation Use of Telephone Taking Medications Important Functions to Assess

26. Evaluation of Gait • Main Causes of Gait Impairment • Decreased range of motion • Muscle weakness • Sensory/Balance Deficit • Spasticity • Pain • Impaired Central Processing

27. Evaluation of Gait • Observation of patient in the exam room • Tinetti Balance and Gait Tool • Get Up and Go Test • Rise from a chair - without the use of armrests • Walk 3 meters(10 Feet) • Turn, walk back and sit down • further evaluation indicated if not completed in <14 seconds

28. Evaluation of Cognitive Function • Dementia often goes undetected • Quick Screen • recall of 3 items at 1 minute • serial sevens • clock drawing • Folstein Mini Mental State Exam

29. Folstein Mini Mental State Exam

30. Evaluation of Mood • Depression is very common in older adults • May have great impact on functional status • Often presents differently than in younger patients • May be very amenable to treatment with either medication and/or psychotherapy • Use of the Short Form Yesavage Geriatric Depression Scale is a useful screening tool

31. Yesavage Geriatric Depression Scale • 1. Are you basically satisfied with your life? (no) • 2. Have you dropped many of your activities and interests? (yes) • 3. Do you feel that your life is empty? (yes) • 4. Do you often get bored? (yes) • 5. Are you in good spirits most of the time? (no) • 6. Are you afraid that something bad is going to happen to you? (yes) • 7. Do you feel happy most of the time? (no) • 8. Do you often feel helpless? (yes) • 9. Do you prefer to stay home at night rather than go out and do new things? (yes) • 10. Do you feel you have more problems with memory than most? (yes) • 11. Do you think it is wonderful to be alive now? (no) • 12. Do you feel pretty worthless the way you are now? (yes) • 13. Do you feel full of energy? (no) • 14. Do you feel your situation is hopeless? (yes) • 15. Do you think that most persons are better off than you are? (yes)

32. Social Assessment • Look for signs of caregiver burnout - an important factor in the institutionalization of elders • Be alert for signs of elder abuse/neglect • someone other than the usual caregiver bringing patient to ER • behavioral changes witnessed in the presence of the caregiver - agitation or fearfulness • delay between injury and sought treatment • mechanism of injury inconsistent with findings • missed appointment or evidence of nonadherence with medications, etc.

33. A Typical Clinical Situation Mrs. A. is a n 83 year old woman who is brought to see you by her son and daughter-in-law. This is her 1st visit to you. She has a hx of htn, DM, CHF, mild renal insufficiency, hypothyroidism and osteoarthritis. Mrs. A had been essentially independent at home with some support form family until about 5 weeks prior to this visit. About 1 week ago, Mrs. A. was discharged from another hospital after a 20 day stay for pneumonia and decompensated CHF. She had complications of a UTI as well as development of a sacral pressure sore. She had several episodes of confusion and agitation while in the ICU which were very upsetting to the patient and her family. She was discharged home on the following meds: cipro 500 bid, synthroid 100 mcg qd, captopril 12.5 mg tid, glyburide 5 mg qd, haldol .5 mg bid, ativan .5 mg tid, lasix 20 mg qd

34. A Typical Clinical Situation • Mrs. A’s son is extremely concerned about her condition. Prior to this illness she was independent in all her activities of daily living and she ambulated with a cane. Now, she can barely transfer from a wheelchair to bed, in fact she fell once attempting to get out of bed. She is frequently incontinent of urine and seems disinterested and/or lethargic at times during the day. She is not sleeping well at night and she recently became despondent about her condition. • She was d/c’d home with visiting nurse services as well as with a home health aide (HHA) for 4 hours each day (the patient only has medicare and they were told that this was all the help they could get). The family is trying with difficulty to be with the patient when the HHA is not there as they are afraid to leave her alone. They have spoken to her about moving in with them or possibly to a skilled nursing facility but she is adamant about staying in her own home. • Where do you start? • What are the geriatric issues which need to be addressed in this patient and with what priority? • What is the likely prognosis for Mrs. A? • What do you tell her and what do tell her family?

35. Geriatric Issues to Address with Mrs. A • Functional decline - due to hospitalization - due to comorbid conditions • Iatrogenesis - hospitalization, polypharmacy, delirium, incontinence, infection, pressure sore • falls - safety issue • approp rehab efforts • depression • cognitive deficits • long -term care issues • caregiver burnout