Evaluation of The Elder Patient

1. Evaluation of The Elder Patient David V. Espino, M.D. Vice Chair & Director, Div. Of Community Geriatrics Dept. of Family & Community Medicine University of Texas Health Science Cntr-San Antonio

2. Elder Evaluation • Introduction • Evaluation • Review • Summary

3. Aging • Is Not A Disease • Occurs at Different Rates • Among Individuals • Within Individuals • Increases Susceptibility to Specific Conditions

4. Characteristics of Geriatric Medical Conditions • Chronic with Superimposed Acute Illness • Multiple and Coexisting

5. Iatrogenesis • Medication Misuse • Hospitalization • Falls, Delirium, Immobility • Diagnostic/ Therapeutic Procedures

6. Presentation of Geriatric Patient • Typically “Atypical” • Nonspecific • “Cascade Phenomenon”

7. Goals of Geriatric Care • Care vs. Cure • Iatrogenesis • Function • Quality of Life • Prevention • Palliation

8. Geriatric “Money Balls” • Small Changes In Function = Big QOL Gains • Taking Things Away Can Make Things Really Better or Really Worse!

9. Elder Evaluation • Introduction • Evaluation • Orientation • Summary

10. Geriatric H&P Functional Cognitive/Affective Medications Nutritional Bone Integrity/Falls Strength/Sarcopenia Continence Eyes/Ears ETOH/Tobacco/Sex EnviroSocial Capacity Geriatric Evaluation

11. History: {Communication & Rapport} • Impaired Communication? • Eye Contact, Physical Contact • Use Last Name • Speak Directly to Elder • Establish Decision Maker • Address CC • Make Only One Change/Visit

12. Geriatric History • Avoid Open Ended Questions • Focus On Current Medical Problems • Address Families Concerns • Focus On Medications

13. Physical Exam: Blood Pressure • Blood Pressure • 24% of Elders have Orthostasis • Pseudohypertension • Trial of Hypertensives? • 25% Normotensive

14. Physical Exam: Height/Weight/Skin • Serial Heights • Serial Weights Essential • Skin • Senile Lentigines, Skin Tags • Physical Abuse Signs? • Decubs? • Examine at Annual Exam

15. Physical Exam • Areas to Focus On • Cardiovascular • Musculoskeletal • Neurological • Thyroid?

16. Functional Evaluation • Instrumental Activities of Daily Living • (IADL’s) • Activities of Daily Living • (ADL’s) • Executive Functioning • Gait & Balance

17. Gait & Balance • Get Up and Go ! • Tinetti Gait & Balance

18. Cognitive/Affective Status • Folstein’s MiniMental State Exam • (MMSE) • Clock Drawing • Geriatric Depression Scale • (GDS)

19. Mini Mental State Exam[ General Information ] • Developed by Marshall Folstein in 1975 • Estimate Severity of Cognitive Impairment • NOT Designed To Make Specific Diagnoses

20. MMSE[Cognitive Domains] • Orientation/Time 5 points • Orientation/Place 5 points • Registration 3 points • Attention/Calculation 5 points • Recall of Three Words 3 points • Language 8 points • Visual Construction 1 point

21. MMSE[Scoring / Cutoffs] • Total Number of Correct Answers • 24-30 Correct No Cognitive Imp. • 18-23 Correct Mild Cognitive Imp. • 0-17 Correct Severe Cog. Imp.

22. MMSE[Influences] • Educational Level • Race / Ethnicity • Socioeconomic Status?

23. Clock Drawing Test • Different Versions • 4 Point Scale Most Useful • 1 Point- Circle • 1 Point-Numbers • 1 Point-Hands/Arrows • 1 Point-Right Time

24. Geriatric Depression Scale[ General Information ] • Total Number of Questions • Long Version = 30 • Short Version = 15 • Administered in about 5 Minutes • Count the Missed Questions

25. Geriatric Depression Scale[ Error Cut-Offs ] • Long Version • < 11 Not Depressed • 11-14 Possible Depression • ≥14 Depression • Short Version • <11 Not Depressed • ≥11 Probable Depression

26. Geriatric Depression Scale[ Clinical Utility ] • Use As Screener Only • Utilize Suggested Cut-Offs • Recognized Ethnicity or Language Influence GDS Interpretation

27. Medications • Only Use When Life, Function or Comfort Threatened • Medications Must Be Reviewed On Each Visit

28. Medication Review • Prescription • Shared • OTC • OTB • Alternative

29. Nutritional Status • Often Overlooked • Oral Screening • Poor Dentures? • “Weigh All Of The Elders, All Of The Time” • BMI

30. Bone Integrity • Risk Factors • DEXA • Falls Risk

31. Strength/Sarcopenia • Strength Decreased • Immobility Issues

32. Continence • Major Cause of Morbidity • Urinary & Fecal Incontinence

33. Eyes/Ears • Eyeglasses • Screen With Snellen Chart • Hearing Aids • Ask About Hearing • Alternative Aids • $55 Radio Shack

34. ETOH/Tobacco/Sex • Alcohol and Smoking Common • CAGE? • Smoking Cessation • Sex Also Common • Major QOL

35. Enviro-Social Status • Does The Elder Live Alone? • Who Functionally Assists? • Home Assessment, If Necessary

36. Enviro-Social Status • Social Activity, Relationships and Resources • Caregiver Burden • Quality Of Life Issues • Advance Directives • Capacity

37. Determining Capacity • Describe Illness and Course • Explain Proposed Treatment • Understand Treatment Consequences • Understand Risks and Benefits

38. Develop Plan • Set Goals • Realistic, Measurable, Achievable • Discuss With Family, If Appropriate • Develop Stepwise Approach

39. Approach To Evaluation • Visit 1 • Address CC, Initial Hx • Visit 2 • PX and Labs • Visit 3 • Cognitive/Functional Eval • Visit 4 • Social, QOL, and Plan

40. Elder Evaluation • Introduction • Evaluation • Orientation • Summary

41. Geriatrics Clinic • South Module-FHC • Both Frail Elder & CDC • Be Prompt • 8:AM • 1:PM • Unexcused Absences

42. Process • White Board • Put Initials • See Patient • Present Patient • Fill Out Orders • Finish Note

43. Other Required Activities • Keep Problem List Current • Keep Meds List Current • Fill Out Prescriptions • Check Out before you leave

44. Final Points • Learning and Knowledge Content Are Different Things • Just Because You Complete A Task Does Not Imply That You Completed It Well

45. SUMMARY • Chronic Problems With Acute Events Interspersed • Communication Essential • Expect the Unexpected • Iatrogenesis Rules!