The Stealth Geriatrician: How to learn what you need to know from your patients

1. The Stealth Geriatrician:How to learn what you need to know from your patients Tiffany Shubert, Ph.D., MPT Zeke Zamora, MD Anthony Caprio, MD

2. Course Objectives • Define “geriatric syndrome” • Identify key risk factors for falling • Perform a comprehensive geriatric functional assessment • Identify appropriate interventions • “Build a Team” – Determine disciplines, community resources, and evidence-based programs to manage patient health

3. Why falls? > 35% of your patients fall annually AAMC Minimum Competency • All adults over 65 years should be asked a falls history • All adults should be observed and assessed rising from a chair and walking • All patients who have fallen or at risk of falling should have a differential diagnosis and evaluation plan

4. Standard of Care AGS/BMJ Practice Guidelines http://www.medcats.com/FALLS/frameset.htm All older adults screened for falls by health care provider Key questions Two or more falls in prior 12 months Presents with acute fall Difficulty with walking or balance If yes to any question, then comprehensive falls assessment 4

5. Who is going to fall?

6. How do you identify fallers?

7. History of falls Medications Gait, balance, mobility Visual acuity Other neurological impairments Muscle strength Heart rate/rhythm Postural hypotension Feet and footware Environmental hazards Comprehensive Falls Risk = Comprehensive Geriatric Assessment http://www.medcats.com/FALLS/frameset.htm

8. Comprehensive geriatric assessment = falls risk

9. A comprehensive exam: A standard review of systems = limited information Functional assessment and a comprehensive exam will identify multiple factors contributing to falls

10. Geriatric Syndromes • Multiple underlying factors (interacting causes) affecting multiple systems • Delirium, Incontinence, Frailty, Falls • Shared risk factors such as older age, cognitive impairment, functional impairment • Falls as a geriatric syndrome • Dizziness, auditory, hearing • Cardiovascular • Orthopedic, arthritis, neuropathy • Depression, cognitive impairment

11. Introducing Mrs. Jones

12. Chief Complaint • It depends on who you ask: • Patient: “No complaints, I feel fine” • Daughter: “Difficulty getting around the house, I am afraid she may fall” • MD: “Blood pressure should be better controlled”

13. History of Present Illness • What do you want to know? • Previous Falls • Changes in medications • Trips to the opthamologist • Trips to the ER • Changes in mood/activity levels

14. Past Medical History • Hypertension • Paroxysmal Atrial Fibrillation • Chronic Renal Insufficiency • Anxiety/Depression • “Dizziness” • Osteoporosis

15. Metoprolol Hydrochlorothiazide Digoxin Warfarin Sertraline Diazepam Zolpidem Meclizine Fosinopril Alendronate Medication List

16. Medication Review • > 4 Drugs = Increased risk of falls • Red Flags – Classes that increase falls risk • Benzodiazepines (short and long-acting agents) • Antidepressants (tricyclics and SSRIs) • Antipsychotics • Anticonvulsants • Opioids • Antispasmodics • Over the counter medications

17. Social History • What do you want to know? • Living Situation • Type of house? Stairs? ADLs, IADLs • Social Supports • Economic Status • Smoke/Drink • Current Activity Level • Fear of Falling

18. ADLs Transferring Toileting Bathing Dressing Continence Feeding IADLS Transportation Use the phone Buy groceries Meal preparation Housework Medication Pay bills Activities of Daily Living:Ask or Observe

19. Physical Exam Findings • General Impression • Vital Signs • BP sitting 140/90, HR 88 • BP standing 110/80, HR 100 • Pain • HEENT • Bilateral cataracts, difficulty reading magazine and wall poster • CV • Grade II/VI systolic murmur (right upper sternal border) • MS • Neuro

20. Functional Assessment:Timed Up and Go

21. Functional Assessment: Walking Speed

22. Functional Assessment:Timed Chair Rise

23. Functional Assessment:Chair Rise Mrs. Jones

24. Functional Assessment:Balance

25. Mrs. JonesWhat Happens at Home

26. Cognitive Screening Cognitive Impairment • Cognitive assessment should be performed in all adults > 65 years • 23.4% community dwelling elderly have some level of cognitive impairment • Mild – moderate cognitive impairment increases risk of falls and hip fracture *Neurology 2001 Nov 13; 57(9): 1655-62

27. Screening Tools: MMSE • Screens for Alzheimer’s Disease • Orientation • Registration • Attention/Calculation • Recall • Language • Copy Pentagons • Limitations • Age, education, cultural, socioeconomic, English proficiency affects scores • Length to administer

28. Screening Tools: Mini-Cog General screen for cognitive impairment • Dictate three items, ask to repeat • Clock Drawing Test • Ask to recall the three items

29. Screening Tools: Mini-Cog • Score 1 point for each recalled word • Score normal/abnormal clock draw • Score of 0 positive screen for dementia • Score of 1 or 2 with abnormal clock draw positive screen for dementia • Score of 1 or 2 with normal clock negative for screen for dementia • Score of 3 negative screen for dementia

30. Mrs. Jones Clock

31. Clock Draw Example

32. Home Safety Evaluation • Use an environmental assessment sheet • Must utilize occupational therapy, social work, etc to have an effect • Financial difficulties may be culprit

33. History of falls Medications Gait, balance, mobility Visual acuity Other neurological impairments Muscle strength Heart rate/rhythm Postural hypotension Feet and footware Environmental hazards Comprehensive Geriatric Assessment:Ms. Jones http://www.medcats.com/FALLS/frameset.htm

34. Assessment: Mrs. Jones • What are the risk factors? • History of falls • Leg muscle weakness • Polypharmacy • Orthostatic Hypotension • Osteoporosis • ? Cognition

35. Plan: Mrs. Jones • What will you do about it? • Fix orthostasis • Address osteoporosis • Modify medications • Interventions? • Occupational Therapy - home safety evaluation • Physical Therapy - leg strengthening, gait training, and assessment for assistive device • Consult with pharmacy about current medication list and insurance coverage • Community Services for behavior change programs, wellness and socialization activities

36. Community Resources • North Carolina Roadmap for Healthy Aging • www.ncroadmap.org • Locates evidence-based programs in your area • NC Division of Aging and Adult Services • http://www.ncdhhs.gov/aging/ • For every county: health promotion, long term care, in-home care, caregiver resources, meals on wheels, etc

37. Synthesis • Evaluating major risk factors for falls is fundamental to a geriatric assessment • A functional assessment will identify individuals at risk for falls • A functional assessment can (and should) be done with your older patients • Refer to other disciplines to best manage complex older adults

38. Key Physical Findings in Older Adults I HATE FALLING I Inflammation of joints or joint deformity H Hypotension (orthostatic) A Auditory/visual problems T Tremor (Parkinson’s disease) E Equilibrium (balance problems) F Foot problems A Arrhythmia, heart block L Leg length discrepancy L Lack of conditioning

39. Practice Practice Practice • Practice with volunteers • Physical, Cognitive, and Medication Assessment • On the wards • Perform at least one mini-Cog • Shadow a physical therapist and perform 1-2 functional assessments • Identify which of your patients are at risk for falls