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

The Stealth Geriatrician: How to learn what you need to know from your patients. Tiffany Shubert, Ph.D., MPT Tony Caprio, MD. Course Objectives. Identify four key risk factors for falling in older adults Perform a comprehensive geriatric functional assessment Evaluate the need for referral

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

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

  2. Course Objectives • Identify four key risk factors for falling in older adults • Perform a comprehensive geriatric functional assessment • Evaluate the need for referral • “Build a Team” – Determine disciplines and community resources to aid in patient health management

  3. Why Falls? AAMC Minimum Competency • All adults over 65 years should be asked about falls • All adults should be observed and assessed rising from a chair and walking • All patients who have fallen should have a differential diagnosis and evaluation plan to address the fall and potential risk of falls

  4. Why Falls? • Medicare PQRI Program • Incentive pay for falls screening! • Good Practice • Facilitates successful aging • Opportunity for health promotion • Collaboration with other disciplines • Collaboration with community

  5. Who is going to fall?

  6. How will you identify who will fall?

  7. A comprehensive geriatric assessment uncovers falls risk

  8. What you can find in your comprehensive exam If you take their shoes off!

  9. Introducing Mrs. Jones

  10. 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”

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

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

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

  14. 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

  15. 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

  16. 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

  17. Review of Systems • Systems vs. Syndromes • Organ-based review may give you limited information • Geriatric syndromes encompass multiple organ systems • Falls • Dizziness, Vision, hearing • Cardiovascular • Orthopedic problems, arthritis, neuropathy • Depression, cognitive impairment

  18. 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

  19. Functional Assessment:Timed Up and Go

  20. Functional Assessment: Walking Speed

  21. Functional Assessment:Timed Chair Rise

  22. Functional Assessment:Chair Rise Mrs. Jones

  23. Functional Assessment:Balance

  24. Mrs. JonesWhat Happens at Home

  25. Functional Assessment • What Do You Learn? • How Do You Assess? • Referral

  26. Cognitive Assessment • Clock Draw Test • Mini-Cog

  27. Mrs. Jones Clock

  28. Clock Draw Example

  29. Home Safety Evaluation • Use an environmental assessment sheet • Occupational therapy • Financial difficulties may be culprit

  30. Assessment: Mrs. Jones • What are the problems? • History of falls • 3 of the 4 risk factors for falls • Leg muscle weakness, poor walking, polypharmacy • Orthostatic Hypotension • Osteoporosis

  31. Plan: Mrs. Jones • What will you do about it? • Fix orthostasis • Address osteoporosis • Modify medications • Who will you refer to? • Occupational Therapy - home safety eval • 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

  32. 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

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

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