INTRODUCTION TO HEALTHCARE AN APPROACH TO GERIATRICS

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INTRODUCTION TO HEALTHCAREAN APPROACH TO
GERIATRICS

• SHYRL SISTRUNK, MD
• ASSOCIATE PROFESSOR OF MEDICINE
• GEORGETOWN UNIVERSITY
• SCHOOL OF MEDICINE
• January 30,2009

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OBJECTIVES

• Know and understand the Profile of the Aging
  American
• How to assess the functional ability of the older
  adult
• Why a focus on function is important
• How to perform a comprehensive geriatric
  assessment
• Strategies to enhance communication with older
  patients

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Demographics

• The Older Population
• Racial and Ethnic Composition
• Living Arrangements
• Income/Poverty
• Health and Chronic Conditions

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Older Population

• 37.3 million in 2006
• 12.4 of the population
• 21.6 million women and 15.7 million men

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Life Expectancy

• For a 65 year old person the average life
  expectancy of additional years is 18.7 years
• 20 years for women
• 17.1 years for men

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Minority Populations

• 19 in 2006
• 8.3 Black
• 3.1 Asian/Pacific Islander
• 1 American Indian/Native Alaskan
• 6.4 Hispanic origin(may be of any race)
• Projected for 2020 .23.6 of the elderly.

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Income

• Family Households headed by 6539,649 (median)
• Individual median incomes in 2006
• 23,500 for males
• 13,603 for females
• SOURCES OF INCOME????

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Income-2

• Social security
• Income from assets
• Private Pensions
• Government employee pensions
• Earnings (reported by 24)

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Are there any poor old people?

• 3.4 million(9.4) elderly persons were below the
  poverty line in 2006.
• 2.2 million (6.2) were near poor
• 23.7 Blacks
• 19.5 Hispanics
• 14.3 Asians
• 8.8 Whites

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LIVING ARRANGEMENTS

• 30 (10.7 million) noninstitutionalized elderly
  lived alone
• 4.4 (1.62 million) lived in nursing homes in
  2006.
• 1.3 young old
• 4.4 old
• 15.4 oldest old

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HEALTH AND CHRONIC CONDITIONS

• 6. Sinusitis 14
• 5. Diabetes 16
• 4. Any cancer 20
• 3. All types of heart disease 29
• 2. Diagnosed arthritis 47
• 1. HYPERTENSION 48

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TOPICS COVERED

• Principles of geriatric assessment
• Communication strategies
• Physical assessment
• Cognitive assessment
• Psychologic assessment
• Social assessment

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PRINCIPLES OF GERIATRIC ASSESSMENT
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MEDICAL
COGNITIVE
AFFECTIVE
FUNCTIONAL STATUS
ENVIRONMENTAL
SOCIAL SUPPORT
SPIRITUALITY
ECONOMIC
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GOAL OF COMPREHENSIVE GERIATRIC ASSESSMENT

• To determine a patients
• medical status
• functional capabilities
• psychosocial status
• in order to develop an overall plan for treatment
  and long-term follow-up

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GOAL OF COMPREHENSIVE GERIATRIC ASSESSMENT

• IS THE DONT KILL GRANNY CURRICULUM

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PHYSICAL ASSESSMENT

• Complete physical assessment includes
• Functional status
• Nutrition
• Vision
• Hearing

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TOOLS TO ASSESS FUNCTIONAL STATUS

• Activities of Daily Living (ADLs)
• Bathing, dressing, transferring, toileting,
  grooming, feeding, mobility
• Instrumental Activities of Daily Living (IADLs)
• Using telephone, preparing meals, managing
  finances, taking medications, doing laundry,
  doing housework, shopping, managing own
  transportation
• Get Up and Go test
• Qualitative, timed, assesses gait, balance, and
  transfers

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ASSESS NUTRITIONAL STATUS

• Screen for malnutrition
• Visual inspection
• Measure height, weight, body mass index (BMI)
• BMI weight (kg) / height (m2)
• low BMI
• Unintentional weight loss 10 lbs
• Poor nutrition may reflect medical illness,
• depression, functional losses, financial
  hardship

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DETERMINE Your Nutritional Health

• DISEASE
• EATING POORLY
• TOOTH LOSS/MOUTH PAIN
• ECONOMIC HARDSHIP
• REDUCED SOCIAL CONTACT
• MULTIPLE MEDICATIONS
• INVOLUNTARY WEIGHT LOSS
• NEEDS ASSISTANCE IN SELF CARE
• ELDERS ABOVE AGE 80

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VISION

• Cataracts, glaucoma, macular degeneration, and
  abnormalities of accommodation worsen with age
• Assess difficulties by asking about everyday
  tasks
• driving watching TV reading
• Use performance-based screening
• ask to read from newspaper, magazine
• use Snellen chart or Jaeger card

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HEARING

• Hearing loss is common among older adults
• Impaired hearing ? depression, social withdrawal
• Assess first for cerumen impaction
• Use hand-held audioscope to test for abnormality
• loss of 40 dB tone at 1000 or 2000 Hz in one or
  both ears is abnormal
• refer for formal audiometry testing

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WHY SCREEN FOR COGNITIVE LOSS?

• Prevalence of Alzheimers disease
• 10 of those aged 65
• nearly 50 of those aged 85
• Most people with dementia do not complain of
  memory loss
• Cognitively impaired older persons are at ? risk
  for accidents, delirium, medical nonadherence,
  and disability

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COGNITIVE ASSESSMENT PERFORMANCE MEASURES

• Recall 3 items
• Folsteins Mini-Mental State Examination (MMSE)
• widely used
• tests orientation, registration, recall,
  attention, calculation, language, visuospatial
  skills
• Tests of executive control
• clock-drawing test
• listing 4-legged animals test

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ASSESS PSYCHOLOGICAL STATUS

• Although prevalence of major depression among
  older adults is low (1-2), subclinical
  depression is common
• Ask Do you often feel sad or depressed?
• If Yes, do further evaluation, e.g., Geriatric
  Depression Scale
• Watch for signs of anxiety, bereavement

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SOCIAL ASSESSMENT SHOULD INCLUDE

• Caregiver burden
• Economic well-being
• Elder mistreatment (If concerned, consider
  referral to visiting nurse to assess home safety,
  level of personal risk)
• Advance directives
• Support system

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CLINICAL APPROACH TO THE OLDER PATIENT

• FUNCTIONAL ACTIVITIES ARE OFTEN THE
• PRIMARY OUTCOMES TARGET IN THE TREATMENT OF THE
  OLDER PATIENT

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• CONVENTIONAL DISEASE SPECIFIC APPROACH MAY NOT BE
  OPTIMAL IN OLDER ADULTS

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• MANY DISTRESSING SYMPTOMS OR IMPAIRMENTS AMONG
  OLDER PERSONS CANNOT BE ASCRIBED TO A SINGLE
  DISEASEBUT THE ACCUMULATED EFFECT

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• PRIORITIZE BETWEEN COMPETING GOALS OF INCREASED
  SURVIVAL, COMFORT, COGNITIVE AND PHYSICAL FUNCTION

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SUMMARY

• The focus of geriatric assessment is on function
• Successful assessment promotes wellness and
  independence
• Strategies that enhance communication with older
  patients should be used
• Comprehensive assessment includes physical,
  cognitive, psychologic, and social aspects of
  health

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GERIATRIC REVIEW OF SYSTEMS

• 11. Depression
• 10. Nutrition
• 9. Incontinence
• 8. Vision
• 7.Hearing
• 6. Advanced Directives
• 5. Social Support
• 4. Activities of Daily Living
• 3. Mobility
• 2. Mentation
• 1. Medication

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DR. SEUSS IS IN.
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• THE CAT IN THE HAT ON AGING
• I CANNOT SEE
• I CANNOT PEE
• I CANNOT CHEW
• I CANNOT SCREW
• OH, MY GOD, WHAT CAN I DO?
• MY MEMORY SHRINKS
• MY HEARING STINKS
• NO SENSE OF SMELL
• I LOOK LIKE HELL
• cont

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• MY MOOD IS BADCAN YOU TELL?
• MY BODYS DROOPING
• HAVE TROUBLE POOPING
• THE GOLDEN YEARS HAVE COME AT LAST
• THE GOLDEN YEARS CAN KISS MY ASS

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