Evaluation of The Elder Patient

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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

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Elder Evaluation

• Introduction
• Evaluation
• Review
• Summary

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Aging

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

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Characteristics of Geriatric Medical Conditions

• Chronic with Superimposed Acute Illness
• Multiple and Coexisting

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Iatrogenesis

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

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Presentation of Geriatric Patient

• Typically Atypical
• Nonspecific
• Cascade Phenomenon

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Goals of Geriatric Care

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

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Geriatric Money Balls

• Small Changes In Function Big QOL Gains
• Taking Things Away Can Make Things Really Better
  or Really Worse!

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Elder Evaluation

• Introduction
• Evaluation
• Orientation
• Summary

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Geriatric Evaluation

• Geriatric HP
• Functional
• Cognitive/Affective
• Medications
• Nutritional
• Bone Integrity/Falls
• Strength/Sarcopenia

• Continence
• Eyes/Ears
• ETOH/Tobacco/Sex
• EnviroSocial
• Capacity

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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

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Geriatric History

• Avoid Open Ended Questions
• Focus On Current Medical Problems
• Address Families Concerns
• Focus On Medications

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Physical Exam Blood Pressure

• Blood Pressure
• 24 of Elders have Orthostasis
• Pseudohypertension
• Trial of Hypertensives?
• 25 Normotensive

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Physical Exam Height/Weight/Skin

• Serial Heights
• Serial Weights Essential
• Skin
• Senile Lentigines, Skin Tags
• Physical Abuse Signs?
• Decubs?
• Examine at Annual Exam

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Physical Exam

• Areas to Focus On
• Cardiovascular
• Musculoskeletal
• Neurological
• Thyroid?

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Functional Evaluation

• Instrumental Activities of Daily Living
• (IADLs)
• Activities of Daily Living
• (ADLs)
• Executive Functioning
• Gait Balance

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Gait Balance

• Get Up and Go !
• Tinetti Gait Balance

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Cognitive/Affective Status

• Folsteins MiniMental State Exam
• (MMSE)
• Clock Drawing
• Geriatric Depression Scale
• (GDS)

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Mini Mental State Exam General Information

• Developed by Marshall Folstein in 1975
• Estimate Severity of Cognitive Impairment
• NOT Designed To Make Specific Diagnoses

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MMSECognitive 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

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MMSEScoring / Cutoffs

• Total Number of Correct Answers
• 24-30 Correct No Cognitive Imp.
• 18-23 Correct Mild Cognitive Imp.
• 0-17 Correct Severe Cog. Imp.

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MMSEInfluences

• Educational Level
• Race / Ethnicity
• Socioeconomic Status?

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Clock Drawing Test

• Different Versions
• 4 Point Scale Most Useful
• 1 Point- Circle
• 1 Point-Numbers
• 1 Point-Hands/Arrows
• 1 Point-Right Time

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Geriatric Depression Scale General Information

• Total Number of Questions
• Long Version 30
• Short Version 15
• Administered in about 5 Minutes
• Count the Missed Questions

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Geriatric Depression Scale Error Cut-Offs

• Long Version
• lt 11 Not Depressed
• 11-14 Possible Depression
• 14 Depression
• Short Version
• lt11 Not Depressed
• 11 Probable Depression

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Geriatric Depression Scale Clinical Utility

• Use As Screener Only
• Utilize Suggested Cut-Offs
• Recognized Ethnicity or Language Influence GDS
  Interpretation

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Medications

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

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Medication Review

• Prescription
• Shared
• OTC
• OTB
• Alternative

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Nutritional Status

• Often Overlooked
• Oral Screening
• Poor Dentures?
• Weigh All Of The Elders, All Of The Time
• BMI

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Bone Integrity

• Risk Factors
• DEXA
• Falls Risk

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Strength/Sarcopenia

• Strength Decreased
• Immobility Issues

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Continence

• Major Cause of Morbidity
• Urinary Fecal Incontinence

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Eyes/Ears

• Eyeglasses
• Screen With Snellen Chart
• Hearing Aids
• Ask About Hearing
• Alternative Aids
• 55 Radio Shack

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ETOH/Tobacco/Sex

• Alcohol and Smoking Common
• CAGE?
• Smoking Cessation
• Sex Also Common
• Major QOL

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Enviro-Social Status

• Does The Elder Live Alone?
• Who Functionally Assists?
• Home Assessment, If Necessary

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Enviro-Social Status

• Social Activity, Relationships and Resources
• Caregiver Burden
• Quality Of Life Issues
• Advance Directives
• Capacity

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Determining Capacity

• Describe Illness and Course
• Explain Proposed Treatment
• Understand Treatment Consequences
• Understand Risks and Benefits

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Develop Plan

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

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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

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Elder Evaluation

• Introduction
• Evaluation
• Orientation
• Summary

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Geriatrics Clinic

• South Module-FHC
• Both Frail Elder CDC
• Be Prompt
• 8AM
• 1PM
• Unexcused Absences

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Process

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

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Other Required Activities

• Keep Problem List Current
• Keep Meds List Current
• Fill Out Prescriptions
• Check Out before you leave

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Final Points

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

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SUMMARY

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