Geriatric Medicine Grand Rounds

1
Geriatric Medicine Grand Rounds

• Primary Care Track
• January 15, 2003
• Richard Christie, M.D.
• Internal Medicine Residency
• St. Vincent Charity Hospital

2
Overview

• A common geriatric problem - innumerable learning
  opportunities
• Join the process now and later
• Geriatric thinking or approach
• Geriatric primary care an oxymoron?
• First contact
• Comprehensive, Coordinated, Continuous

3
I Hope to Leave You Thinkingabout

• The individual patient - their system
• Their disease -gt
• Their wishes -gt
• Their treatment -gt
• The dangers benefits of intervention -gt

4
The Case

• What concerns you about this case?
• A Fall
• Cause?
• Injury?
• Dx
• Hx
• PE
• Lab/Imaging studies
• Actions
• Other issues

5
Diagnostic Assessment

• Hip fracture
• Dementia
• UTI
• Hypertension
• CAD with remote MI
• Visual impairment
• Presbycusis

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A Fall

• Cause
• Medication
• Disease process (acute or chronic?)
• Injury (functional implications)
• Mild
• Moderate
• Severe

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Recent or Remote History

• Fallen before? Cause? Injury?
• What is her usual self?
• Has she had previous episodes of not being her
  usual self, and, if so, why?
• Quantitate her dementia
• -Folstein another scale?
• -What is her level of function?
• -How much of her limitations are due to the
  dementia?
• Response to Aricept?
• How soon should she have responded?
  
• Is she on the correct dose?
• Could this fall be related to this medication?

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Recent or Remote History

• Hypertension duration, responsive to treatment,
  usual levels, end organ disease, renal function?
• CAD angina, CHF?
• Is Toprol XL for angina or hypertension or both
  is it effective
• Effect of Zocor?
• Do they have any side effects pertinent to the
  present situation (fall, change in mental status)?

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Recent or Remote History

• DJD
• Where, When, How bad?
• Response to therapy
• Why on Darvocet?
• Any adverse consequences of the disease and/or
  the medication?
• Should patient be receiving glucosamine,
  chondroitin, NSAIDs, corticosteroids
• How impaired is her hearing, her sight?

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Additional Physical Examination

• General exam cause of mental status change
  and/or fall any other injuries from fall?
• Cardiac exam CHF, arrhythmia, ischemia?
• Pulmonary exam rales, rhonchi, effusion?

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Lab/Imaging Tests (done now at the nursing home)

• Consider hip x-ray
• Urinalysis/CS
• None

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Actions/Management

• Transfer to ED/hospital Risks/Benefits
• Review of advance directives
• Notification of family/DPA for HC
• Surgical approach
• Pin vs. Replacement

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Management if Admitted

• Operative risk vs risk of symptomatic care in NH
• Helps to decide
• Hx
• PE
• EKG, ECHO
• Blood sugar, BMP vs CMP
• CBC
• CXR

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Other Issues

• Patient is in an intermediate care facility
• How capable is the staff?
• Why is she there?
• What does that tell me about her?

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Other Issues (2)

• Time of call
• Why not called sooner?
• Why called at all?
• What does the nurse want me to do?
• Notifying the director of nursing about the
  failure to call you sooner about the fracture NH
  ombudsman or other official person

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Principles

• Geriatrics a primary care specialty?
• Function vs diagnosis
• The individual -gt the system
• Core Competencies

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Core Competencies

• Patient Care
• Medical Knowledge
• Practice-Based Learning Improvement
• Interpersonal Communication Skills
• Professionalism
• System-Based Practice

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Take Home Messages

• Medications
• Different presentations of illness
• Detailed history is often difficult
• Limited value of lab and imaging
• Whole patient considered
• Aggressive vs comfort medical care

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Take Home Messages (2)

• Systems where your patient exists
• ED/hospital cascade
• Hospitals - dangerous places for older patients.
• Responsibility to the greater community.