Approach%20to%20the%20Geriatric%20Patient

1
Approach to the Geriatric Patient

• Geriatric Assessment in a Primary Care Setting
• Hazards of Hospitalization

2
Learning Objectives

• To understand some basic principles of geriatrics
  including demographics of our population
• To heighten awareness about what is unique about
  the older patient and how these factors should
  impact on the approach to care
• To have a working knowledge of the value and
  essential components of a geriatric functional
  assessment

3
Demographics of the US Graying of America

• By 2030 25 of population will be over 65 years
  old
• Squaring of the pyramid many more older persons
  living longer
• Great impact on socioeconomics, health care, and
  long-term care issues

4
Who are these older patients?

• Largest growing segment is the over 85 group
• 69 men per 100 women
• Most are living in the community
• Overall percentage of older adults living in
  skilled nursing facilities only 5
• 1 - 65-74
• 6 - 75-84
• 22 - 85 and older
• So still 75 of those gt85 are living in the
  community

5
Health Care Utilization

• 12.5 of current population yet older persons
  account for up to 40 of health care expenditures
• 80 of costs incurred by approximately 20 of
  older age group
• A large percentage of this cost is incurred in
  the very last days of life

6
What is different about these older patients?

• Heterogeneity of population
• Physiologic changes
• Increased prevalence of disease changes in
  patterns of illness
• Under-reporting of symptoms
• Atypical presentation of illness
• Symptoms in one organ system often reflects
  abnormalities in another

7
How are elderly patients different?

• Increased reliance on social supports
• Increased role of adverse effects to meds and
  therapies
• Up to 40 in older adults
• Predisposing factors advanced age, hepatic or
  renal insufficiency, small body size, polypharmacy

8
Cascade To Dependency
9
Hazards of HospitalizationHigh Risk
EnvironmentHigh Risk Situation

• Falls
• Delirium
• Functional Decline

• Pressure Ulcers
• Adverse Drug Effects
• Transition Failure

10
Delirium acute onset of disturbance in
consciousness in which cognition or perception is
altered
11
Assessing Risk of Delirium Medical Inpatient
Prediction Rule

• Cognitive Impairment
• Severe Illness
• High BUN/Cr
• Vision Impairment

• Low Risk (0) 10 risk
• Int Risk (1-2) 25 risk
• High Risk (3-4) 80 risk

12
Assessing Delirium Risk -

• Mini-Cog
• 3 item recall (up to 3 points)
• Clock Draw (10 minutes after 11 )
• all or nothing 0 or 2 points
• On admission
• scores of 0,1or 2 carries a 4-5X risk for
  delirium
• True whether the pt has dementia or not

13
How Common?

• Affects 20 of hospitalized elderly gt65
• Up to 70-80 of older patients in ICU settings
• Up to 83 of older patients at end of life
• Affects about 40 of postoperative patients
• Cataract 1-3
• General surgery 10-15
• Orthopedic Surgery 30-60

14
So what why does it matter?

• Increased length of stay by 8 days
• Increased Mortality
• Double the mortality in pts with delirium
• Functional Decline/NH placement
• Prolonged Cognitive Defects pts may never get
  back to their pre-delirium state
• Newer research 1/3 of pts d/c to SNF delirious
  will still be delirious 6 months later

15
Mechanism of Delirium

• Imbalance of neurotransmitters
• Acetylcholine
• Dopamine
• Hypothalamic pituitary adrenal axis
• Inflammation
• Cytokines (TNF, Interleukins)
• Occult diffuse brain injury
• Especially following sepsis

16
Delirium Prevention

• Modifiable Risk Factors
• Cognitive Impairment
• Immobility
• Visual Impairment
• Hearing Impairment
• Dehydration
• Sleep Deprivation

• Prospective Interventions
• Orienting communication
• Early mobilization, reduce restraints
• Visual Aides adaptive equipment
• Amplifiers adaptive equipment
• Prevent and correct dehydration
• Uninterrupted sleep, nonpharmacologic aides

40 relative risk reduction Inouye SK et al. A
multicomponent Intervention to Prevent Delirium
in Hospitalized Geriatric Patients. NEJM
1999340669-676 Vidan MT et al. An Intervention
Integrated into Daily Clinical Practice Reduces
Incidence of Delirium During Hospitalization in
Elderly Patients.
17
The Hospital is a dangerous place

• Sensory deprivation used as mechanism of
  torture
• Sleep deprivation many consequences
• In healthy volunteers irritability and impaired
  attention
• Noise, vital sign checks, lights, pain, illness,
  skin care, phlebotomy, medication administration
  at all hours .SLEEP???

18
Elderly Patients Spend the Majority of their
Hospital Time Immobile

• Translation ad-lib means 97 of time
  immobile one study found median amount of time
  standing or walking 43 minutes out of a several
  day hospitalization
• Implications
• Schedule mobility
• Culture of Unit activity
• Universal Awareness that deconditioning has
  consequences

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Other Important Characteristics of the Older
Patient

• Goals of treatment may be different care vs.
  cure
• Greater emphasis on function and quality of life
• But we need to be careful not to withhold
  treatment look at each pt individually and
  analyze the morbidity/mortality of each treatment
  and effect of withholding taking into account
  pts values

20
Clinical Approach to the Elderly Patient

• History needs to be tailored to address the
  problems and concerns prevalent in this group
  (discuss cognitive and sensory impairments,
  social history, functional status, detailed
  review of medications prescribed as well as OTC
• Be aware that there is rarely a chief complaint
• Get history from caregivers, family members,
  spouses those most likely to notice subtle
  changes in the patients status

21
Clinical Approach to the Elderly Patient

• Ask the questions patients will usually not
  report falls, incontinence, cognitive
  dysfunction, sexual dysfunction, depression
  unless they are asked
• Advanced Directives discussion of the patients
  values concerning end of life care should begin
  in the outpatient setting while the patient is
  well and still able to fully express their wishes

22
Geriatric Assessment

• A Primary Care Approach

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What is Geriatric Assessment?

• A multidimensional evaluation of older persons
  designed specifically for those individuals who
  are frail or at increased risk for functional
  decline

• Evaluation of physical and mental health as well
  as the determination of functional status, social
  and economic status, elucidation of personal
  values, screening for elder abuse and caregiver
  burnout

24
Components of the Geriatric Assessment

• Functional Assessment
• Evaluation of Gait
• Evaluation of Cognitive Function
• Evaluation of Mood
• Social Assessment
• Economic Assessment

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Important Functions to Assess

• Activities of Daily Living
• Bathing
• Feeding
• Transfers
• Toileting
• Dressing
• Continence

• Instrumental Activities of Daily Living
• Shopping
• Housekeeping
• Managing Money
• Food Preparation
• Use of Transportation
• Use of Telephone
• Taking Medications

26
Evaluation of Gait

• Main Causes of Gait Impairment
• Decreased range of motion
• Muscle weakness
• Sensory/Balance Deficit
• Spasticity
• Pain
• Impaired Central Processing

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Evaluation of Gait

• Observation of patient in the exam room
• Tinetti Balance and Gait Tool
• Get Up and Go Test
• Rise from a chair - without the use of armrests
• Walk 3 meters(10 Feet)
• Turn, walk back and sit down
• further evaluation indicated if not completed in
  lt14 seconds

28
Evaluation of Cognitive Function

• Dementia often goes undetected
• Quick Screen
• recall of 3 items at 1 minute
• serial sevens
• clock drawing
• Folstein Mini Mental State Exam

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Folstein Mini Mental State Exam
30
Evaluation of Mood

• Depression is very common in older adults
• May have great impact on functional status
• Often presents differently than in younger
  patients
• May be very amenable to treatment with either
  medication and/or psychotherapy
• Use of the Short Form Yesavage Geriatric
  Depression Scale is a useful screening tool

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Yesavage Geriatric Depression Scale

• 1. Are you basically satisfied with your life?
  (no)
• 2. Have you dropped many of your activities and
  interests? (yes)
• 3. Do you feel that your life is empty? (yes)
• 4. Do you often get bored? (yes)
• 5. Are you in good spirits most of the time?
  (no)
• 6. Are you afraid that something bad is going
  to happen to you? (yes)
• 7. Do you feel happy most of the time? (no)
• 8. Do you often feel helpless? (yes)
• 9. Do you prefer to stay home at night rather
  than go out and do new things? (yes)
• 10. Do you feel you have more problems with
  memory than most? (yes)
• 11. Do you think it is wonderful to be alive now?
  (no)
• 12. Do you feel pretty worthless the way you are
  now? (yes)
• 13. Do you feel full of energy? (no)
• 14. Do you feel your situation is hopeless? (yes)
• 15. Do you think that most persons are better off
  than you are? (yes)

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Social Assessment

• Look for signs of caregiver burnout - an
  important factor in the institutionalization of
  elders
• Be alert for signs of elder abuse/neglect
• someone other than the usual caregiver bringing
  patient to ER
• behavioral changes witnessed in the presence of
  the caregiver - agitation or fearfulness
• delay between injury and sought treatment
• mechanism of injury inconsistent with findings
• missed appointment or evidence of nonadherence
  with medications, etc.

33
A Typical Clinical Situation

• Mrs. A. is a n 83 year old woman who is brought
  to see you by her son and daughter-in-law. This
  is her 1st visit to you. She has a hx of htn,
  DM, CHF, mild renal insufficiency, hypothyroidism
  and osteoarthritis.
• Mrs. A had been essentially independent at home
  with some support form family until about 5 weeks
  prior to this visit. About 1 week ago, Mrs. A.
  was discharged from another hospital after a 20
  day stay for pneumonia and decompensated CHF.
  She had complications of a UTI as well as
  development of a sacral pressure sore. She had
  several episodes of confusion and agitation while
  in the ICU which were very upsetting to the
  patient and her family. She was discharged home
  on the following meds
• cipro 500 bid, synthroid 100 mcg qd, captopril
  12.5 mg tid,
• glyburide 5 mg qd, haldol .5 mg bid, ativan .5 mg
  tid, lasix 20 mg qd

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A Typical Clinical Situation

• Mrs. As son is extremely concerned about her
  condition. Prior to this illness she was
  independent in all her activities of daily living
  and she ambulated with a cane. Now, she can
  barely transfer from a wheelchair to bed, in fact
  she fell once attempting to get out of bed. She
  is frequently incontinent of urine and seems
  disinterested and/or lethargic at times during
  the day. She is not sleeping well at night and
  she recently became despondent about her
  condition.
• She was d/cd home with visiting nurse services
  as well as with a home health aide (HHA) for 4
  hours each day (the patient only has medicare and
  they were told that this was all the help they
  could get). The family is trying with difficulty
  to be with the patient when the HHA is not there
  as they are afraid to leave her alone. They have
  spoken to her about moving in with them or
  possibly to a skilled nursing facility but she is
  adamant about staying in her own home.
• Where do you start?
• What are the geriatric issues which need to be
  addressed in this patient and with what priority?
• What is the likely prognosis for Mrs. A?
• What do you tell her and what do tell her family?

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Geriatric Issues to Address with Mrs. A

• Functional decline - due to hospitalization - due
  to comorbid conditions
• Iatrogenesis - hospitalization, polypharmacy,
  delirium, incontinence, infection, pressure sore
• falls - safety issue
• approp rehab efforts
• depression
• cognitive deficits
• long -term care issues
• caregiver burnout