Transcript Geriatric assesment

Geriatric assessment
Prof Mollentze / Dr . D. Greyling
Questionnaire
• 1. Continue this sequence in a logical way:
• M T W T
• 2.Correct this formula with a single stroke:
• 5 + 5 + 5 = 550
Questionnaire
• 3. Please write anything here:
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• 4. Draw a rectangle with 3 lines:
General
• Definition of aging: a Progressive , universal
decline first in functional reserve and then in
function over time.
• Old age is not a disease, but the risk of
developing disease is increased.
Presentation of disease in older people
• Factors that influence recognition of disease
in older people:
• 1. Acceptance of ill health and seeking medical
advice.
• 2. Atypical presentation of disease processes
Background
• Between 2000 and 2030 , the number of
older adults is expected to increase from 420
to 974 million people.
• 59 % of older adults are living in the
developing countries of Africa, Asia, Latin
America and the developing world have the
largest increase in older adults because of the
AIDS epidemic and because of better health
services and lifestyle.
Geriatric giants
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Immobility , instability and /or falls
Intellectual impairment
Sleep disorders
Confusion
Impaired senses – hearing , vision, proprioseption
Incontinence
Heart disease
Syncope/ Dizziness
Stroke
Malignancies
Definition of frailty
• Frailty is a clinical syndrome : 3/> of the
following:
• 1.- Unintentional weight loss of > 4,5 kg in the
past year
• 2.-Feeling exhausted
• 3.-Weakness( poor grip strength)
• 4.-Slow walking speed
• 5.-Low physical activity
Frailty
• Associated with a high risk of falls , disability
and death.
• Frailty is part of a single or multiple clinical
syndromes
Approach to the geriatric patient
• Functional status is the best indicator of
prognosis and longevity.
• Functional status: defined as the ability of a
person to provide in his/her own daily needs.
The comprehensive geriatric
assessment
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Focus on the evaluation of:
1. Physical health
2. Mental health
3. Functional status
4. Social functioning
5. Environment
• A multidisciplinary team approach – Social
worker , Dedicated nursing staff, Occupational
and physiotherapist , Podiatrist , Biokinetician
Activities of Daily
Living
Medication
Advance directives
Hearing
Domain Approach
Vision
Mobility
Incontinence
Mentation
Social Support
Depression
Vision
When is a multidisciplinary approach
necessary
• The number of medical and surgical and
neurological/mental problems
• The number of prescription medications
• Functional limitations in two or more activities
of daily living
History taking
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“ Don’t talk about patients , talk with them”
Introduction, purpose
First impression give clues to disease/present problem
Eye contact
Handshake
What is your name?
Don’t rush
Permission needed for collaborate history
Collateral information: Family, Caregiver , Environment
Ask about aids – hearing, spectacles, walking and
wheelchair
History to be emphasized
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1. The patient profile: Current residence
Care giver
Employment history
2. History of the present illness
3. Medication review: Drug side effects
Dosage adjustment ; Calculate creatinine
clearance ( Cockroft Gold formula )
Over the counter medications
Indications
Compliance
Drug interactions
Correct dose
Protein levels and nutritional status
Attention to anticholinergic , psychotropic's and drugs with
a narrow therapeutic index
Adjustment dosage in renal
impairment
• Calculate creatinine clearance:
[140-age(y)] x weight (kg)
CCr (GFR) =
(males)
S-Cr (μmol/L) x 1.23
[140-age(y)] x weight (kg)
CCr (GFR) =
(females)
S-Cr (μmol/L) x 1.04
History continue.
• 4. Family history : Dementia , Early Parkinson's , atherosclerotic
disease ,diabetes mellitus , hypertension and cancer.
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5. Extended social history:
Alcohol , smoking and drug use.
Sexual history.
Home : Stairs , Bathrooms , Support , Medical emergency care ,
Health aides.
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• 6. Past history: surgical ,major illnesses and hospitalizations
• 7. Review all systems / old notes and results
History continues
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8. Collateral history
• 9. Social support systems
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10. Advanced directives
- Specific wishes when dying
- Living will
- Advanced directives
- Health proxy
• 11. Nutrition
• 12. Mood , Depression question are
Physical examination
• Emphasis on:
• 1. The vital signs : Pulse , Respiratory rate , Blood pressure , General
signs, Height and weight
• 2. Skin : Careful examination
• 3. Eyes : Vision , Fundoscopy
• 4. Ears
• 5. Mouth and teeth
• 6. Cardiovascular : pulses and rhythm, murmurs , aorta and bruits
• 7. Breast examination
• 8. Pelvic and rectal examination : Incontinence
• 9. Muscle and joints
• 10. Gait and balance
• 11. Nervous system
Functional assessment
• Functional impairment should not be
accepted as “ just part of getting old”.
• Documentation of the patients baseline
function is essential so that changes can be
identified and addressed.
Geriatric assessment instruments
Domain
Time( minutes) for
performing tests
Instrument
Dementia
9
Folstein Mini mental
Delirium
<5
Confusion assessment
Hearing
<0,5
Whisper test , Rinne and
Weber test , Audiometric
Nutrition
<2
Weight < 4,5 kg / 6 months
Gait and Balance
<1 ( < 20 sec for test)
Timed get up and go test ,
timed gait speed, One leg
Basic activity of daily living( ADLs)
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- Dressing
- Eating
- Ambulating
- Toileting
- Hygiene
( DEATH )
Independent DALs
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Shopping
Housekeeping
Accounting
Food preparation
Using Transport
Using the telephone
(SHAFT)
Other dimensions of geriatric
assessment
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Dental health
Nutrition
Driving ability
Social functioning
Recreational activities
Cognition
• Screening : 3 Item recall test
• Minimental Questionnaire
• Other questionnaires : TYM
Get up and go test
• Observed and time to rise from a chair and
walk 3 meters , turn around and return to sit
down in a chair.
• Normal : 10 seconds.
• Impairment is associated with increased fall
risk.
Vision testing
• Schnellen Chart – impairment <20/40 line
• Test near vision
• Postural stability is father determined by
depth perception , Binocular vision and
contrast sensitivity.
Whisper test
• Cover the opposite ear of the patient, exhale
completely and whisper an easily answered
question at 60 cm from the ear being tested.
Assess nutrition
• 1.Involuntary weight loss > 4,5 kg over 6 months.
• 2. Abnormal body mass index ( kg/m²): < 22 or
>27
• 3. Hypoalbuminemia
• 4. Hypocholesterolemia
• 5. Consider specific vitamin deficiencies – Vitamin
B12 , Folate ,Niacin, Thiamine.
• Nutrition screening questionnaire
Dentition
• Dental problems like loose dentures , missing
teeth or oral pathology might interfere with
eating.
• Poor dental hygiene is a risk for bacteraemia and
pneumonia or infective endocarditic.
• Many medical conditions in the elderly interfere
with absorption, digestion, increased nutritional
needs or require dietary restrictions .
Depression
• Common due to chronic disease ,chronic pain,
isolation, loss of spouse and peers
• Financial stressors
• Old age home placement
• Being alone – most important cause
• Self esteem diminished due to loss of
independence
Depression
Driving
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Predictors of poor driving events:
1. Vision impairment
2. Hearing impairment
3. Minimental impairment
4. Fewer blocks walked
5. Foot abnormalities
Incontinence
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Urinary incontinence: 30 % community
50% nursing home
Up to 80 years : Female 2 x > Male
“ DRIIIPP”
D- Delirium
R-Restricted mobility
I : Infection( UTI); Inflammation(Atrophic
vaginitis ); Impaction of faces
• P-Pharmaceuticals
• P-Post prostatectomy/ post bladder surgery
Pressure sores
Pressure ulcers/sores
• Risk factors for development of pressure ulcers:
• 1. Alterations in sensation or response to
discomfort:
• Degenerative neurological disease, CVA’s, CNS
injury ,Depression , Drugs that affect alertness
• 2. Alteration in mobility:
• -2.1. Neurological diseases
• -2.2. Fractures, Pain , Restraints
Pressure ulcers cont.
• 3. Change in weight the past 6 months:
Protein calorie under nutrition , Edema
• 4. Incontinence: Bowel or Bladder
Summary
• DEEP MIC N:
• D- Depression, Dementia, Delirium , Dental,
Dermis.
• E- Eyes
• E- Ears
• P-Polypharmacia
• M-Malignancies, Metabolic
• I- Incontinence
• C – Cardiac failure and coronary artery disease
• N – Nutritional state
References
• Brown JS; Ann Intern Med 144: 715, 2006
• Cassel CK; Geriatric Medicine, 4th ed,2003
• Reuben DB; Geriatrics at your finger tips:2007;
8th ed.
• Geriatric secrets ; 3 rd ed.
• Hazzards: Geriatric Medicine
• and Gerontology ; 6 th ed.
• Davidson ‘s