Transcript Assessment and Treatment of the Older Adult Client

Lillian Ehiemua-Pope, PhD, APRN-CNP
The University of Oklahoma College of Nursing
1. Distinguish variations in developmental changes,
physiologic changes, and psychosocial changes of older
adults.
2. Distinguish appropriate screenings, health
promotion/disease and injury prevention strategies
appropriate for the frail adult and aged.
3. Discuss assessments for function, cognitive/mental status,
for the frail adult and aged.
4. Discuss management of social and end of life issues of the
older adult.
 By 2030, the number of U.S.
adults aged 65 or older will
more than double to about 71
million.
 The increasing number of
older Americans will place
unprecedented demands on
the provision of health care
and aging-related services.
 Primary Care Providers must
be prepared to care for
increasingly older
populations.
 Approximately one-half of the ambulatory primary
care for adults older than 65 years is provided by
family providers.
 Approximately 22 percent of visits to family providers
are from older adults.
 It is estimated that older adults will comprise at least
30 percent of patients in typical family medicine
outpatient practices
 Normal Part of Life.
 Begins around age 30.
 Chronic vs.. Acute.
 Normal aging vs. disease progression
 Brain changes with age.
 Deterioration of nerve cells.
 Slowing reflexes.
 Clinical depression.
 Frustration common.
 Altered mental status.
 Hypertension common.
 Changes in heart rate and rhythm.
 Calcium deposits around heart valves.
 Cardiac Hypertrophy
 Thickening of walls of the heart.
 Decreased cardiac output.
 Affects of CAD.
 Weak heart trying to pump against constricted vessels.
 Constipation common.
 Smooth muscle contraction diminished.
 Deterioration of structures in mouth common.
 Decline in efficiency of liver.
 Reduced ability to aid in digestion and metabolism of
certain drugs
 Impaired swallowing.
 Stomach sphincter valve loss.
 Increase in heartburn
 Malnutrition due to deterioration of small intestine.
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Decrease in nutrient absorption.
 Osteoporosis common.
 Mineral loss.
 Bones become brittle.
 Narrowing disks causes kyphosis.
 Curving of the spine.
 Osteoarthritis common.
 Affects joints.
 Cause of falls.
 Immobility can lead to death.
 Cough power diminished.
 Increased tendency for infection.
 Less air and gas exchange due to general decline.
 Lung tissue loses elasticity.
 Muscles used to breath lose strength and coordination.
 Drug toxicity problem common.
 General decline in efficiency.
 Reduced size causes decrease in filtration surface area.
 Fluid and electrolyte imbalance.
 Can not filter out drugs properly.
 Perspires less.
 Tears more easily.
 Heals slowly.
 Microorganisms can enter the body.
 Fever often absent.
 Lessened ability to fight disease.
 Adults surviving into late life suffer from high rates of
chronic illness; 80 percent have at least one and 50
percent have at least two chronic conditions.
 There is a strong association between the presence of
geriatric syndromes (cognitive impairment, falls,
incontinence, vision or hearing impairment, low body
mass index, dizziness) and dependency in activities of
daily living.
 A complete assessment is
usually initiated when
the provider detects a
potential problem such
as confusion, falls,
immobility, or
incontinence.
A multidisciplinary diagnostic and treatment process
that identifies medical, psychosocial, and functional
limitations of a frail older person in order to develop a
coordinated plan to maximize overall health with aging.
PRINCIPLES OF GERIATRIC ASSESSMENT
Goal:
Focus:
Scope:
Approach:
Efficiency:
Success:
Promote wellness, independence
Function, performance (gait, balance,
transfers)
Physical, cognitive, psychological, social
domains
Multidisciplinary
Ability to perform rapid screens to identify
target areas
Maintaining or improving quality of life
GOAL OF THE GERIATRIC ASSESSMENT
 To determine a patient’s
• medical status
• functional capabilities
• psychosocial status
 in order to develop an overall plan for treatment
and long-term follow-up
 Functional capacity
 Advanced care preferences
 Fall risk
 Nutrition/weight change
 Cognition
 Urinary continence
 Mood
 Sexual function
 Polypharmacy
 Vision/hearing
 Social support
 Dentition
 Financial concerns
 Living situation
 Goals of care
 Spirituality
 Use a well-lit room
 Avoid backlighting
 Minimize extraneous
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noise
Minimize interruptions
Introduce yourself
Address the patient by
last name
Face the patient directly
Sit at eye level
 Speak slowly in a deep
tone
 Ask open-ended
questions: “What would
you like me to do for
you?”
 Inquire about hearing
deficits, raise voice
volume accordingly
 • If necessary, write
questions in large print
Allow ample time for
patient to answer
Complete physical assessment includes:
• Functional status
• Nutrition
• Vision
• Hearing
Functional status — Functional status refers to the ability
to perform activities necessary or desirable in daily life.
 Activities of Daily Living (ADLs): Bathing, dressing,
transferring, toileting, grooming, feeding, mobility
-Katz Index of Independence in Activities of Daily Living
 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
FALLS/IMBALANCE
Approximately one-third of community-dwelling
persons age 65 years and one-half of those over 80 years
of age fall each year.
Patients who have fallen or have a gait or balance
problem are at higher risk of having a subsequent fall
and losing independence.
-The Tinetti Balance and Gait Evaluation is a useful tool
to assess a patient's fall risk.
NUTRITIONAL ASSESSMENT
Four components specific to the geriatric nutritional
assessment:
(1) nutritional history
(2) a record of a patient's usual food intake based on 24hour dietary recall;
(3) physical examination with particular attention to
signs associated with inadequate nutrition or
overconsumption
(4) select laboratory tests (pre-albumin, albumin,
protein, etc.)
PHYSICAL NUTRITIONAL ASSESSMENT
• Visual inspection
• Measure height, weight, body mass index (BMI)
—BMI = weight (kg) / height (m2)
—low BMI < 20 kg/m2)
• Unintentional weight loss > 10 lbs
-MST- malnutrition screening tool < 65
-MNA- mini-nutritional assessment >65
VISION ASSESSMENT
 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
 The most common causes of vision impairment in older
persons include presbyopia, glaucoma, diabetic
retinopathy, cataracts, and age-related macular
degeneration.
HEARING ASSESSMENT
 Hearing loss is common among older adults
 Impaired hearing- depression, social withdrawal
 Assess first for cerumen impaction
 Whisper test
 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
Presbycusis is the third most common chronic condition
in older Americans, after hypertension and arthritis.
COGNITIVE SCREENING
 Prevalence of Alzheimer’s 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 non-adherence, and
disability.
COGNITIVE PERFORMANCE MEASURES
 Mini Cognitive Assessment Instrument
 Folstein’s 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
ASSESS PSYCHOLOGICAL STATUS
Although prevalence of major depression among older
adults is low (1%-2%), “subclinical” depression is
common .
Depression in the elderly may present atypically, and
may be masked in patients with cognitive impairment.
Watch for signs of anxiety, bereavement.
DEPRESSION SCREENING TOOLS
2 Questions:
"During the past month, have you been bothered by feeling
down, depressed or hopeless?”
"During the past month, have you been bothered by little
interest or pleasure in doing things?"
-If “Yes,” do further evaluation.
1. Patient Health Questionnaire-9 (PHQ-9)
2. Geriatric Depression Scale
POLYPHARMACY
 Older persons are often prescribed multiple
medications by different health care providers, putting
them at increased risk for drug-drug interactions and
adverse drug events.
 The clinician should review the patient's medications
at each visit.
SOCIAL ASSESSMENT
 Availability of a personal support system
 Caregiver burden
 Economic well-being
 Elder mistreatment
 Advance directives
Caregiver Burden
Caregivers should be screened periodically for symptoms
of depression or caregiver burnout; and if present,
referred for counseling or support groups
Burden Interview: Zarit Score
Financial Assessment
 The financial situation of a functionally impaired older
adult is important to assess.
 Older adults may qualify for state or local benefits,
depending upon their income.
 Older patients occasionally have other benefits such as
long-term care insurance or veteran's benefits that can
help in paying for caregivers or prevent the need for
institutionalization.
Elder Abuse
Common types of elder abuse include physical abuse,
psychological abuse, neglect, and financial abuse. Each
type may be intentional or unintentional. The
perpetrators are usually adult children but may be other
family members or paid or informal caregivers.
-The patient should be interviewed alone, other involved
people may also be interviewed separately.
-Ask general questions about feelings of safety but,
include direct questions about possible mistreatment.
Signs of Elder Abuse
Item
Sign
Behavior
Withdrawal by the patient
Infantilization of the patient by the caregiver
Caregiver's insistence on providing the history
General appearance
Poor hygiene (e.g., unkempt appearance,
uncleanliness), Inappropriate dress
Skin and mucous membranes
Poor skin turgor or other signs of dehydration
Bruises, particularly multiple bruises in various stages of
evolution
Pressure ulcers, Deficient care of established skin lesions
Head and neck
Traumatic alopecia (distinguished from male-pattern
alopecia by distribution)
Trunk
Bruises, Welts (shape may suggest implement—e.g.,
utensil, stick, belt)
GU region
Rectal bleeding, Vaginal bleeding, Pressure ulcers
Infestations
Extremities
Musculoskeletal system
Wrist or ankle lesions suggesting use of restraints or
immersion burns (i.e., in a stocking-glove distribution)
Previously undiagnosed fracture, Unexplained pain
Unexplained gait disturbance
Mental and emotional health
Depressive symptoms, Anxiety
Advance directives
Legal documents that extend a person's control over
health care decisions in the event that the person
becomes incapacitated. Communicate preferences
before incapacitation occurs.
Two primary types:
-Living will: Expresses preferences for end-of-life care
-Durable power of attorney for health care: Designates a
surrogate decision maker
The do-not-resuscitate (DNR) order: placed in a
patient's medical record by a physician informs the
medical staff that CPR should be done
Physician Orders for Life-Sustaining Treatment
(POLST): set of medical orders/programs put in place if
the clinician for patients expected to die usually within
the next year.
Although the number of crashes among older drivers is
low . . .
The number of crashes per mile driven and the
likelihood of serious injury and death are higher than for
any other age group except those 16 to 24 years old
RISK FACTORS FOR OLDER DRIVERS
 Reduced vision
 Dementia
 Impaired neck and truck rotation
 Limitations of shoulders, hips, ankles
 Foot abnormalities
 Poor motor coordination
 Medications and alcohol that affect alertness
When an Accident or Driving Violation Occurs
 Assess Risks
 Discuss safety concerns with the older driver and with
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spouse or family member, if possible
Urge consideration of other modes of transportation
Refer for formal driving evaluation
Encourage the Driver to Reduce Risks
Avoid rush hour, congested traffic
Avoid night driving
Avoid driving in poor weather
 Most older adult patients who are appropriate for
geriatric assessment have limited potential to return to
fully healthy and independent lives. Choices must be
made about what outcomes are most important for
them and their families.
 Must be patient-centric and individualized.
 Both short-term and longer-range goals should be
considered and progress towards meeting these goals
should be routinely assessed.
 Refer patients who are found to have problems in multiple
areas during geriatric assessment screens.
 Major illnesses (e.g., those requiring hospitalization or
increased home resources to manage medical and
functional needs) should be referred, particularly for
functional status, fall risk, cognitive problems, and mood
disorders.
 Referral team: social worker, physical and occupational
therapists, nutritionists, pharmacists, psychiatrists,
psychologists, dentists, audiologists, podiatrists, and
opticians.
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83( 1), 48-56
GRS 5th Edition, (2014). Assessment of the older adult, Retrieved from
http://www.ouhsc.edu/geriatricmedicine/documents/GRSS-geriatric-assessment
Iowa Geriatric Education Center, (2015). Geriatric assessment tools. Retrieved from:
http://www.healthcare.uiowa.edu/igec/tools
The Merck Manual Professors Edition (2015). Evaluation of the elderly patient. Retrieved
from: http://www.merckmanuals.com/professional/geriatrics/
approach_to_the_geriatric_patient/evaluation_of_the_elderly_patient.html
Up To Date (2015). Comprehensive geriatric assessment. Retrieved from:
http://www.uptodate.com/contents/comprehensive-geriatrics-assessment