Transcript Approach to the Older Patient

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
Elder Evaluation
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Introduction
Evaluation
Review
Summary
Aging
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Is Not A Disease
Occurs at Different Rates
• Among Individuals
• Within Individuals
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Increases Susceptibility to Specific
Conditions
Characteristics of Geriatric Medical
Conditions
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Chronic with
Superimposed Acute
Illness
 Multiple and
Coexisting
Iatrogenesis
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Medication Misuse
 Hospitalization
• Falls, Delirium,
Immobility
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Diagnostic/
Therapeutic
Procedures
Presentation of Geriatric Patient
Typically “Atypical”
 Nonspecific
 “Cascade
Phenomenon”
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Goals of Geriatric Care
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Care vs. Cure
• Iatrogenesis
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Function
 Quality of Life
 Prevention
 Palliation
Geriatric “Money Balls”
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Small Changes In
Function = Big QOL
Gains
 Taking Things Away
Can Make Things
Really Better or Really
Worse!
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Elder Evaluation
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Introduction
Evaluation
Orientation
Summary
Geriatric Evaluation
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Geriatric H&P
Functional
Cognitive/Affective
Medications
Nutritional
Bone Integrity/Falls
Strength/Sarcopenia
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Continence
Eyes/Ears
ETOH/Tobacco/Sex
EnviroSocial
Capacity
History:
{Communication & Rapport}
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Impaired Communication?
Eye Contact, Physical Contact
Use Last Name
Speak Directly to Elder
• Establish Decision Maker
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Address CC
Make Only One Change/Visit
Geriatric History
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Avoid Open Ended
Questions
 Focus On Current
Medical Problems
 Address Families
Concerns
 Focus On Medications
Physical Exam: Blood Pressure
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Blood Pressure
• 24% of Elders have
Orthostasis
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Pseudohypertension
 Trial of
Hypertensives?
• 25% Normotensive
Physical Exam: Height/Weight/Skin
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Serial Heights
Serial Weights Essential
Skin
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Senile Lentigines, Skin Tags
Physical Abuse Signs?
Decubs?
Examine at Annual Exam
Physical Exam
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Areas to Focus On
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Cardiovascular
Musculoskeletal
Neurological
Thyroid?
Functional Evaluation
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Instrumental Activities of Daily Living
• (IADL’s)
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Activities of Daily Living
• (ADL’s)
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Executive Functioning
Gait & Balance
Gait & Balance
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Get Up and Go !
Tinetti Gait &
Balance
Cognitive/Affective Status
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Folstein’s MiniMental State Exam
• (MMSE)
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Clock Drawing
Geriatric Depression Scale
• (GDS)
Mini Mental State Exam
[ General Information ]
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Developed by Marshall Folstein in 1975
Estimate Severity of Cognitive Impairment
NOT Designed To Make Specific Diagnoses
MMSE
[Cognitive Domains]
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Orientation/Time
Orientation/Place
Registration
Attention/Calculation
Recall of Three Words
Language
Visual Construction
5 points
5 points
3 points
5 points
3 points
8 points
1 point
MMSE
[Scoring / Cutoffs]
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Total Number of Correct Answers
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24-30 Correct
18-23 Correct
0-17 Correct
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No Cognitive Imp.
Mild Cognitive Imp.
Severe Cog. Imp.
MMSE
[Influences]
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Educational Level
Race / Ethnicity
Socioeconomic Status?
Clock Drawing Test
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Different Versions
 4 Point Scale Most
Useful
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1 Point- Circle
1 Point-Numbers
1 Point-Hands/Arrows
1 Point-Right Time
Geriatric Depression Scale
[ General Information ]
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Total Number of Questions
Long Version = 30
Short Version = 15
Administered in about 5 Minutes
Count the Missed Questions
Geriatric Depression Scale
[ Error Cut-Offs ]
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Long Version
• < 11
• 11-14
• ≥14
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Not Depressed
Possible Depression
Depression
Short Version
• <11
• ≥11
Not Depressed
Probable Depression
Geriatric Depression Scale
[ Clinical Utility ]
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Use As Screener Only
Utilize Suggested Cut-Offs
Recognized Ethnicity or Language
Influence GDS Interpretation
Medications
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Only Use When Life,
Function or Comfort
Threatened
 Medications Must Be
Reviewed On Each
Visit
Medication Review
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Prescription
• Shared
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OTC
 OTB
 Alternative
Nutritional Status
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Often Overlooked
 Oral Screening
• Poor Dentures?
“Weigh All Of The
Elders, All Of The
Time”
 BMI
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Bone Integrity
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Risk Factors
 DEXA
 Falls Risk
Strength/Sarcopenia
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Strength Decreased
Immobility Issues
Continence
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Major Cause of
Morbidity
 Urinary & Fecal
Incontinence
Eyes/Ears
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Eyeglasses
• Screen With
Snellen Chart
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Hearing Aids
• Ask About Hearing
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Alternative Aids
• $55 Radio Shack
ETOH/Tobacco/Sex
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Alcohol and Smoking
Common
• CAGE?
• Smoking Cessation
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Sex Also Common
• Major QOL
Enviro-Social Status
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Does The Elder Live
Alone?
 Who Functionally
Assists?
 Home Assessment, If
Necessary
Enviro-Social Status
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Social Activity,
Relationships and
Resources
Caregiver Burden
Quality Of Life Issues
Advance Directives
Capacity
Determining Capacity
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Describe Illness and
Course
 Explain Proposed
Treatment
 Understand Treatment
Consequences
 Understand Risks and
Benefits
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Develop Plan
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Set Goals
• Realistic, Measurable,
Achievable
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Discuss With Family,
If Appropriate
 Develop Stepwise
Approach
Approach To Evaluation
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Visit 1
• Address CC, Initial Hx
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Visit 2
• PX and Labs
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Visit 3
• Cognitive/Functional
Eval
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Visit 4
• Social, QOL, and Plan
Elder Evaluation
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Introduction
 Evaluation
 Orientation
 Summary
Geriatrics Clinic
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South Module-FHC
 Both Frail Elder &
CDC
 Be Prompt
• 8:AM
• 1:PM
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Unexcused Absences
Process
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White Board
Put Initials
See Patient
Present Patient
Fill Out Orders
Finish Note
Other Required Activities
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Keep Problem List
Current
 Keep Meds List
Current
 Fill Out Prescriptions
 Check Out before you
leave
Final Points
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Learning and
Knowledge Content
Are Different Things
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Just Because You
Complete A Task Does
Not Imply That You
Completed It Well
SUMMARY
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Chronic Problems With Acute Events
Interspersed
Communication Essential
Expect the Unexpected
Iatrogenesis Rules!