Transcript Approach to the Geriatric Patient

Approach to the Geriatric
Patient
Geriatric Assessment in a Primary
Care Setting
Hazards of Hospitalization
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
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
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 >85 are living in the
community
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
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
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
Cascade To Dependency
Hazards of Hospitalization
High Risk Environment
High Risk Situation
• Falls
• Delirium
• Functional Decline
• Pressure Ulcers
• Adverse Drug Effects
• Transition Failure
Delirium – acute onset of disturbance in
consciousness in which cognition or perception is
altered
Disturbance in Cognition
Acute/Fluctuating
AND
Inattention
Altered Level of Consciousness
OR
Disorganized Thinking
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
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
How Common?
• Affects 20% of hospitalized elderly >65
– 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%
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
Mechanism of Delirium
• Imbalance of neurotransmitters
• Acetylcholine
• Dopamine
• Hypothalamic –pituitary –adrenal axis
• Inflammation
• Cytokines (TNF, Interleukins)
• Occult diffuse brain injury
• Especially following sepsis
Delirium Prevention
Modifiable Risk Factors
Prospective Interventions
Cognitive Impairment
Immobility
Orienting communication
Early mobilization, reduce
restraints
Visual Aides; adaptive equipment
Amplifiers; adaptive equipment
Prevent and correct dehydration
Uninterrupted sleep,
nonpharmacologic aides
Visual Impairment
Hearing Impairment
Dehydration
Sleep Deprivation
40% relative risk reduction
Inouye SK et al. A multicomponent Intervention to Prevent Delirium in Hospitalized Geriatric Patients.
NEJM 1999;340:669-676
Vidan MT et al. An Intervention Integrated into Daily Clinical Practice Reduces Incidence of Delirium
During Hospitalization in Elderly Patients.
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???
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
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 pt’s values
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 patient’s
status
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 patient’s
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
Geriatric Assessment
A Primary Care Approach
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
Components of the Geriatric
Assessment
• Functional Assessment
• Evaluation of Gait
• Evaluation of Cognitive Function
• Evaluation of Mood
• Social Assessment
• Economic Assessment
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
Evaluation of Gait
• Main Causes of Gait Impairment
–
–
–
–
–
–
Decreased range of motion
Muscle weakness
Sensory/Balance Deficit
Spasticity
Pain
Impaired Central Processing
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
<14 seconds
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
Folstein Mini Mental State Exam
Questions (Total of 30 points)
A. Orientation (10 points)
1. Year, Season, Date, Day of week, and Month
2. State, County, Town or City
3. Hospital or clinic, Floor
B. Registration (3 points)
1. Name three obects: Apple, Table, Penny
2. Each one spoken distinctly and with brief pause
3. Patient repeats all three (one point for each)
4. Repeat process until all three objects learned
5. Record number of trials needed to learn all 3 objects
C. Attention and Calculation (5 points)
1. Spell WORLD backwards: DLROW
2. Points given up to first misplaced letter
3. Example: DLORW scored as 2 points only
D. Recall (3 points)
1. Recite the 3 objects memorized in Registration above
E. Language (9 points)
1. Patient names two objects when they are displayed
a. Example: Pencil and Watch (1 point each)
2. Repeat a sentence: 'No ifs ands or buts'
3. Follow three stage command
a. Take a paper in your right hand
b. Fold it in half
c. Put it on the floor
4. Read and obey the following
a. Close your eyes
b. Write a sentence
c. Copy the design (picture of 2 overlapped
pentagons)
Interpretation of Mini-mental State Score (Maximum: 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
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)
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.
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
A Typical Clinical Situation
• Mrs. A’s 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/c’d 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?
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