Transcript Geriatric Review of Systems

Geriatric Functional Assessment:
The Geriatric Review of Systems
Mary B. Preston MD FACP
Associate Clinical Professor of
Geriatrics
University of Virginia
Objectives
• Understanding of basic differences in organ
systems in the elderly
• Knowledge of functional geriatric
assessment
– With emphasis on mental status, mobility and
medication
Different metabolism/function
• Cells and tissues
– Increased fat to lean (even in skinny people)
– Heat production falls (the older, the colder)
– Connective tissue has decreased elasticity
• Example: lungs and skin
Cardiovascular
• More sensitive to volume changes
• Stroke volume, resting cardiac output
decreases 1% per year
• More ischemia therefore more myocardial
infarction and more congestive heart failure
• More problems with cardiac rhythm
• Tendency to have orthostatic hypotension
Respiratory
• Decreased forced expiratory volume in 1
sec (FEV1)
• Decreased vital capacity
• Arterial oxygen is less: the formula which
adjusts for age is
– PaO2 = 100.10 - 0 .323 x age
– example, 60 yo average pa02 is about 82
GI
• Diverticulosis occurs in over 1/2 of people
over the age of 60
• Decreased esophageal motility
• Decreased saliva (by 2/3)
• Less ability of liver to detoxify
Renal
• Nephron loss
• Blood supply to kidneys decreases
• Decreased creatinine clearance
Musculo-skeletal
• Decreased muscle strength and mass
• Cartilage deteriorates with narrowing of
joint spaces
• Bone mass decreased (osteoporosis)
Neurology
• Parkinson’s disease seen in 10% of this
population
• Memory loss is NOT part of normal aging
• Retention of new information decreases
with aging
• There is a slower processing time with
aging
Sensory
• Vision: trouble with glare and dim light;
increased farsightedness, cataracts
• Hearing: decreased universally by age 85;
high frequency sounds harder to hear
• Taste buds: ½ are non-functional
• Smell decreased
• Decreased proprioception
NOT normal aging
•
•
•
•
Fatigue is not part of normal aging
Anemia is not part of normal aging
Incontinence is not part of normal aging
Depression is not part of normal aging
• DESPITE what patients themselves tell you
– “I guess I am just getting old”
Interviewing skills
• Speak to the patient, not the caregiver
• Speak distinctly and where the person can
see your lips
• Take your time
• Avoid age-ist remarks, EVEN if the patient
themselves makes them; don’t agree
• Older patients tend to be more conservative
in their dress and expect you to be also
Examination skills
• Deafness: speak in front of the patient, not
to the side or behind them; do not shout
• Attend to their comfort realizing that they
may have arthritis
• Warm your hands
• Realize that they may respond slower; this
does not indicate dementia
Covering the geriatric issues: The
screening geriatric assessment
•
•
•
•
•
•
•
•
Medication, mentation, mobility
Activities of daily living
Social Support
Advance directives
Hearing and Vision
Incontinence
Nutrition
Depression
CANDY TIME
• Today’s mneumonic: You will be quizzed on this
at the end of the hour! MMM
– MEDICATION
– MENTATION
– MOBILITY
Medication
•
•
•
•
•
The list is NOT enough
Do they need each medication ?
Are there any medications that interact?
What is their renal function?
What drugs are potentially inappropriate in the
elderly?
• What is the average number of medications taken
by an elderly person – at home, in the nursing
home?
Medications - #2
• The list: must include over the counter,
doses, as needed (“prn”), how often taken
• Major interactions: Software programs help
• Renal function: if you are a 90 yo man with
a creatinine of 1.0 (“normal”), a weight of
72 kg, your clearance is--------?
• Average number of meds: 4.5 for
community dwelling, 7-9 for nursing homes
Medications #3
• Clearance is 50cc/hr (nearly half normal)
• Potentially inappropriate medications
–
–
–
–
–
–
Anti-cholinergics
Benzodiazepines
Tricyclics (ex: anti-depressants, muscle relaxers)
Quinolones
Meperidine
Indomethacin
Mentation
• Common sense approach: look at the patient’s
dress, observe way questions are answered
• Need a baseline: from records or family
• Tests confirm your common sense and allow you
to not be fooled by the socially adept but
demented patient
• Prevalence of dementia is about 50% in those over
the age of 85
Mentation #2
• You must distinguish between dementia,
delirium and depression
• Dementia: gradual onset, progressive
• Delirium: acute onset, fluctuation, patient is
inattentive
• Depression: sad affect, sees future as no
better or even worse than the present
Tests for dementia
• MMSE: developed 1975; educationally
dependent; poor specificity and sensitivity
but extensively used for screening
• Questions: Orientation, Registration,
Attention, Recall, Language
• How to score: no half credit for being close
• Traditionally, less than 24 = cognitive
impairment
Tips for doing MMSE
• Use spelling WORLD backwards rather
than serial 7s: easier for patient and for you
• Overcoming resistance (yours and theirs)
– “I do these tests on ALL over age 65”
– “Some of the questions may seem silly - just
bear with me”
– If patient upset by not doing well, skip to the
easier items
Other tests
• Animal naming: Name all the animals you can in
one minute
• Lab: Thyroid stimulating hormone (TSH), B12,
(VDRL only with appropriate history), CBC,
Chemistry (renal and hepatic function). It is rare
that a lab test shows you a problem that is
responsible for the dementia.
• X-ray: one time MRI or CT scan - especially to
check for subdural hematoma
Mobility
• Why might this be a problem?
–
–
–
–
–
Arthritis
Muscle atrophy (remember more fat than lean)
Sedentary life style
May contribute to incontinence
May contribute to depression
Exam for mobility/balance
• The Get Up and Go test : person sitting in chair,
gets up, walks 10 feet, turns and walks back to
chair and sits down
• The Functional Reach: standing, not moving legs,
reach with outstretched hand about 6 inches
• One leg balance: should be able to stand a few
seconds on each leg independently
Activities of daily living
• This is part of the geriatric history
• ADLs versus IADLs
– ADLs are basic, I =Independent or Instrumental
like using public transportation, using a phone
• Mneumonic for ADLs: DEATH
– Dressing, eating, ambulating, toileting, hygeine
Social Support
• This is a variation of the “social history”
that you have been doing
• Ask who would be able to help if the patient
became sick
• Ask where the children live; do not assume
that if they live next door they help out
Advance Directives
• ASK what the patient wants
• Difference between the living will and the
durable power of attorney for health care
• Offer the patient some concrete scenarios
• Listen
• Document
Hearing/Vision
• Whisper test:” Boxcar” or several numbers,
or finger rubbing
• 20/40 is functional vision (glasses on); it is
the equivalent of newspaper print
Incontinence
• There are 2 main types of incontinence
– Stress: the history question here is “Do you
pass urine if you cough or sneeze, or other
times involuntarily?”
– Urge: “Do you have to rush to get to the
bathroom?”
Nutrition
• Ask if they have lost more than 10 pounds in the
last 6 months
• The cause is likely to be not a disease, but a
situation
–
–
–
–
Medications
Depression/Loneliness
Finances
If a disease, hyperthyroidism, cancer
Depression
• Single question approach;
– “How do you see your future?”
– “Are you often sad or depressed?”
– “What do you do for fun?”
Depression #2
• Distinguish between grief, minor depression and
major depression
• Depression in the elderly CAN be treated
successfully
• Grief: look at it functionally – not in terms of time
• Major depression: the janitor can recognize; the
excellent clinician can recognize “minor”
depression and greatly benefit their patient
MMM - what are they?
• Medication
• Mentation
• Mobility
Conclusion
• You are now ready to do an excellent history and
physical with your elderly patient
• You know that it takes a different knowledge base,
a different set of skills, and above all, a non-ageist
attitude
• If you remember nothing else, remember THE
THREE M approach