Transcript Helping the Elderly Stay Active - University of Nebraska Medical

Functional Disability Screening
Brenda K. Keller, M..D.
Section of Geriatrics, Dept. of Internal Medicine
University of Nebraska Medical Center
Disability Screening
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Two realms of Abilities:
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Activities of Daily Living
Instrumental Activities of Daily Living
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Activities of Daily Living
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Activities needed to prepare for the day
Toileting
Dressing
Bathing
Feeding
Grooming
Ambulation
Activities of Daily Living
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90
80
70
60
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40
30
20
10
0
65-74
75-84
85+
low
mid
high
Instrumental Activities of Daily
Living
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Shopping
Transportation
Housekeeping
Telephone Use
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Food preparation
Laundry
Medications
Finances
Instrumental Activities of Daily
Living
100
90
80
70
60
50
40
30
20
10
0
65-74
75-84
85
low
mid
high
Disability Screening:Who Needs It?
All asymptomatic elderly
outpatients
Initial Visit
Annual H&P
 Not done during acute illness
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Disability Screening:What do we Want?
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Incorporate into General Exam
Target Common problems
Keep it simple
Screens should be of high yield
Clear next step to treatment
Disability Screening:Target Areas
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Vision
Hearing
Arm & Leg
function
Urinary
Incontinence
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Mental Status
Nutrition
Depression
Home Safety
Social Support
Vision
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Visual impairment, particularly from
decreased accommodation and cataracts, is
more common with age.
Role of the primary care MD is
identification of vision loss and f/u of care
plan outlined by eye specialist
Vision Screening
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Jaeger card
14 inches from face
Well lit room, minimize glare
If unable to read 20/40 or better refer to
ophthalmologist
Hearing
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Hearing Loss is prevalent among elderly.
Associated with: isolation, confusion,
depression
High frequency hearing loss common
Affects conversation
Hearing Screening
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Whisper Test: consistent with a 30 Db.
Loss. Validated against audiometry
Stand 2 feet behind patient and whisper a
series of 3 numbers into each ear
Hearing Screening
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If unable to respond: check for wax
Wax in ears: remove and repeat test
If still fails -- refer for audiogram
Hearing Loss
Options for Treatment
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Prosthesis: hearing aides
Assistive listening devices
Environmental Changes
Hearing Aides
Hearing Aides
Arm Function
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Decrease in arm function leads to difficulty
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Gross tasks such as dressing,
Fine tasks such as writing and eating
Community dwelling elderly, this increases
reliance on family, formal services
Arm Function Screening
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Proximal Function“Touch the back of
your head with both hands.”
Distal Function “Pick up a pen.”
Arm Function Evaluation
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If difficulties, then full neuromuscular
exam:
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pain
Range of motion
weakness
Arm Function Disability
Options for Treatment
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Treat underlying medical condition
Occupational therapy consultation
Assistive devices
Leg Function Screening
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Get Up and Go
Patient arises from chair, walks 10 ft., turns
& returns to chair
Leg Function Evaluation
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If unable to walk or transfer:
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full neuromuscular exam,
 focus on pain
 Range of motion
 Balance and Gait
Leg Function Disability
Options for Treatment
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Initiation of exercise program
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Physical Therapy consult for:Gait
Training, Strengthening
Assistive Devices
Mental Status
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Dementia is the most common important
disturbance in mental status in elderly persons
Older people compensate well for the problem,
so it may be missed if not specifically tested
Short term memory and calculations are sensitive
indicators of cognitive decline
Mental Status Screening
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Three item recall
Names of three items presented to pt.
Pt. asked to repeat 3 items immediately and
remember them for later
Recall at 1 minute
If unable to recall any at 1 minute, then
MMSE
Mental Status
Further Evaluation
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Folstein MMSE < 24
Ascertain onset, duration, and fluctuation of
overt symptoms
Complete Neuro Exam
Assess Affect, level of consciousness
Med review, appropriate lab, x-ray
Depression
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Affects over 1 million
over age 65
13% of community
dwelling elderly
25% of all suicides
committed by old
Depression Screening
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Do you often feel sad or depressed?
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If yes, then: Geriatric Depression Scale
Score > 10 Check meds, labs. Consider
counseling or antidepressant Rx.
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Urinary Incontinence
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Ten million Americans suffer from urinary
incontinence
30% of community dwelling elderly
50% of people in Nursing Facilities
Over half of those afflicted have had no
treatment or evaluation
75-90% of individuals can be helped
Urinary Incontinence
Screening
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Ask “Do you ever lose urine and get wet?
If yes, then:
Ascertain frequency, amount,
circumstances, time of day
Look for acute reversible causes for
incontinence
Nutrition
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Poor nutrition in the elderly can be a
reflection of:
Concurrent Illness
Depression
Poor dentition
Financial Hardship
Inability to shop or cook
Inability to feed oneself
Nutrition Screening
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Have you lost more than 10 lbs in the
past year.?
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If yes, or if appears of low body weight,
then:
Evaluate intake with food diaries
If inadequate, dietitian to see
If adequate, evaluate for medical cause
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Food Pyramid for the Elderly
Nutrition
Evaluation of Weight Loss
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H&P
Investigate Abnormalities
Lab evaluation for occult malignancy
and metabolic disturbances
Home Safety
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Environmental hazards lead to increased
risk of falls
Hip Fx in 1% of falls in community
dwellers and 5% of NH residents
Falls cause 70% of accidental deaths
Stairs and bathrooms are likely sites for
falls.
Home Safety Screening
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Have you had any falls at home?
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Identify potential fall hazards:
# Stairs Throw Rugs Bath rails
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Home Safety Evaluation
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OT or PT Home
visit to identify
and change
hazards
Supply patient or
family with safety
checklist
Social Support
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Degree of social support has been associated with
survival, morbidity and quality of life
Breadth and depth of social circle are important
factors in determining need for formal support
ID of potential caregivers in the medical record
facilitates interactions
Social Support Screening
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Who would be able to help you in case of illness
or emergency?
Who would make health decisions for you if you
were unable to make them for yourself?
Inquire about current advanced directives
Document these individuals in the medical record
Become familiar with community services for the
elderly
Helping the Elderly Stay Active
Conclusions
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Functional Disability is common in the
elderly
Search of Target areas for disability can
lead to early identification and Rx
Screens can be easily incorporated into H &
P or can be done by office personnel prior
to MD visit