Transcript A (hopefully) Practical Approach to the Geriatric Assessment for

A (hopefully) Practical Approach to
the Geriatric Complete Physical in
Family Medicine.
Dr. C Hoggard
R1’s of 2016
Disclosure
• No disclosures
• I have borrowed heavily from many different
doctor’s presentations
• None of the pictures used are mine (except 1)
My Goals for this talk
• Introduce the Complete Geriatric Assessment
(GCA)
• Introduce the Geriatric Syndromes aka Geriatric
Giants
• How do you screen for these syndromes in the
office
• Focusing on aspects of Geriatrics that we are
never taught
• Billing
• Bring it all together with a couple of cases
Geriatrics
Why is Geriatrics Important?: Case
• Gwendolyn Ricci is new to your practice and
arrives with her family for an initial assessment.
Her family does most of the talking for her and
Gwendolyn often looks at them for assistance in
answering your questions. You note she has a
shuffling wide based gait, and turns on block.
She even has a fall in the office! She exit seeks
and is incontinent of bladder and bowels. Her
family seems to think this is normal. What action
do you take?
Why is Geriatrics Important? Case
answer
• Nothing!
Gwendolyn is 1
year old. Like
pediatrics,
geriatrics deals
with a special
population
requiring a
specialized set of
skills. They are
not merely “older
adults”.
What is the Geriatric Assessment?
Brace Yourself
Components of a Geriatric Assessment
•
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•
•
Vision
Hearing
Cognition
Depression
Falls/mobility
Cardiovascular risk factors,
symptoms etc
Respiratory-COPD
Endocrine-thyroid, diabetes
GI-bowels
GU-incontinence, sexual
function
•
•
•
•
•
•
•
•
•
•
Neuro- Strokes etc
MSK –osteoporosis, arthritis
Skin
Medications
Immunizations
POA/PD/AD
Smoking and alcohol
ADL, IADLS, Living situation
Driving
Abuse and Care-giver
burnout
• Capacity
The Complete Geriatric Assessment
What should we be doing?
• Functional Assessment –Collateral is nice
• Geriatric Syndrome screening
• Quarterbacking (ie Case Managing: What we
are trained to do but never taught)
– Legal Paperwork/awkward conversations
– Standard Regular screening/ Preventative
Medicine
Functional Assessment
Functional Assessment
Activities of Daily Living
Eating
Transfer
Grooming
Dressing
Toileting
Bathing
Instrumental Activities of
Daily Living
Medication
Cooking
Cleaning/ Laundry
Finances
Shopping
Telephone Use/ Computer
Driving*
Functional Assessment
iADLs
History to Illicit
Medications
Blister packing, can they walk you through their medications,
Banking
What do they pay? Missed bills, problem with PINS, Automatic
banking, know where their money comes from?
Cooking
Have they changed what they eat? Different tasting, frozen meals,
weight loss
Shopping
List generation, find what they want
Cleaning
Change in the living condition
*Telephone/ Computer
use
Can they work their new _____?
*Driving
Get lost? The finger? Others concerned? accidents? Grandchild test?
Screen for the Geriatric Syndromes
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•
Cognition/ Delirium/ Depression
Polypharmacy
Incontinence
Falls
Osteoporosis
Orthostatic Hypotension
FTT
Abuse
**Driving
Screen for the Geriatric Syndromes
•
•
•
•
•
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•
•
•
Cognition/ Delirium/ Depression
Polypharmacy
Incontinence
Falls
Osteoporosis
Orthostatic Hypotension
FTT
Abuse
**Driving
The 3 D’s of Geriatrics
• Depression, Dementia and Delirium
– look the same, smell the same, mimic each other
and are often in combination.
Dementia
• Routine screening not recommended
• This will come to you in three ways
1. Family is worried
2. Functional Change
3. Hospital Admission
Dementia
• There must be a FUNCTIONAL DECLINE
Activities of Daily Living
Instrumental Activities of Daily
Living
Eating
Medication
Transfer
Cooking
Grooming
Cleaning/ Laundry
Dressing
Finances
Toileting
Shopping
Bathing
Telephone Use/ Computer
Driving*
Testing for Dementia
• SIMARD is not validated
• MOCA – for executive functioning and mild
cognitive impairment
• MMSE – for more severe impairment,
language based, needed to assess supports
• Clock Drawing
• Rudas
• The “head turning sign”
Dementia
Dementia
Depression
• Do you feel sad/depressed?
• Do you feel hopeless?
• Do you feel life is not worth living?
GDS 15 >5 is worrisome for Depression
Depression
The Geriatric Depression Scale (GDS)
Delirium
•
•
•
•
Fluctuating
Behavioral Change
Hyperactive/ Hypoactive
What is your name? Where are you? What is
the date?
• 1/3 of patients >70 yo in hospital are delirious
and it can take up to 3 months to resolve!
Screen for the Geriatric Syndromes
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Cognition/ Delirium/ Depression
Polypharmacy
Incontinence
Falls
Osteoporosis
Orthostatic Hypotension
FTT
Abuse
**Driving
Polypharmacy
Polypharmacy
• Have your pharmacist do a medication review
– 03.01NM (communication with pharmacy if
pharmacy initiated)
• Watch for prescription cascades
• Watch for errors of omission
• Watch for inappropriate medications
Ativan
Polypharmacy
Disease
What are they on?
What should they
be on?
What should they
avoid
HTN
Ramipril 2.5mg
Antihypertensive
NSAIDS
DIABETES
Metformin 1000mg
BID
Glucose lowering
agent, ?ASA,
?Statin, ?Renal
protection
Hypoglycemic
agents
Arthritis
Ibuprofen
Diclofenac Gel,
Tylenol, Injections
Narcotics? Braces?
Ativan
Screen for the Geriatric Syndromes
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Cognition/ Delirium/ Depression
Polypharmacy
Incontinence
Falls
Osteoporosis
Orthostatic Hypotension
FTT
Abuse
**Driving
Incontinence
Incontinence
• Do you have trouble with urine leaking?
• Do you have difficulty controlling your bowels
or bladder?
• Have you ever not made it to the toilet?
• Are you afraid to leave the house if there is no
bathroom easily accessible?
Screen for the Geriatric Syndromes
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•
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•
•
Cognition/ Delirium/ Depression
Polypharmacy
Incontinence
Falls
Osteoporosis
Orthostatic Hypotension
FTT
Abuse
**Driving
Falls
• Have you fallen in the last year?
• Chair Raises
• The timed up and go test aka “TUG” Test
– <10 sec is normal
– <20sec can go out alone
– > 20sec is a fall risk
Screen for the Geriatric Syndromes
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Cognition/ Delirium/ Depression
Polypharmacy
Incontinence
Falls
Osteoporosis
Orthostatic Hypotension
FTT
Abuse
**Driving
Osteoporosis
Osteoporosis
• Are you shorter?
• Do your pants or skirts seem longer/hit the
floor?
• Have you ever broken a bone?
• Have you had prolonged unusual back pain?
Osteoporosis
• TUG
• > 3cm (men) 2 cm (women) height loss in a
year
• Wall to occiput
• Bone Mineral Density
Osteoporosis
• BMD can’t do it alone!
– FRAX
– CAROC
A fragility fracture is OP. Your
diagnosis is made! No BMD
needed!
Screen for the Geriatric Syndromes
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Cognition/ Delirium/ Depression
Polypharmacy
Incontinence
Falls
Osteoporosis
Orthostatic Hypotension
FTT
Abuse
**Driving
Orthostatic Hypotension
• Just do it
• Systolic goal 150 >80 yo or Frail
Screen for the Geriatric Syndromes
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Cognition/ Delirium/ Depression
Polypharmacy
Incontinence
Falls
Osteoporosis
Orthostatic Hypotension
FTT
Abuse
**Driving
Failure to Thrive
• Has your weight changed?
• Look at their clothes
• Have you been buying new clothes?
• Are you driving?
• Any accidents in the last 5 years?
Nutrition
• Weigh your patients at every visit
– Unintentional weight loss
– 10% in the last 3-6 months
• Under-nutrition is often overlooked.
• Ask:
– Have you lost weight?
– What is your usual weight?
– Have you had to buy new clothes, how are your
clothes fitting?
– How are your dentures fitting?
– Who makes the meals?
Nutrition
• Causes: “normal aging physiology”,
depression, dementia, delirium, isolation,
medication, $, mobility, dental care…..etc
• Quick Fixes: Tx dx and change meds, meals on
wheels, aids, companions, supplementation,
presentation
Social issues
• Etoh/drugs
• Isolation
Screen for the Geriatric Syndromes
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Cognition/ Delirium/ Depression
Polypharmacy
Incontinence
Falls
Osteoporosis
Orthostatic Hypotension
FTT
Abuse
**Driving
Abuse
• Abuse
–
–
–
–
Verbal/emotional
Financial (home?)
Physical
Computer scams
• Is anyone making life difficult for you?
• Is there someone in your life that you think does
not have your best interests in mind?
• Are you afraid of someone?
Safety
• Environmental assessment:
• Personal safety
– Wandering bracelets, fall detectors
• Home hazards (think Rourke)
– Guns, water temp, smoke detector, seat belts
– Rugs, lighting, rails, bathing chair
• Care giver burn out
– Respite (over night and daytime)
– Counseling
– Support services (Kirby center, early dementia case
worker, HC)
Screen for the Geriatric Syndromes
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Cognition/ Delirium/ Depression
Polypharmacy
Incontinence
Falls
Osteoporosis
Orthostatic Hypotension
FTT
Abuse
**Driving
Driving
Driving
• Don’t Miss Dr. DeFina’s Amazing Talk!!
Screen for the Geriatric Syndromes
Geriatric Syndrome
Quick Screen
3 D’s
Functional Assessment
Maybe a MMSE/MoCA/Clock
Polypharmacy
Cascades/ drug interactions
Errors of omission
Pharmacy involvement ?
Incontinence
4 questions
Falls
1 question
Chair raise/ TUG
Orthostatic BP
Nurse?
FTT
Nurse?
2 questions
Abuse
3 very important questions
Driving
2 question
Recap
• Functional assessment
• Geriatric Syndromes
Quarterbacking
• This is the “stuff” every
talk glosses over BUT is
perhaps the most
beneficial to your patients.
This is where WE, the
family doctor, make a
difference. WE do what
no other physician can do.
This is OUR “specialty”.
Quarterback’s Check List
Goals of Care talk
Paperwork (PD/EPOA/Will)
Immunizations
Screening
Safety (Abuse, Injury prevention)
Driving
Nutrition
Social (Drinking, supports, ADLs/iADLs)
HOME CARE!
Goals of Care
• It is not a legal document
• 3% of all-comers survive resuscitation and ½
will have “significant impairment”
• We don’t all have the same values and beliefs
• Special populations
• Discussions with the family (especially the
Agent)
Goals of Care
• What phrases have you heard?
• Keep the goals of care on the fridge, EMS is
trained to look for it there.
Goals of Care
R1
R2
R3
M1
M2
C1
C2
“Full
resuscitation”
“No Chest
Compressions
”
“No
machines”
“No ICU”
“No surgery
unless for
symptoms
control”
No hospital
transfer
Palliative
Everything we
could possibly
do for them.
CPR 3%
unwitnessed
in healthy
adults
Go to ICU
Go to ICU for
medications
and post
surgery
People would
do surgery and
chemo.
Active
screening with
these ppl
Will go to
hospital only if
it improves
symptoms
For facility
patients really
Can go for
things like
fracture.
Dying or
terminal
illness
Personal Directives
• Just do it
Personal Directives
• Must have decisional capacity to make a
personal directive
• Often done with a Lawyer but can just Google
“Alberta Personal Directive”
• Name an “Agent” and hopefully an alternate –
caution with spouses. Watch for abuse.
• The “Agent” can not be the witness
Personal Directive
• 2 Types of PDs – one that names whom can
deem them incapable and one that deems
them by two healthcare workers
Personal Directives
• Schedule 1
• A person can name a person to deem them
incapable
• If no person is chosen the default is a doctor
or psychologist or designated capacity
assessor
Personal Directives
• 03.04N is the code for enacting a PD (ie
deeming someone incapable in one or more
domains of decisional capacity)
• You should cover this in your talk on capacity
• Do not skip this day
Enduring Power of Attorney
•
•
•
•
Usually done with a Lawyer
Two types of EPOAs
Immediate Clause
Springing Clause
A Will
• Deals with someone’s ESTATE after they DIE
• Usually if this is up to date so is the EPOA
PD/EPOA/Will
• Do this as part of your regular physical or
swear I will haunt you until the end of your
practice….
Immunizations for Seniors
• Influenza – annually
• Pneumococcal –
– PCV13 (Prevnar) once if
immunocomprimized
– PSV 23 once or twice q 5 year
apart (may have gotten it
before 65 with resp disease or
smoking)
– Space PCV13 and PSV23 apart
by 1 year
• Tetanus-diptheria – q10 years
• Shingles – once after 50 yo
(60’s optimal?)
Screening
• To screen or not to screen
Screening
• Depends on the patient’s goals
• Depends on the patient’s life expectancy
– No survival benefit if the life expectancy is <5
years
• No real evidence in this population for
screening
Screening
• Don’t Forget: Vision, Hearing and Dental
• Environmental assessment
Screening: Vision
• Vision:
– Visual impairment is <20/40 (20% of 75+ seniors)
and blindness is <20/200 (2% of the 75+seniors).
– Ask: "has your vision changed??".
– Snellen Chart = ocular vitals
• Screening: Glaucoma - >50yo q 1-2 years.
DM2 q 1-2years,
Screening: Hearing
• Hearing: presbycusis is the high frequencies
loss first and difficulty with background noise.
– Ask: Do other’s complain about the TV or Radio
being too loud? Is conversation difficult with
background noise?
– Look for social isolation (humm is it depression or
dementia?), misinterpretation of what you are
saying.
– Review medications for lasix, salicylates,
vancomycin and gentamicin.
Hearing: Tricks
• Tricks for talking to someone with poor
hearing are:
– Look directly at them
– Speak slowly (don't shout and use sentences so it
is easier to lip read)
– Write things down
– Reduce background noise
– Have the patient repeat what they have heard
back to you
Hearing
• Aids:
– Hearing aids. There should be feedback when
they turn on. Red in Right ear and Blue in Left ear.
– Don’t refer for a hearing aid if they won’t wear it
as they cost $600-900!! At least do the 30day trial
– Personal amplifiers
– Telephone for the deaf/
– Texting/ emails
YES! YOU CAN REALLY
DO THIS!!
Dr. Hoggard’s Geriatric Physical
Template
History
Physical
Plan
At today’s visit:
Issues:
1.
2…
Orthostatic Vitals: _____/_______
Height:
Weight:
Labs ordered:
F/u 1 year
Nurse to perform GDS and MoCA ??
Driving assessment?
Home Care?
Pharmacy Review?
Physio?
Function: Independent in iADLs
Screening: Pap, Mammogram, BMD, CRC, DRE
Diet: Recommended Vit D, 3 servings of dairy
Exercise:
Sleep:
Geriatric Syndromes:
Cognition: NC
Mood: NC
Incontinence: NC
OP: NC
Falls: NC
Polypharmacy: Reviewed
Driving: Driving, NC
PD/EPOA: Both completed
GOC: M1
Vaccinations: UTD
HEENT – Vision Hearing Dental: Up to date
CVS – S1s2 GAEB
Abdo – def
MSK – TUG < 10sec
-No Edema
-Good shoes, no aids
MoCA/ MMSE – “nurse to perform”
GDS – “nurse to perform”
Show me the money!!!!
Billing: Office Practice
Service
Code
Amount
Regular office visit
03.03A
Time modifier
CMGP01-06 (15min units)
15.70
Complete Physical
03.04A + modifier
88.90
Complex Care Plan (can be
billed with complete
physical)
03.04J + 03.04A + time
modifier
213.80 + 88.90 = >302.70!
Psychiatric Code (290)
08.19G/ 08.19D (family
member)
45ish/50ish
Drivers Medical >74.5yo
03.05H
76.90
Geriatric Assessment
03.04K
300.00
Anticoagulation
Management
03.01N
16.95
Phone Call Nursing/
pharmacy
03.01ng/03.01NM
16.95
Phone Call Patient/ family
03.05JR/ 03.05JP
35.91 (or 43.09 if >75 yo)
18.88/ ?50
Billing:LTC
Service
Code
Amount
Regular once weekly visit
03.03E
27.17
Admission to LTC
03.04D
105.50
Team Conference
03.05JD (per 5 min unit!!)
13.09
Formal Medication Review
03.05JE
27.29
Billing: Supportive Living
Service
Code
Amount
Regular once weekly visit
03.03NA (first visit onsite)/
03.03NB (subsequent
visits)
Team Conference
03.05JD (per 5 min unit!!)
13.09
Formal Medication Review
03.05JE
27.29
Enacting a PD
03.04N
$100 ish
84.61 + CMPG