Transcript Introduction to Geriatric Assessments

INTRODUCTION TO GERIATRIC
ASSESSMENTS
Geriatrics and Aging through Transitional
Environments (GATE)
MS-2 Curriculum
Shellie Williams, M.D.
Assistant Professor of Medicine
Section of Geriatrics and Palliative Medicine
The plan
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Why is geriatrics important?
What are special considerations in interviewing
elderly?
What are common communication issues in
geriatric encounters?
What are the assessment tools common in
geriatric medical encounters?
Why is geriatrics
important?
Population: Number of Persons
65+, 1900 – 2030
US Census Bureau Aug 14, 2008
Geriatric Medical Consumers
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66 % outpatient visits/year
40-48% hospital discharges/year
40% all US health care expenditures/year
1:6 US elderly has a chronic condition limiting
function
Vast majority living and seeking care in the
community
Geriatric or Older Medical patient?
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Different presentations of disease
Different reactions to medications
Different MEDICAL of problems
Memory and cognition
 Incontinence
 Arthritis
 Falls
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Communication is key
Not enough geriatricians!
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Currently 9,000
Actually need 20,000
By 2030, we will need 36,000
Increased demand Limited supply
All medical professionals should learn the basics
in elder care!
Why does geriatrics
require a special session?
HETEROGENOUS POPULATION
(Insert photos of seniors doing activity such as biking,
playing an instrument, holding hands romantically.)
Goal of Geriatric Medicine
Optimizing/Maintaining Function
Affective
Cognition
Medical
Conditions
Social
Supports
FUNCTION
Sensory
Limitations
Quality of Life
Unique challenges to
communication
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Expectations & Assumptions
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On the part of older patients
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Expectation that they will be treated with respect
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Mr. or Mrs. 
NEVER first names (unless you are specifically invited to do so)
“Sweetie…” is an insult to many
How can someone as young as you
know anything?
On the part of young doctors:
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Ageism
Over-accommodation
Ageism: Discrimination based on age, especially
prejudice against the elderly
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Seeing aging as a disease state
Attributing symptoms to age and not addressing
suffering
Withholding medical resources from older adults
(“why bother?”)
Failure to pursue uncomfortable subjectsSexuality, Alcohol abuse
Over-Accommodation:
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Avoid!
Treating older patients as children or with limited
respect or autonomy!
 Shouting or being condescending
 Just because a person is old does not mean they are:
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Stupid (avoid baby talk)
 Deaf (avoid shouting unnecessarily)
 Childlike (don’t call them “sweet,” “cute,” etc)
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General communication pointers
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Accommodate to the patient:
Get closer-vision and hearing may limit interaction
 Sit, don’t hover
 Speak slow, don’t rush thru
 Lower the pitch or use a Pocket amplifier
 Minimize background noise
 Write information
 Collateral historian, if cognition
impaired
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General Communication Pointers:
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Normalize questions and screens: “ This is
something I ask all my patients to gain a
better sense of their baseline function.”
Encourage and reassure.
Limit information to 2-3 key points.
Explain before doing.
Let them tell their story (open ended-1 min),
then focus with direct questions.
4 Communication
Challenges
It’s just old age, doc!
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What if your patient is hung up by
misconceptions about aging?
“Debility & pain are all I can expect” = Fatalism
 “Nothing can really be done” = Nihilism
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Or the patient is in denial because of fear (aging,
death, doctors)?
So your patient disagrees with your assessment–
what do you do??
5 STEPS TOWARD GOOD COMMUNICATION:
VPPMN
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Validate – Respect & Acknowledge the patient’s beliefs.
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Probe -- WHY do you feel this way?
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Perspective of situation
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“Osteoarthritis is a common condition, but there are lots of
treatment options available that can help improve your pain
and quality of life.”
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Motivate – Demonstrate ways in which options could
improve patient’s situation/achieve their goals.
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Negotiate –Try to achieve some middle ground of care
plan, agreeable to patient lifestyle/values.
Health Literacy
ASK-me- 3: What is my main problem?
What do I need to do?
Why is it important for me to do this?
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-Use LAYMANS’ Terms
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-Clarify misunderstandings
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-Assess understanding; reframe (ask-me-3)
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-Negotiate and document a plan
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“I’m not depressed!”
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Depression is highly stigmatized
Especially for older generations
 Depression is not a moral failing, proof of a bad
relationship with God
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Ageism, fatalism, nihilism can come into play
Getting old means misery and suffering
 So it’s natural to be depressed
 So treatment won’t help
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Federal Interagency Forum on Aging-Related Statistics.
http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2008_Document
s/Health_Status.aspx
Discussing Depression:
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Mini Assessment:
Direct approach (PQI-2)
“Are you depressed?”
“Have you dropped many of the activities you used to enjoy?”
 Indirect approach
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“Are you under stress? Are your nerves on edge?”
Mind-body connection “You feeling imbalanced?”
If yes to either approach:
Have things felt so bad you’ve wanted to end life?”
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Discussing Depression
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Depression often manifests with somatic
symptoms (headache, stomach ache, vague pain)
Common S/S elderly: persistent sadness, fatigue,
altered sleep, loss of interest in prior enjoyable
activity, irritable, anxious
Important to validate, acknowledge feelings
Important to assess suicide risk
“Have you thought of ending your life?”
“Do you have a plan for ending your life?”
5 Step Communication-Depression
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Validate “I can see this must be difficult for you. It
seems you are in a lot of pain.”
Probe “Why do you feel this is happening?”
Present your perspective (Education)
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“Depression is a medical disease, like high blood pressure or
diabetes.”
Motivate “I think there is hope for you returning to
your prior energy and activity level.”
Negotiate “ Let’s try the counseling and medication for
the next month. If things are better great if not, we will
work on a plan that gets you feeling better.”
Interacting With Patients with
Dementia
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Address the patient directly
Ask brief, directed questions
Allow time to communicate
Ask permission to involve others
Use short bits of information, reiterate key
points
Consider speaking with caregiver separately if
upsetting to patient for others to be present
Interacting with a Caregiver
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17% of the US population is an informal
caregiver for an adult who is ill or disabled
59-75% of caregivers are female
59% of caregivers work full time or part time
31% of those caring for the elderly describe
their own health as “fair” to “poor”
Caregivers experience depression, anxiety, and
insomnia
http://www.caregiver.org/caregiver/jsp
What if there’s a caregiver present
when you are taking the history?
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Pros:
Easy source of collateral history
 Suggests the patient has support at home
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Cons:
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3rd person can:
Monopolize the conversation
 Have their own needs and problems
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Conflicts between the patient and
caregiver can arise during the interview
Interacting with a Caregiver
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Avoid letting the caregiver monopolize the situation
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Set ground rules: Assure time for both parties, be respectful
Sit close to patient and give them 1 minute to tell their story.
(Open ended- “How are you doing?”
Focus patient with direct questions 1min
Allow 2 minutes open questions and concerns of caregiver
OK to redirect the conversation if needed
“I very much value your input and information, but I also
want to hear what mrs.____ thinks”
OK to ask caregiver to exit room for remainder of exam if
Too disruptive
Discussing Advance Directives
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Any statement about preferences for future medical
care: I want to die at home, do not resuscitate, do
not hospitalize, do not dialyze, do treat pain,
etc.
Advance
Directives can include:
Health Care Power of Attorney
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Advocates for your wishes
 Living will:
 Statement of medical care wishes
 Specifies conditions for
implementing wishes: terminal illness,
incurable condition.
 Types medical care
 CPR (compressions, intubation)
 Dialysis
 Insertion of large bore IV’s
 Artificial Hydration & Nutrition:
 Short term--NG Tube, IVF
 Long Term--PEG Tube
http://www.idph.state.il.us/public/books/advdir4.htm
Health Care Power of Attorney
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Surrogate to make health care decisions if
she/he unable to do so
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If no HCPOA designated, doctors will rely on
statutorily designated surrogate
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Does not need to be a family member
Substituted judgment utilized
Spouse, children, parents, siblings, friends
Substituted Judgment:
Supposed to make decisions based on what the
PATIENT would want if they were making decisions
How to Begin the Discussion
(with a non-terminally ill patient)
1. Introduce the Topic (Normalize)
“ I would like to talk with you about some possible health care decisions in
the future. This is something I do with all of my patients, so I can be
sure that I know and can follow your wishes, if you were to become very
ill or were near death. Have you ever thought of establishing a will for
your health in this type of situation?
2. Define Advance Directives (if needed).
“This is a document that explains to your doctors and those who love you
what is the focus if your care and who should help with decisions if you
were seriously ill or actively.”
The Advance Directives Discussion
3.
Explain no right or wrong decisions, the decision is
based on a quality of life acceptable to YOU.
Start with Health Care Power of Attorney (HCPOA)
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“If you were unable to make your own medical decisions, who would
you like to make them for you?”
Discuss Living Will (goals and preferences for future
care)
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What would you define an acceptable (or good) quality of life?
If you had limited time to live, how would you want to live or what
would be an important focus?
Are there any circumstances which would make life not worth living
to you?
Do you have any religious or spiritual beliefs that are an important
part of this decision for you?
The Advance Directives Discussion
6. If the patient has decided:
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Document the HCPOA and Living Will wishes
Give original to the patient, keep copy for the chart
Tell patient to discuss with HCPOA and family
Tell the patient to give copies to all other doctors
7. If the patient is undecided:
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Give them pamphlet and let them think about it at home
Make sure the patient knows to discuss wishes with family and friends,
especially the HCPOA
Make a future appointment to discuss
Do Not Resuscitate
(Insert photo of body tattoo stating “Do not
Resuscitate” wishes, if possible.)
Selected Aspects of the Physical
Examination in the Older Patient
Insert photo of older adult engaging in
exercise.
General Guidelines for Physical
Examination
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Explain what you are doing, before doing!
Use the Physical Exam to gain additional history
Surgical scars
 Cognitive impairment- are they able to understand
and follow instructions
 Upper & Lower extremity exam confirm functional
status
 Hearing, vision: Identify barriers
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Good positioning is key
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Challenging due to:
 Mobility
 Due
 Some
problems
to weakness, paralysis, pain
unable to follow instructions
 dementia,
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delirium
Make sure to:
Ask for help
 Use the bed to help you
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Geriatric Assessment
Tools:
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4.
Functional assessment: Adl, IAdl
Cognitive assessment: MMSE
Gait Assessment: Get up and Go
Pain Assessment: 7 steps, FACES
Evaluating Cognition
Federal Interagency Forum on Aging-Related Statistics.
http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2004_Documents/heal
thstatus.aspx#Indicator 17
Mini Mental State
Examination
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Standard screening test for cognitive impairment
Takes about <15 minutes to administer
Sensitivity and specificity both around 85%
Measures multiple cognitive domains
Orientation
 Memory
 Calculation & attention
 Language
 Visual-spatial skills
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Administering the MMSE
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Introducing the MMSE
“I’d like to get a baseline for how you are doing with
memory”
 “I would like to ask you some questions that will help
me know if you may be having memory problems.”
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Administering the MMSE
Encourage the patient to try
 Don’t tell patient if they are right or wrong
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“You’re doing just fine.” “Just a few more questions.”
Keep on track
 Must be exactly correct to get credit
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Functional Assessment:
Katz ADL
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ADLs (Activities of Daily Living)
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Do you need assistance or help with..
Transfer bed to chair?
 Walking? Do you use Cane? Walker?
 Caring for yourself in bathroom?
 Controlling your bladder?
 Bathing?
 Dressing or Undressing?
 Eating?
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Functional Assessment:
Lawton IADL
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IADLs (Instrumental ADLs)
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Do you need assistance or help with..
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Meal Preparation
Shopping/Buying Groceries
Managing Meds
Managing Money
Housework
Using Telephone
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? 911
Transportation (driving? public?)
Federal Interagency Forum on Aging-Related Statistics.
http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2008_Documents/Health_St
atus.aspx
Functional Status Assessment
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Determines safety living alone
Identifies areas of assistance need early, so help
can be instituted—homemaker, meal program,
transport service
Delays institutionalization
Prevents falls
Prevents morbidity and mortality
Community Care for Functionally Impaired
Environment
Health Providers
Services
Payment
Home Care
Nurse
PT/OT
Speech
Nutrition
Social Work
Homemaker
Hospice
Meds, wound care, diagnostics (labs, ekg, xrays), assess (wt,
bp).
Exercise & massage/ Physical and cognitive therapy, improve
ADLs
Language and swallowing therapy, education.
Assess & educate on nutrition issues.
Medical equipment (walker, cane).
Coordinate care services and counseling.
Personal care, housekeeping, food programs.
Multi-disciplinary care for terminal patients which addresses
pain,
other symptoms and care needs. Hospice is provided in
home,
nursing home or hospital hospice units.
Medicare if:
*Homebound
*Skilled services
*Physician Certifies
Other Community
Services
*Adult Day Health
*Meals
on Wheel
*Senior Centers
*Life Line
4-8 hr care and activities for seniors who are unable to be
home
independently without caregiver.
Delivered meal service for seniors
Senior programming sites which offer exercise, meals,
educational
programs, screenings. Emergency alert system for seniors in
community.
Private pay,
State funding
based on income
Independent Living
None
Independent apartment. Common area for meals and social
activity.
Private pay
Assisted Living
(all variable)
Nurse
Health Aide
Independent apartment. Common area for meals, social
activity.
Nurse, PT/OT services, health aide variable by facility.
Nurse for medications, vitals, wounds, education
Aide for adl care, housekeeping, shopping, laundry
Private pay
Nurse
Social Work
Therapist (SW, PT,
OT)
Nursing homes provide SNF care for residents within a 30day
period of acute hospitalization (3 midnight stay). Services (PT,
OT, SW, and Nursing wound care, IV medications, enteral
feedings, monitoring vitals and physician supervision &
documentation of SNF level.
Custodial care is nursing home care which provides 24 care
for functional impaired adults.
Medicare(100
days/enrollment
period).
Private or Medicaid
for custodial care
Supportive Living
(SLF)
Skilled Nursing
Facility
(Nursing Home)
SLF subsidized
based on financial
criteria
Why Do Gait Assessment?
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Identify Fall Risk
Identify orthopedic abnormalities
-Antalgic gait-protection of limb 2nd arthritic pain
-Unequal step length, stride due to fracture, dislocation
Identify neurologic conditions
-Shuffling, small, quick steps of Parkinson’s disease
-Staggering gait of Cerebellar disease
-Unilateral weakness of a Stroke (hemiplegic gait)
Identify metabolic conditions
-Ataxia (wide based gait with exaggerated step height/length)
due to alcoholism
(4) Primary Fall Risks:
ASK: (If yes consider below 4)
Have you fallen in past year?
Are you afraid of falling?
1. Cognitive deficits ( abnormal MMSE)
2. Social support limitation (Stairs, ADL level, care
environment)
3. Medications (>5 meds, sedative? anti-hypertensive?)
4. Lower extremity weakness (Get-up and go)
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Testing Upper Extremity Function
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Hands over head
Hands behind head
Scratch back with each thumb
Pick up coin with each hand
Look for limitations in range of
motion
Look for any signs of pain /
discomfort
Testing Lower Extremity Function
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Get Up and Go Test
Excellent test of functional mobility
 Timing: >20min, 40% fall without help
 Ask patient to:
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Get up from chair
 Walk approximately 12 feet=3meters
 Turn around
 Return to the chair
 Sit down
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Testing Lower Extremity Function
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Observe For:
(6) “S”
Stand-> trouble stand from chair (rock, use arms)?
Speed->20sec, slow?
Stance->stammer, sway with still or turn?
Stride->arm swing, leg/foot swing?
Symmetry-> equal steps (height, length)?
Straight-> path?
Proper use of assist device
Gait Assess with Cane:
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Make sure the cane is the correct height: come to
your wrist when patient are standing still and straight.
Use your cane in the hand that is opposite of the side
of your pain (normal, unaffected side).
If the cane is a proper fit, your elbow will be flexed
15-20 degrees when you hold the cane while standing.
Shift as much weight to the cane as necessary.
Make sure that the tip of the cane is in good
condition.
http://www.mayoclinic.com/health/canes
Pain Assessment:
Self-report best indicator of pain
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PQRSTU:
Precipitating/Provoking factors?
Quality of pain
Region/Radiation of pain
Severity of pain (1-10, faces, thermometer scale of
choice)
Temporal (constant, sporadic)
U (how your pain affects you and day/day activity)
Pain AD-Pain Assessment in
Advanced Dementia
Warden, V, etal. Development and psychometric
Evaluation of Pain Assessment in Advanced Dementia.
J Am Med Dir Assc. 2003; 4 (1) 9-15.
Pain Assessment
Good for patients with dementia
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Good for patients with dementia
Hockenberry MJ, Wilson D:
Wong’s Nursing Care of Infants and Children, ed 8, St. Louis,
2007, Mosby
RECAP
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Elderly population is heterogeneous
Varied presentations of disease requires unique
communication and clinical skills
Recognize common geriatric screening tools:
MMSE, Get up and go, ADLs, IADLs
Pointers: Be patient, adjust voice, pitch &
height as needed, consider collateral historian
Caregivers are collateral; Patient is primary!
Plan for the future: HCPOA, Living Will
RECAP: Geri Screens to KNOW
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(MMSE) Mini Mental State Examination
Get Up and Go Test
(ADL) Katz Activity of Daily Living
(IADL) Lawton Instrumental Activity of D. L.
Mini Depression Screen (PHQ-2)
ASK-Me 3 patient teaching
Pain PQRSTU and FACES card
Geriatric Quiz
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What are common signs/symptoms of
depression in elderly patients?
What are Activities of Daily Living (ADL)s?
What are Instrumental Activities of Daily Living
(IADL)s?
What is a health care power of attorney?
What is a living will?
Describe a test of lower extremity function.
Geriatric Quiz
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What is an example of ageism?
What are 3 communication pointers to consider
when interacting with geriatric patients?
What are 5 steps to effective communication?
What tips would you give your patient for using
their cane?
What is the primary goal of geriatrics?
For More Info on Geriatric Medicine
and Gerontology
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American Geriatrics Society
http://www.americangeriatrics.org/
(Geriatrics at Your Fingertips)
American Society on Aging
http://www.asaging.org/index.cfm
American Federation for Aging Research
http://www.afar.org/
U of C Geriatric Intern Rotation Website
http://arkham.bsd.uchicago.edu/gerioutpatientrotation/index.html
Advanced Directives:
1) EPERC = End of Life / Palliative Education Resource Center http://www.eperc.mcw.edu/
2) 5-Wishes Advance Directive Form—Probably the best
http://www.agingwithdignity.org/5wishes.html