Approach to the Elderly Patient

Question 1

List 5 morbid processes involved in the geriatric syndrome of falls syndrome

Question 2

List 9 giants of geriatric medicine

Answer 2

Instability

Immobility

Incontinence

Intellectual decline (delirium and dementia)

Iatrogenesis

Functional decline

Pressure ulcers

Dizziness

Frailty

Question 3

Outline Fried’s criteria for frailty

Answer 3

1) Unintentional LOW
2) Weakness
3) Exhaustion
4) Slow walking speed
5) Low physical activity

Pre-frail meets 1-2 criteria, frail 3 or more criteria

Question 4

What is the comprehensive geriatric assessment (CGA)?

Answer 4

Multidimensional, interdisciplinary process to determine the medical, psychological and functional capabilities of a frail elderly person in order to develop an integrated plan for treatment and follow up

Question 5

What is the purpose of the CGA?

Answer 5

Highest priorities are the prevention of decline in performance of ADLs, and the use of the CGA to drive the Dx process and clinical decision making

Screen for preventable diseases

Screen for functional impairments that may result in physical disability and are amenable to intervention

Question 6

What is the rationale underlying the CGA?

Answer 6

Early detection of RFs for functional decline when linked to specific interventions may help reduce the incidence of functional disability and dependency for older patients

Question 7

What were the findings of the Cochrane review of use of CGA vs general medical care with a median follow up of 12/12?

Answer 7

Lower death rate

Less functional decline

More likely to be living at home

Better cognition

Question 8

What is the 3 stage process of the CGA?

Answer 8

1) Targeting appropriate patients
2) Assessing and developing recommendations
3) Implementing recommendations

Question 9

What criteria are used to identify those who are too sick to benefit from the CGA?

Answer 9

Critically ill or medically unstable

Terminally ill

Disorders with no effective treatment

Question 10

What criteria are used to identify those who are too well to benefit from the CGA?

Answer 10

One or a few medical conditions

Needing prevention measures only

Question 11

What criteria are used to identify those who are appropriate and will benefit from the CGA?

Answer 11

Recent onset of physical and/or cognitive impairment

Changing physical and/or cognitive status

Multiple interacting problems that are amenable to treatment

Patients with fragmented specialty medical care

Disorders that require rehabilitation therapy

Consideration of change in living situation

Evaluating patient competency/capacity

Dealing with medico-legal issues

Question 12

Outline the medical, functional, neuropsychological, social, environmental and beliefs components of the patient which should be assessed in the CGA

Answer 12

Medical: problem list including comorbidities and disease severity, medication review, nutrition/dentition

Functional: ADLs, gait and balance, continence

Neuropsychological: cognition, mood

Social: living arrangements, supports (formal and informal)

Environmental: home safety, transport/community access

Beliefs: religion/spirituality, end of life care

Question 13

List 7 PADLs

Answer 13

Bathing

Dressing

Toileting

Continence

Grooming

Feeding

Transferring

Question 14

List 8 IADLs

Answer 14

Shopping

Cooking

Housework

Home maintenance

Using the telephone

Taking medications

Finances

Driving/transportation

Question 15

List 3 neuropsychological assessment tools which may be employed as part of the CGA

Answer 15

CAM (confusion assessment method): delirium

MMSE: dementia

Geriatric depression scale (GDS)

Question 16

List 9 potential members of a multidisciplinary team involved in the CGA

Answer 16

Medical

Nursing

Physiotherapy

OT

SW

Neuropsychology/clinical psychology

Podiatry

Speech pathology

Dietetics

Question 17

What are some of the challenges that may serve as barriers to a successful CGA?

Answer 17

Limited Hx: due to cognitive impairment, sensory impairment, other communication issues (may require a collateral Hx)

Difficult physical examination: poor cooperation, fatigue

Atypical presentation of disease

Lack of sensitivity and specificity of Ix: e.g. absence of leukocytosis with sepsis, raised creatinine indicating renal dysfunction

Ageism/nihilism: from health professionals, family/carers, patients themselves

Question 18

List some tips for communicating with a person with dementia

Answer 18

Use a tone of voice that conveys respect and dignity

Use clear and flexible language

Keep your explanations short

Position yourself at the person’s eye level and maintain eye contact

Ensure you have the person’s attention before you speak

Always begin by identifying yourself and explain what you are going to do

Use visual cues whenever possible

Be realistic in expectations

Observe and attempt to interpret the person’s non-verbal communication

Paraphrase and use a calm reassuring tone of voice

Speak slowly and clearly

Use strategies to reduce the effect of hearing impairment

Encourage talk about things they are familiar with

Use touch if appropriate

Question 19

Outline “ten top tips” for caring for a person with dementia

Answer 19

1) Stop
2) Plan and explain
3) Smile
4) Go slow
5) Give them space
6) Stand aside
7) Distract them
8) Keep it quiet
9) Don’t argue
10) Brainstorm and debrief