Approach to the Geriatric Patient

Question 1

How do the elderly differ from other age groups in clinical presentation?

Answer 1

Ocham’s Razor reversed: Often multiple causes s/s
Addressing modifiable (not all) factors can help
Presentation of acute illness is often nonspecific
May be substantial lag between dx/tx improve

Question 2

How does the incidence of fever change in the elderly?

Answer 2

Fever may be absent in 20%-30% elderly w/serious infxn

Fever may be absent in 30-50% frail elderly w/serious infxn

Adjust diagnostic criteria for elderly

• single temp > 100F (37.8C) or
• repeated temp > 99F (37.2C), or
• rise > 2F (1.1C) over baseline

Increased sensitivity to over 80%, maintains specificity 90%

Question 3

One iatrogenic issue that must be addressed

Answer 3

Immobility

80% willing/able to walk short distance independ
During 5 day stay:
83% of time spent lying in bed
13% time sitting
3% time (median 43 min/d) standing or walking

Clinical consequences
Orthostatic intolerance
Loss of muscle mass within 24hrs supine position
After adj for illness severity and comorbidity
low mobility in hosp  functional decline
low mobility in hosp   new NH placement

Question 4

Why is it important to understand a geriatric patient’s functional status?

Answer 4

Measuring functional status objectively allows appreciation of deterioration/improvement over time

Changed functional status is an important presenting sxm

Function helps prioritize individual problems

Function is important in deciding treatment efficacy

Knowing baseline funx helps in managing acute illness

Question 5

What are the four areas of the geriatric assessment?

Answer 5

Functional
Physical
Mental
Social

Question 6

What activities are addressed by the ADL assessment?

Answer 6

Bathing
Dressing
Transferring (bed to chair)
Toileting
Grooming
Feeding

Bathing is often where help is first needed

Question 7

What are the Instrumental Activities of Daily Life?

Answer 7

Using the telephone
Shopping
Food preparation
Housekeeping
Doing laundry
Utilization of transportation
Ability to medicate
Ability to handle finances

Question 8

Why is a medication review important?

Answer 8

Major cause of illness, hospitalization, mortality
High risk for Adverse Drug Reactions (ADR)
- Polypharmacy
- Comorbid conditions
- Impaired renal function not evident in serum Cr
Compliance/adherence is often problematic
Includes OTC, herbals, and alcohol use

Question 9

What are the two questions of the depression screening test?

Answer 9

“During the past 2 wks have you felt down, depressed, or hopeless?”

“During the past 2 wks have you felt little interest or pleasure in doing things”?

Question 10

What are the two broad aspects of the geriatric mental assessment

Answer 10

Depression

• 2 question screen
• Geriatric depression scale (GDS)

Cognitive impairment

• Mini-mental status exam: 30 pt screen
• “Mini-cog” – 3 item recall + clock test

Question 11

What should be screened for in post-menopausal women?

Answer 11

Osteoporosis

50% post-menop F will have OP fx

• 25% vertebral deformity
• 15% hip fx

Screen all women age 65+ (grade B, no RCTs)

Screen at age 60 if risk factors
- low body wt (