Evaluating and Caring for the Geriatric Patient (Mimis with some edits)) Flashcards
What is the main purpose of the geriatric assessment
To be effective in keeping patients in the community and reducing mortality
how should you handle a geriatric patient with multiple complaints
- don’t feel like you have to gather all information at one visit
- shorter interviews in separate sessions may be more beneficial
what approach provides better chronic disease management and informed medical decision making
Teach-back approach
how can we Ensure awareness and sensitivity to cultural differences with regards to patient preferences and personal aging goals
Make every attempt to provide information in patients native language and offer interpreters
Why may a patient with lower health literacy not be as perceptive to treatment? How can we aid in preventing this?
- Often feel less empowered when interacting with health care providers
- Assess what the patient already knows or understands
- Slow speech and avoid medical terminology
- Use pictures if reading literacy is low
- Literacy appropriate written instructions help to improve chronic disease management
- 5th grade reading level or lower, clear heading, bright contrasting colors, large font size (14 or larger)
7 Components of a Geriatric Assessment
- Comprehensive History and Physical Exam
- Functional assessment
- Social assessment
- Environmental assessment
- Nutritional assessment
- Psychological assessment
- Patient goals
challenges with geriatric assessments
- communication
- underreporting of sx
- vague sx
- multiple complaints
PMHx should include?
- Previous surgical procedures
- Major illnesses and hospitalizations
- Previous transfusions - Immunization status
- Influenza
- pneumococcus
- Td
- Zoster
- Covid - Preventive health measures
- Mammography
- Pap smear
- Colon cancer screening
- Antimicrobial prophylaxis
- Estrogen replacement - Tuberculosis history and testing
what should be included in medication hx?
“Brown bag” technique
Knowledge of current medication regimen
Compliance
Perceived beneficial or adverse drug effects
Previous allergies
What is the determining factors of whether a patient can remain at home or needs to be placed in an institution
A strong social support network
how can social assessments be helpful?
- Determine who would be available to help if your patient becomes ill.
- Early identification of social support problems can help with planning and timely development of resource referrals.
- For patients with functional impairment, ascertain who can help your patient with ADLs and IADLs.
areas of high importance in PE
- Visual and auditory acuity
- Gait and ambulation
- Abdomen – aortic dilation
- Mental status and cognitive function
- MMSE
- MoCA - Montreal Cognitive Assessment
Pathologic findings can be superimposed on age-related physical changes
Which cognitive assessment is more sensitive to detecting milder forms of cognitive impairment? what is a major perk of using this assessment
MoCA - Montreal Cognitive Assessment
it comes in multiple languages, versions for audiovisual impairments and lower literacy
what is the potential significance of elevated blood pressure in the geriatric population
Increased risk for cardiovascular morbidity; therapy should be considered if repeated measurements are high
What is the potential significance of postural changes in blood pressure in a geriatric patient
- May be asx and occur in the absence of volume depletion
- Aging changes, deconditioning, and drugs may play a role
- Can be exaggerated after meals
- Can be worsened and become symptomatic with antihypertensive,vasodilator, and TCA
What is the potential signifigance of an irregular pulse in the elderly
Arrhythmias are relatively common in otherwise asymptomatic elderly; seldom need specific evaluation or treatment
what is the potential significance of tachypnea in the elderly
Baseline rate should be accurately recorded to help assess future complaints (such as dyspnea) or conditions (such as pneumonia or heart failure)
what is the potential significance of weight changes in the elderly population
- Weight gain should prompt search for edema or ascites
- Gradual loss of small amounts of weight common; losses in excess of 5% of usual body weight over 12 months or less should prompt search of underlying disease
Poor personal grooming and hygiene can be signs of what?
poor overall function, caregiver’s neglect, and/or depression; often indicates a need for intervention
Slow thought processes and speech usually represents what?
Usually represents an aging change; Parkinson disease and depression can also cause these signs
what is the potential significance of ulcerations in the elderly population
- Lower extremity vascular and neuropathic ulcers common
- Pressure ulcers common and easily overlooked in immobile patients may indicate a lack of adequate patient care
Diminished turgor often results from ?
- atrophy of subcutaneous tissues rather than volume depletion
- when dehydration suspected, skin turgor over chest and abdomen most reliable
what is the potential significance of diminished hearing in the elderly population
- High-frequency hearing loss common; patients with difficulty hearing normal conversation or a whispered phrase next to the ear should be evaluated further
- Portable audioscopes can be helpful in screening for impairment
with decreased visual acuity, what is often overlooked?
Hemianopsia is easily overlooked and can usually be ruled out by simple confrontation testing
what is the potential significance of cataracts and other ocular abnormalities in the elderly populaiton
Fundoscopic examination often difficult and limited; if retinal pathology suspected, thorough ophthalmologic examination necessary
Diminished turgor is often results from ? how to best assess this?
Often results from atrophy of subcutaneous tissues rather than volume depletion; when dehydration suspected, skin turgor over chest and abdomen most reliable
what is the potential significance of missing teeth
Dentures often present; they should be removed to check for evidence of poor fit and other pathology in oral cavity
what is the common site for early sign of malignancies
Area under the tongue
what abnormal lung sounds can be heard in geriatric assessments? what do they indicate?
Crackles can be heard in the absence of pulmonary dz and HF
often indicate atelectasis
what is the potential significance for systolic murmurs in the elderly population
Common and most often benign; clinical history and bedside maneuvers can help to differentiate those needing further evaluation
Carotid bruits may need further evaluation
what is the potential significance of vascular bruits
Femoral bruits often present in patients with symptomatic peripheral vascular disease
what is the potential significance of diminished distal pulses
Presence or absence should be recorded as this information may be diagnostically useful at a later time (eg, if symptoms of claudication or an embolism develop)
Prominent aortic pulsation is suspicious of ?
abdominal aneurysms
what are the MC lesions seen in geriatric assessments?
Actinic keratoses and Basal Cell Carcinomas
most others are benign
may see “old age spots”
what genitourinary things can be seen in a geriatric assessment?
-
atrophy
- Testicular atrophy normal
- atrophic vaginal tissue - possible dyspareunia and dysuria
— tx may be beneficial -
Pelvic prolapse (cystocele, rectocele)
- Common
- may be unrelated to sx
- gynecologic evaluation helpful if pt has bothersome, potentially-related sx
what is the potential significance of periarticular joint pain
Can result from a variety of causes and is not always the result of degenerative joint disease; each area of pain should be carefully evaluated and treated
limited ROM is often caused by ?
pain resulting from active inflammation, scarring from old injury, or neurological disease; if limitations impair function, a rehabilitation therapist could be consulted
what is the potential significance of edema?
- Can result from venous insufficiency and/or heart failure; mild edema often a cosmetic problem; treatment necessary if impairing ambulation, contributing to nocturia, predisposing to skin breakdown, or causing discomfort
- Unilateral edema should prompt search for a proximal obstructive process
Arm drift may be the only sign of ?
residual weakness from a stroke
Determining appropriate lab assessment is based upon ?
what are the managements?
life expectancy
Life expectancy is >10 years no change in recommendation on management of disease
Life expectancy is <10 years (and especially when it is much less) order labs only if it will improve the patient’s prognosis and quality of life
Misinterpretation of abnormal lab values in geriatrics leads to ?
underdiagnosis and undertreatment
what arethe laboratory parameters unchanged by aging
- Hemoglobin and hematocrit
- WBC
- Platelet count
- Electrolytes (sodium, potassium, chloride, bicarbonate)
- BUN
- LFT (transaminases, bilirubin, prothrombin time)
- Free thyroxine index
- TSH
- Ca
- Phosphorus
Common abnormal laboratory parameters
- Sedimentation rate - age-related change
- Glucose - elevated during illnesses
- creatinine - elevated values may indicate reduced renal function
- albumin - decline indicate undernutrition
- alkaline phosphatase - mild asx elevations common; liver and Paget disease if elevated
- Serum iron, iron-binding capacity, ferritin - decrease is NOT an aging change - undernutrition and/or GI bleed
- Prostate-specific antigen - elevated with BPH, consider prostate cancer
- Urinalysis - asx pyuria and bacteriuria MC, hematuria abnormal
- Chest radiographs - Interstitial changes are a common age-related finding
- Electrocardiogram - ST-segment and T-wave changes, atrial and ventricular arrhythmias, and blocks _MC in asx and may not need specific evaluation/tx _
An evaluation of how a patient’s health conditions impact their physical and psychosocial function
Central focus of geriatric care
Functional Assessment
what are the multiple factors of functional decline?
Medical (physical)
Psychological
Social
Environmental
what are ADLs?
Activities that people need to be able to do to take care of themselves
ex: Ambulation, bathing, dressing, eating, transferring, continence, toileting
what are IADLs
Activitiesthat allow an individual to live independently in the community
ex: Transportation, shopping, cooking, using the telephone, managing money, taking medications, cleaning, laundry
what should you distinguish when observing an IADL/ADL impairment?
If possible, whether it is due to:
cognitive decline
physical disability
cultural / family customs
how often should functional assessments be preformed?
- Assess during first comprehensive exam and periodically
- Always assess after hospitalization, severe illness, or the loss of a spouse or caregiver - Loss of ADL or IADL function often signals a worsening disease
- Look for reversible causes
- No identifiable cause perform an environmental assessment
what is an environmental assessment
An evaluation of a patient in their living space to provide more independence – allows patient to remain at home
Environmental Assessment is best if performed by who?
PT, OT, or speech therapist
Environmental recommendations after geriatric assessments
- Physical tools: Ramps, grab bars, elevated toilet seats, shower chairs, walkers, bedside toilets
- Special services: Meals on wheels, homehealth
- Increased social contact: Friendly visits, telephone reassurance, participation in recreational activities
- Provision of critical elements: Food, money
what nutritional assessment findings are common in older adults? why does this happen?
- wt loss and malnutrition are common in older adults
- A general decline in caloric need happens as we age
- Slower metabolism
- Reduced physical activity
what is the trend with body weight in geriatrics?
increases from age 30 – 60
plateaus for ~10 years
then declines
when does nutritional assessment findings need to be evaluated further?
low BMI (< 20)
unintentional weight loss of > 10 pounds in 6 months
Risk factors for malnutrition
- Drugs altering appetite (digoxin, chemo, chronic steroid use)
- Chronic dz (CHF, COPD, renal insufficiency, chronic GI dz)
- Depression
- Dental and periodontal disease
- Decreased taste and smell
- Low socioeconomic level
- Physical weakness
- Isolation
- Food fads
Reasons to use the Mini Nutritional Assessment? scoring?
- Declining food intake over the past 3 months
- wt loss during the last 3 months
- Mobility
- Psychological stress or acute disease in past 3 months
- Evidence of dementia/depression
- BMI
- Calf Circumference
12-14: Normal
8-11: At risk
0-7: Malnourished
Micronutrients (vitamins and minerals) recommendations
- Ca
- Increases from 1000 mg/day to 1200 mg/day
— Age 50 for F
— Age 70 for M - Vit D
- Increase from 600 IU to 800 IU at age 70 - Most OTC multivitamins meet remaining micronutrient needs
Macronutrients (proteins, carbohydrates, fats) recommendations
No change recommended
- Omega 3 & Omega 6 fatty acids are not made, so must be consumed
- Fat intake <30% of total calories consumed
- carbs should make up 55% of total calorie intake
What are some ways to manage Undernourishment and Malnutrition in the geriatric population
- Eat w/ family/friends and increase social support
- Control pain
- Increase physical activity
- tx depression: preferably with Rx that has appetite stimulate
- Caloric liquid or powder supplements 1 hr before meals
- Not as a replacement - unless pt refuses to eat
- Powder formulation can be mixed with food - Artificial tube feeding
- temporary vs permanent: consider patient overall goal
How to improve geriatric obesity
- Healthy well-balanced diet
- Exercise regimen
- Must be feasible and detailed
- Provide specific short-term goals
- Exercise should include aerobic and resistance training - Pharmacologic agents have not been adequately investigated in the geriatric population
Factors that can interfere with functional status on psychological assessment
- Bereavement: Intervene Early
- Widowhood
- One of the most stressful transitions in later life
- Better outcomes if patient has previous history of independence
- Encourage volunteering and social engagement - Medical condition with a poor prognosis
- Financial burden
- Caregiver neglect
- Depression
- sx often atypical
- Often deny dysphoric mood
- Common sx include:
— Fatigue, weakness, anorexia, wt loss
— Anxiety, insomnia
— “Pain all over”
— Apathy
— Feelings of guilt
— Lack of concentration
screening tools used for psych assessment? scoring?
- Geriatric Depression Scale
- PHQ-9 Patient Depression Questionnaire
- score > 5 - suggestive of depression and should warrant f/u interview
- Scores > 10 - depression
for patient goals, Identify patient values and preferences such as:
Maintaining independence
Symptom relief
Prolonging survival
Intentional or neglectful acts by a caregiver or trusted individual that led to or may lead to harm of a vulnerable older adult
elder abuse
Affects 2% to 10% of elders despite being underreported
pt w/ cognitive impairment are at highest risk
Five types of abuse
Physical
Sexual
Psychological / emotional
Financial
Neglect
what are physical findings suggestive of physical elder abuse
- Pattern of bruising or burns
- Areas not likely to bruise during routine activity - abd, neck, posterior legs
- Bruises that encircle elder person’s arms, legs, or torso
- Burns in the shape of an object - Unexplained fractures, sprains, dislocations, internal injuries
- Open wounds or cuts
- Untreated injuries
what type of elder abuse?
what history and physical findings are suggestive of sexual elder abuse
Unusual sexual behavior
Unusual or inappropriate relationship between pt and abuser
Bruises on or around the genital area/breasts
Unexplained sexually transmitted or genital infections
Unexplained vaginal or anal bleeding
Torn, stained, or bloody underwear
Pain with walking or sitting
what history and physical exam findings might you see in psychological/emotional elder abuse
hx shows Depression, Anxiety, Agitation, Excessive fears, Sleep changes, Change in appetite
PE shows Passiveness, Evasive, Fear—possibly in presence of abuser, Confusion, Agitation, Significant wt changes, Sudden worsening medical conditions
what can be seen in financial abuse?
- Ambiguity of financial status
- Inability to pay bills, buy food or medications
- Sudden changes in legal documents (will, power of attorney, health care agent)
- Excessive concern regarding expenses necessary for patient’s care by the possible abuser
- Living excessively below the patient’s means
- Discomfort/evasiveness when discussing finances
what are signs and symptoms of neglect
- Absence of Hearing devices, Eyeglasses, Dentures, Assisted walking devices
- Sudden changes or decline in health
- Malnutrition, Dehydration, Poor hygiene, Inadequate or inappropriate clothing, Decubitus ulcers/bedsores, Recurrent infections
what screenings can be done for potential elder abuse? scoring?
- Elder Abuse Suspicion Index (EASI)
- a “yes” answer to questions 2, 3, 4, 5, or 6 should raise a red flag for abuse
Patient should be interviewed alone to avoid intimidation
Elder Abuse – Intervention and Management
- Requires a comprehensive geriatric assessment
- Ensure immediate safety of the patient
- Admit to hospital if patient is unable to return to home safely
- Contact local law enforcement if necessary - Contact Adult Protective Services (APS)
