Evaluating the Geriatric Patient Flashcards
Activities of Daily Living (ADLs)
- Necessary for self-care
– Eating, dressing, bathing, standing sitting,
transferring, toileting on demand
Instrumental Activities of Daily Living (IADLs)
- Necessary for independent living
– Cleaning, meal preparation, proper
medication utilization, financial literacy &
ability, communication (ie phone/devices)
Whats included in a welcome to medicare visit?
- Record & evaluate medical & family hx,
current health conditions, & Rx’s - Measure baseline blood pressure, vision,
weight, & height - Make sure pt is up-to-date with
preventive screenings & services - Order testing, based on pts health & Hx
- Following the visit, give pt or caregiver a
plan with Medicare-covered screenings &
preventive services needed
What should be emphasized when asking about a social history for geriatric patients?
Nutrition
What number on a nutritional health checklist is considered high nutrition risk? what about good nutrition?
0-2 = Good nutrition
– Recheck 6 in months
3-5 = Moderate nutrition risk
– Improve eating habits
lifestyle
Recheck 3 months
6+ = High nutrition risk
– Professional help to improve
nutrition status
key factor for SNF placement
– Incontinence
Whats an important general health thing to be looking for during a comprehensive geriatric history?
FUNCTIONAL STATUS CHANGE
HEENT screening for geriatric patients
– Vision
* ↓acuity (close objects, low lighting)
* Light sensitivity
* Efficacy of corrective lenses
– Hearing
* Amplification device
* Hearing Handicap Inventory for the
Elderly-Short (HHIE-S)
– For symptomatic adults only
– Asymptomatic adults >50 yo
» USPSTF rating = I
Mouth
* See Geriatric Oral Health lecture
Cardiovascular ROS for geriatric patients
Orthopnea
– Edema
– Angina
– Claudication
– Palpitations
– Dizziness
– Syncope
Musculoskeletal ROS for geriatric patients
– Focal or diffuse pain
– Focal or diffuse weakness
Neurological ROS for geriatric patients
– Visual disturbances (transient or progressive?)
– Progressive hearing loss
– Unsteadiness &/or falls
– Transient focal symptoms
Hearing loss screening for geriatric patients
- Presbycusis, acoustic neuroma, meds,
cerumen impaction, faulty/ill-fitting
hearing aids, Paget disease - 3 ft whisper test
- Hearing Handicap Inventory for the Elderly-Short
(HHIE-S)
Looking for muscle wasting in Geriatric patients
– atrophy
– malnutrition
– ↓ calf circumference
& hand strength
Patient functional outcomes are the product of
working with the patient to:
- Remedy what can be changed
- Develop an “environment” in which the
patient can thrive
Importance of OT in geriatric rehabilitation
– OT environmental assessment in
asymptomatic adult ↓ subsequent
hospitalizations
Assessing Activities of Daily Living:
- Feeding
- Dressing
- Ambulation
- Toileting
- Bathing
- Transfer (bed, toilet)
- Continence
- Grooming
- Communication
What is a “Times up & go” test?
- Patient stands up from a standard arm chair.
– clinician starts a timer on the word “Go” - Pt walks 10 ft to a line on the floor at normal pace
– wear regular footwear & may use a walking aid, prn - Turn
- Walk back to the chair at your normal pace.
- Sit down again (stop the timer & record time)
* Observe for any deficits in leg strength,
balance, vestibular dysfunction, & gait.
What is a 30-second chair stand used to assess?
Assess leg strength & endurance
1. Patient sits upright on a standard chair & places
hands on opposite shoulders, crossed, with the feet
flat on the floor.
2. Clinician starts a timer on the word “Go”
3. Patient stands up, then sits down again.
4. Repeated for 30 seconds
Assessing Instrumental Activities of Daily Living:
- Writing
- Reading
- Cooking
- Cleaning
- Shopping
- Doing laundry
- Climbing stairs
- Using telephone
- Managing medication
- Managing money
- Ability to perform paid
employment duties or
outside work (eg, gardening) - Ability to travel (use public
transportation, go out of town)
Global measure of function & well-being used in outpatient settings
Medical outcomes study questionaire short form-36
Comprehensive assessment mandated on
admission to SNFs
Minimum data set
* Most current version = MDS 3.0
* Medicare/Medicaid-Certified Nursing Facilities
Part of the Inpatient Rehabilitation Facility–
Patient Assessment Instrument [IRF-PA
Functional independence measure
Medicare mandated comprehensive data
collection system
The outcome & assessment information set (OASIS)
Delirium
Acute, confused state, common in the elderly
* ↓ attention & awareness
* Quick onset (hours – days), with ↑↓ course
* Altered cognition
* Not the result of another neurocognitive d/o
* Caused by medical condition or substance (ie meds)
Assessment tool for Delirium
Confusion Assessment Method (CAM)
Dementia
Chronic decline in 1+ cognitive domains
* Learning & memory
* Language
* Executive function
* Complex attention
* Perceptual-motor
* Social cognition
* Must be acquired & represent a significant
↓ of prior functioning
* Cognitive deficits must interfere with
independence in everyday activities
* Disturbances do not occur exclusively during
delirium
* The disturbances are not better accounted
for by another mental disorder (eg, major
depressive disorder, schizophrenia)
MMSE Cognitive Domains
- Attention
- Language
- Memory
- Orientation
- Visuo-construction
- Praxis
MoCA cognitive domains
- Attention
- Language
- Memory
- Orientation
- Visuo-construction
- Executive functioning
Mini-Cog cognitive domains
- Memory
- Visuo-construction
- Executive-functioning
MMSE Strengths and limitation
Strengths
* Moderate strength for
detection of dementia
* Likely distinguishes pts with
& without dementia
Limits
Optimal cutoff scores affected by
age, education, literacy, &
cultural background
MoCA Strengths and limitations
Strengths
* Sensitive for detection of
mild Alzheimer & cognitive
impairment
* High sensitivity for dementia
in pts with stroke
Limitations
Low specificity for dementia in
pts with stroke
Mini-Cog Strengths and limitations
Strengths
Some studies suggest
moderate sensitivity &
specificity for dementia
screening
Limits
Some studies suggest
very low sensitivity
(43%)
Depression
- Late-life depression is underdiagnosed &
inadequately treated
– Most common psychiatric disorder in
older adults who commit suicide - PCPs provide >80% of depression treatment
in older adults - Often undiagnosed or untreated
5-item geriatric depression scale:
- Are you basically satisfied with your life? Yes/No
- Do you often get bored? Yes/No
- Do you often feel helpless? Yes/No
- Do you prefer to stay at home rather than going out
& doing new things? Yes/No - Do you feel pretty worthless the way you are now?
Yes/No
New Evidence on
Grief Theory
- Disbelief
- Yearning
- Anger
- Depression
- Acceptance
Elder Mistreatment
Behavior by someone with an
ongoing relationship to an elder, & a duty
towards that elder, that may constitute:
– Willful infliction of physical pain or injury
or unnecessary restraint (physical abuse)
– Willful nonconsensual sexual contact
(sexual abuse)
– Willful infliction of emotional harm
(psychological abuse)
Failure to provide for the needs &
protection of a vulnerable elder when that
person had an ongoing relationship with the
elder & a duty to provide for those needs &
protection.
Neglect
Risk Factors for elder mistreatment
Dementia
– Living in the same household as the abuser
– Socially isolated
– Advanced age, ↓ financial literacy,
disability, bereavement
Signs of Elder Mistreatment
- Signs of dehydration
- Weight loss
- Poor hygiene
- Skin breakdown
- Fractures/prior fractures
- Signs of cognitive impairment
- ↓ anal sphincter tone
- Perineal excoriation
- Vaginal bleeding
- Vaginitis
- Cystocele
- Fecal impaction
- Burns
- Excessive/repeat bruising
- Subdural hematoma
- Skin tears
- Rhabdomyolysis
Frailty =
susceptibility to poor outcomes
* Calculated with medical history & functional status
* Performance tests & nutritional status
COMPREHENSIVE GERIATRIC
ASSESSMENT:
FRAILTY INDEX (CPA-FI) interpretation
– Score is expressed as a proportion of potential
abnormalities, actually present in the patient
– CGA-FI can range from 0 to 1
– Higher values = Greater frailty
* E.g. FI = 20/50 = 0.4
