Geriatric Assessment Flashcards
1
Q
the goal in geriatrics
A
- measure, preserve and nurture the functional status of our elderly patients
- assist in maintaining quality of life
- recognize decline
2
Q
geriatric assessment
A
- Observation is key
- ROS is key
- Medications are key
- Problem Lists are invaluable
- Caregivers and situation
3
Q
Barriers to care of the elderly
A
- Beliefs about “normal” symptoms of aging
- Access to care
- Denial, fear, negativity
- Cultural barriers
- Western medicine does not“let people be”
- It takes a long time (for us, for them)
- Multiple medical diagnoses, issues
4
Q
Why do the elderly present differently
A
- Biologic, genetic, social
- Altered central processing (Cellular aging, Pre-existing brain dz (dementia), Current illness affecting brain function)
- Neuronal degeneration (Reduced muscle strength, balance, Reduced peripheral sensitivity)
5
Q
how do the elderly present differently
A
- Confusion, fatigue, anorexia
- Vague, non specific symptoms (“I’m just worn out”,“I feel weak, dizzy”)
- Typical sx’s may be delayed or absent (High suspicion for sx’s which appear abruptly or rapidly over a few days - Dementia takes a LONG time!!, Physical and psychological sx’s)
- “Not acting right” is always significant – always start with your ROS!! (The person who says this knows them! You don’t know them!)
6
Q
common atypical presentations
A
- Delirium vs. Dementia
- Infection (Delirium, altered mental status, Fever, leukocytosis may be absent, Think urinary tract infection first, Both men and women)
- Acute abdomen (May have minimal abdominal complaints, Change in mental status, Stop eating/drinking)
7
Q
common atypical presentations
A
- Acute MI (SOB is most common symptom – nausea and “don’t feel right” are the other common sxs, Epigastric pain can be a presenting sx of inferior wall MI until proven otherwise, Fatigue, weak, epigastric pain, low energy)
- Depression (Confusion, EtOH, isolation, weight loss, vitamin deficiency, anemia)
- Abuse (Delayed presentation, often cannot transport self to office/hospital, Neglect, wounds, fractures)
- Why is abuse so under-reported? What happens to the patient if caretaker goes to jail?
8
Q
elderly assessment
A
- Pre-appointment questionnaires
- PMH (Illnesses, Hosp/Surg, Recent labs/tests, Get old medical records, Specialists)
- Meds/CAM/OTC Meds (Bring all meds to appointment!! - This includes OTC!!, Drug and dosage errors)
9
Q
special ROS
A
- Sleep, weight, appetite
- Skin, sores
- Vision, hearing, teeth, swallowing
- SOB, chest pain, palpitations
- Abd pain, digestion, changes in stool
- Urinary sx’s and bladder function
- Syncope, weakness
- Depression, mood changes, Hx mental illness
10
Q
elderly history: social history
A
- Caregivers/Contacts/Support
- Sexual function/activity
- Exercise
- Dietary habits/Nutrition
- Tobacco/Alcohol/drugs
11
Q
elderly history: comp assessment
A
- Function – ADL’s, IADL’s, vision, hearing, etc
- Cognitive - memory, confusion, etc
- Safety - stairs, lighting, abuse, etc
- Falls
- Transportation
- Activities
- Advanced Directives
12
Q
elderly falls
A
-SPLATT
- Symptoms - before/after
- Previous falls
- Location
- Activity
- Time of day
- Trauma
13
Q
the elderly interview
A
- Adequate time. Review old record
- May undress after history
- Pace of questions, volume of your voice, manners
- Face the patient, interpreter
- Obtain history from patient when possible. Include spouse, family, caregiver when appropriate
- Balance between listening and efficiency
- Hold your place
14
Q
planning for the physical examination
A
- Warm room, warm stethoscope
- Low exam table, chairs for Hx
- Positioning – can’t move well, lie flat, etc (Be creative in accommodating physical ability)
- Modesty - undressing and gowning the patient
- Be gentle but thorough in exam
15
Q
important aspects of the physical exam
A
- General - dress, hygiene, mood, fitness
- Vitals - pulse, orthostatics, height/weight
- Skin – thinning, pressure sores, bruising, lesions
- HEENT – trauma, vision, cataracts, ears, teeth, tongue, MM’s
- Neck - bruits, thyroid, JVD, masses?
- Lungs - chest wall, kyphosis, rales?
- Cardiac - RRR? Murmur? PMI?
- Abdomen - aorta, bruits, liver, hernias, bladder
16
Q
ABCDE mneumonic for suspicious skin lesions
A
- A: asymmetry, B: border irregularity, C: color variegation, D: diameter >6mm, E: evolution
- Beware of lesions that bleed or are one-of-a-kind
17
Q
Dental, oral health issues may lead to poor nutrition
A
- If someone’s tongue is fissured, the person is dehydrated
- Smooth tongue: vitamin deficiency (B12)
- Geographic tongue: usually benign
- Hairy tongue
18
Q
The physical exam
A
- Extremities – edema, bruising, hair (Feet - nails, inter-digital spaces)
- GU exam – special considerations
- Rectal exam – stool guaiac, impaction, prostate, hemorrhoids
- Buttocks/sacrum - pressure sores
- Musculoskeletal – ROM in relation to IADL’s
- Neuro screening: mental status, memory, balance, strength, gait, tremors, sensation
- Listen/watch for clues during history
- Watch them walk! Timed Up and Go Test (10ft in 14 seconds. More time = fall risk)
19
Q
Basic diagnostic tests/tx
A
- Baseline tests on file (CBC, Chem panel, Lipid panel, TSH, UA with microscopy, Stool guaiac, PSA, Vit D, CXR, EKG)
- Immunizations (Pneumovax, flu shot, Zostavax/Shingrix, tetanus)
- Screening tests (Mammogram, colonoscopy, prostate, Pap, DEXA, PPD, etc)
20
Q
Common medications
A
- Aspirin - daily
- Clopidogrel, Coumadin
- Statins
- Beta Blockers, ACEI/ARB, diuretics, alpha blkrs
- Viagra/Ciallis
- Bisphosphonates for osteoporosis, fx risk
- Tylenol, Alleve, etc
- Calcium, Vit D, Multi Vits, glucosamine
- Stool softener, Mylanta, Tums
- OTC meds: elderly are biggest consumer market
21
Q
how to fight polypharmacy
A
- Review meds each visit
- Goal = minimum possible
- Check interactions
- Organize, label, discard old bottles
- Verify understanding of how to take, what to avoid
- Try behavior changes before prescribing pills
22
Q
risk reduction through lifestyle changes
A
- Smoking cessation, limit alcohol
- Nutrition – overall and disease specific
- Exercise – endurance, strength, balance, mobility, joints, weight, breathing all improve
23
Q
goals for treatment
A
- Problem List
- Short-term Plan
- Longer Term Plan
- Anticipatory Guidance
24
Q
Problem list
A
- Today’s issue(s)
- Acute and chronic illnesses/issues
- New findings
- Problematic medications
- Major life events/changes
25
Q
short term plan
A
- Treat today’s problem
- Medication adjustments, measure levels
- Address patient or caregiver concern, questions
- Discuss and schedule plan for Health Maintenance
- Discuss follow-up plan, frequency
26
Q
long term plan
A
- Family involvement
- Health Maintenance (dates)
- Management of chronic conditions - goals
- Goals for diet, exercise, habits
- Safety
- Discuss warning signs and Sx’s
- Advanced Directives - POLST
27
Q
anticipatory guidance
A
- Discuss progression of current illnesses
- Long term side effects of meds
- Future plans (Driving, Meals, Need for increased level of care, Inability to live alone)
28
Q
goals for treatment
A
- Address social and environmental issues
- Don’t only treat physical disease
- Look at the big picture – the whole patient including the home, family and support systems
29
Q
hospital assessment
A
- Often complex, fragile patients
- Don’t lose sight of chronic issues
- History over time OK - old records
- PE with nursing help - be thorough (Check the backside!)
- Attention to cognitive changes, PE and vital sign changes, family support
- “Discharge planning begins on day of admission”
30
Q
nursing home assessment
A
- Unique setting/pt’s - chronic issues
- Multiple meds, illnesses, past procedures – chart review
- Goal to stay or goal to leave?
- Cognitive changes very common (Chemical/physical restraint common)
- Tricky Hx/PE but same skills needed
- Home care goal? Coordinate, educate family, multidisciplinary
31
Q
depression in the elderly
A
- Subclinical depression very common (Anxiety, insomnia also very common)
- Common with multiple medical problems
- Common in nursing homes, care centers
- Affects quality of life - isolation, lethargy, withdrawal, suicidal ideation
- Can affect performance on cognitive tests
- The elderly respond to treatment - both medical and lifestyle changes
32
Q
cognitive impairment
A
- Uncovering it is critical to geriatric care
- Cognition, behavior, judgment
- Impairment of IADL’s is often first sign
- If new/rapid - think illness (delirium)
- If chronic/worsening, may require referral for formal neuropsychiatric testing (Assess for dementia)
33
Q
What does MSE test
A
- Mental/Psychiatric disorders (Depression, Psychiatric illness)
- CNS/Organic Illness (Dementias, Alzheimers Dz, Metabolic imbalances, Appearance and Behavior, Speech and Language, Mood, Thoughts and Perceptions, Insight and Judgment, Cognitive function, Information and Vocabulary
34
Q
mini mental status exam
A
- Shortened, screening version of formal
- Plan visit, extra time, quiet room
- Introduce the exam: “I’m going to test your memory now”, “I have a few questions that may sound silly…” to introduce level of consciousness questions
- Culturally relevant, education level, literacy
- Assess level of consciousness (Comment on LOC in chart, Alert, interactive, sleepy, waning attention, etc…, Language barriers, ability to speak, Hearing disorders)
- Total = 30
- <23 concerning for cognitive, neurological or neuropsychiatric dz
- Hampered by low education level, cultural issues, hearing loss
35
Q
when to do the MMSE
A
- New patient assessment (Outpatient, Skilled Nursing Facility)
- Inpatient assessment (Various times of day if fluctuating mental status)
- Health maintenance visits
- Perform q 6 months after first sign cognitive decline
36
Q
“set test” or category fluency
A
- Cognitive function, MMSE alternative
- Tests language, memory, executive function, concentration
- Name 10 items in categories: fruits, animals, colors, towns - 1 minute each category
- <15 out of 40 = abnormal
- Wandering, repeating also abnormal
37
Q
the caregiver
A
- Key role but what exactly is their role?
- Who are they?
- How long involved in care?
- Live-in? Visit? How often?
- Giving/monitoring medications?
- Participate in ADL’s or IADL’s or both?
38
Q
recognizing caregiver stress
A
- Fragility of caregiver themselves
- Depression
- Other obligations
- Decline in patient’s abilities/faculties/health/mental status
- Do they need help?
- May schedule appt for them, alone
- Provide validation, support, referrals
