Integrated Care Flashcards
What does the Comprehensive Geriatric Assessment involve?
Identify physical, socio-economic, functional, mental/psychological and environmental issues to formulate management plan.
What are the two types of communication models between doctor and patient?
Questioning model - completely doctor-led conversation
Exchange model - share conversation, patient is expert in their own situation.
Describe the model of communication?
Speaker has a thought, then has linguistic representation for which they have facial movements and acoustics to express their thought.
At the same time they have haptic feedback and auditory feedback of what they’re saying.
Perceiver uses audition and vision for linguistic representation and figures out meaning of what has been said.
Different ways to measure functional ability? Who measures this usually?
Occupational therapist. Feet and footwear Gait and balance Pain and joint assessment Lying and standing blood pressure Sensory loss Weight and nutrition PR and genitalia
More info about feet and footwear?
- condition of feet and toenails. Oedema and ulcers.
- Peripheral sensory testing, warmth, pulses, peripheral oedema.
- Recommend well fitting, secure footwear to minimise falls risk.
More info about gait and balance?
- Can walk outdoors? How far? Do they need aid?
- Can patient walk distances needed to go indoors?
- Any changes to walking pattern? Shuffling? Initiating movement? Can’t stop walking? Fall backwards? Feet too wide apart? Swinging on leg out to side? Inability to walk in straight line?
- Restricted activity?
- Had any falls recently?
- Feel off balance, unsteady or dizzy?
How to assess gait and balance?
Watch gait
Timed up and go test:
- sit in knee height chair, stand up, walk 3 meters, turn around, walk back, sit back down.
- normal for over 65s is 8-11 seconds
- > 11 seconds indicates impairment
- if they use arms of chair to help them stand, indicates lower limb weakness.
- Not suitable for patients who need walking aids.
180 degrees turn test:
- Patient stands in position where they are surrounded by potential support.
- Stand behind patient and ask them to turn to face you.
- they shouldn’t need any support to do this.
- patients who take >5 steps are at increased risk of falls.
- Not suitable for patients with walking aids.
Gait speed:
- Should take less than 5 seconds to walk 4 meters.
Referral options for someone with gait and balance problems?
Outpatient service for second medical opinion.
Physiotherapy
Occupational therapy
Community based exercise options if fit enough
Social inclusion groups - psychological impact of poor mobility.
Important points in pain and joint assessment?
Many elderly patients deny pain, or unable to express it.
May be evident by observing patient.
Use other descriptors (stiffness, ache, etc)
May need a thorough assessment by physiotherapy.
Important points in lying and standing blood pressure?
Patient lies flat for 5 minutes -> check BP
Patient stands up -> immediately check BP
Recheck BP after 1 and 3 minutes of standing
Drop of more than 20 systolic or below 90 shows postural hypotension.
Important points in sensory loss?
Deficits can be compensated for. Eg lip reading in deafness.
Whisper in one ear and ask for them to repeat back, whilst rubbing trigs of other ear.
Gross visual testing - how many fingers? Read line from book.
Important points in weight and nutrition?
Check and record weight consistently.
Evidence of weight loss includes poor fitting clothes or loose skin.
Can also be seen in general condition of hair, nails, oral hygiene.
Important points in PR and genitalia?
PR exam - constipation, prostate, haemorrhoids, bleeding, rectal mass.
External genitalia and breast should be briefly examined.
What does social and environmental assessment include?
Live at home? Stairs at home? Stairlift? Toilet facilities easy access? Bathroom access? Access to home for health workers? Cooking facilities? Smoke detector? Does patient get out and about? How do they mobilise outside house? Is patient a carer? Benefits? Health care funding? Capacity? DOLS? Power of attorney? Funeral plan?
Assessment of mood?
Expression and affect?
Depression symptoms?
5-10% of elderly patients have depression.
Risk factors for depression and suicide?
Older age Male Social isolation History of suicidal attempts Chronic pain Chronic illness Drug or alcohol abuse Sleep disorders
Screening questions for depression?
During last month have you ever been bothered by feeling down, depressed or hopeless?
Do you ever sit and cry for no reason?
Do you ever worry about the future?
During the last month have you found little interest in things you used to enjoy?
Do you feel lonely?
What is the formal questionnaire for depression in elderly?
Geriatric depression score.
Assessment of cognition?
Collateral history
Rate of decline
Montreal cognitive assessment (MOCA)
Appreciated mental test
Assessment of medication review?
Full drug history
Review use of drugs - what they take, how much, any problems?
NO TEARS
Need and indication Opinion of patient (do they take it?) Tests and monitoring Evidence and guidelines Adverse effects Risk reduction or prevention Simplification/switches
What would you consider prescribing to reduce effects of fractures?
Calcium and vitamin D for frail, elderly, housebound patients with history of falls.
Bisphosphonates for secondary prevention of osteoporosis - risk of atypical femoral fractures with long term use - FRAX tool to calculate osteoporosis risk.
Drug classes that may increase risk of falls?
Antidepressants Antipsychotics Antiemetics Sedatives and hyponotics Parkinson's drugs Muscle relaxants Drugs with anticholinergic side effects Cardiovascular drugs Analgesics Anticonvulsants
