“Geriatrics” in a Nutshell

1. “Geriatrics”in a Nutshell Karen E. Hall, M.D., Ph.D. Clinical Associate Professor of Internal Medicine University of Michigan, Ann Arbor VA Health Systems Research Scientist, Geriatric Research, Education and Clinical Center

2. Learning Outcomes • Review common Geriatric Syndromes In Coursetools htps://ctools.umich.edu/portal • Review geriatric assessment

3. M3 Clinical Competencies(from CourseTools) • Geriatric syndromes and conditions • Diseases more common in older patients • Psychosocial issues • Disease prevention • Ethical Issues • Health Care Financing (Medicare) • Cultural aspects of aging

4. Geriatric Syndromes (hospital) • Dementia, delerium, depression • common, not documented • Inappropriate medications • anticholinergic • Gait and mobility impairment • not documented • Incontinence • Iatrogenic complications • constipation, pressure ulcers

5. Geriatric Syndromes (outpatient) • Dementia, Depression, Delerium • Incontinence • Osteoporosis • Falls • Hearing and vision impairment • Sleep disorders • Failure to thrive • Iatrogenic (medications)

6. Geriatric Syndromes • Dementia, Depression, Delerium • Cognitive screen, ask about depression, check orientation and concentration (serial 7’s) • Delerium has variable orientation/concentration, dementia doesn’t • Incontinence • Stress, urge, overflow • Stress – small volume; urge – larger volume • Check for UTI with incontinence • Ditropan can cause overflow

7. Geriatric Syndromes • Osteoporosis • Risk – asian > caucasian > AA/black • Kyphosis on physical exam • Dexa scan (femoral neck; L spine) • Everyone gets 1000-1500 mg Ca + 400-800 IU Vit D • Treatment: Alendronate > calcitonin; estrogen/reloxifene; weight lifting • Falls • How many “Any in past 6 months?” • What happened – “trip, slip, drop” • Injury? • Mandatory: test sensation, balance, GAIT (TUG test)

8. Geriatric Syndromes • Hearing and vision impairment • Whisper test, check with glasses on • Sleep disorders • Normal aging – sleep cycles only 3-5 hours max • Going to bed too early? • ETOH; Tylenol PM? • Depression/anxiety? • Hot milk, read outside of bed, consider trazodone

9. Geriatric Syndromes • Failure to thrive • “Dwindling” • Weight loss • Increased frailty • Not able to live independently (without human assistance) • Check for cognition, mobility, medication side effects • Cancer? • Consider hospice for refractory situation (sometimes people get better with hospice!)

10. Geriatric Syndromes • Iatrogenic • Medications • Anticholinergics • Narcotics - don’t forget the laxative • Stool softener alone will not be enough • Antiarrhythmics • Dilantin (nausea; vertigo) • Neuroleptics • PPIs – nausea, diarrhea; Aricept (diarrhea) • Bed Rest (hospitalization) • Rapid loss of muscle strength (>80 years: lose 1 ADL in 3-5 d)

11. Common Diseases in Elderly • Neurologic (Parkinsons, stroke, TIA) • Rheumatologic (RA, PMR, vasculitis) • Genitourinary (BPH, sexual dysfunction) • Cardiovascular (afib, CAD, CHF, HTN) • Endocrine (hypothyroid, diabetes type II, Paget’s) • Renal (HTN, fluid/lyte abnormalities) • Infections (pneumonia, UTI, TB) • Gastrointestinal (dysphagia, constipation, ‘tics) • Oncologic (colon, breast, prostate, hematologic) • Psychiatric (depression, psychosis)

12. Documentation/Skills First rule of history and physical exam “To treat the problem, you have to document the problem”

13. Documentation First rule of geriatrics (similar to first rule of real estate sales) “Function, Function, Function” Patients don’t care about their diagnoses, they care about their function

14. Ask about…. • ADLs (Activities of Daily Living) • IADLs (Independent Activities of Daily Living) • Mobility • Incontinence • Affect/Mood • Cognition (Memory)

15. These items go into the history Either “Social History” or “Functional History” Or In the HPI!

16. Physical Exam Test the following: Mobility – Timed Up and Go test- stand, walk, turn, sit Cognition – Mini-Cog (3 item recall) or MMSE (Mini Mental Status Exam) Affect – Two question Depression screen

17. The results go in the Physical Exam “Timed Up and Go was 15 seconds, patient walked slowly, unsteady, had to hold rail for support” “Two question depression screen positive” “Patient only remembered 2 of 3 items on Mini-Cog”

18. Documentation does not necessarily mean “Diagnosis” Diagnosis belongs in the “Impression/Plan” section BUT…. Rule #1: Avoid the trap of “premature labeling” Problem 1. “Falls” – (list the differential here) Not Problem 1. “Probable spinal stenosis” Or Problem 1. “Musculoskeletal System”

19. Develop a Plan rather than a Diagnosis • Rule #2: • You can start addressing functional impairments without having a specific diagnosis • Patients appreciate a practical plan • Home safety, mobility aids, social supports

20. Prevention = “Screening” Back to First rule of History and Physical Examination …. “To prevent it, you have to document it” Learn about primary and secondary prevention screening that maximizes function and minimizes future impairment Keep current about age-associated recommendations for tertiary prevention (“treatment”)

21. Social, Ethical, Cultural • Learn about cultural influences on health behavior • DNR, family involvement • Learn about stressors that affect patients and families • Caregiver stress, finances • Know what resources are out there to help • Social work (Turner clinic + other), types of assisted living, medication assistance, Area Agency on Aging, 3 day inpatient requirement for Medicare payment of CNH!

22. Social, Ethical, Cultural Ask the patient what THEY WANT TO DO about their problem “Do not assume your preference is their preference!” This will avoid more lawsuits than any other intervention!