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Geriatric Functional Assessment: The Geriatric Review of Systems. Mary B. Preston MD FACP Associate Clinical Professor of Geriatrics University of Virginia. Objectives. Understanding of basic differences in organ systems in the elderly Knowledge of functional geriatric assessment

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geriatric functional assessment the geriatric review of systems

Geriatric Functional Assessment: The Geriatric Review of Systems

Mary B. Preston MD FACP

Associate Clinical Professor of Geriatrics

University of Virginia

objectives
Objectives
  • Understanding of basic differences in organ systems in the elderly
  • Knowledge of functional geriatric assessment
    • With emphasis on mental status, mobility and medication
different metabolism function
Different metabolism/function
  • Cells and tissues
    • Increased fat to lean (even in skinny people)
    • Heat production falls (the older, the colder)
    • Connective tissue has decreased elasticity
      • Example: lungs and skin
cardiovascular
Cardiovascular
  • More sensitive to volume changes
  • Stroke volume, resting cardiac output decreases 1% per year
  • More ischemia therefore more myocardial infarction and more congestive heart failure
  • More problems with cardiac rhythm
  • Tendency to have orthostatic hypotension
respiratory
Respiratory
  • Decreased forced expiratory volume in 1 sec (FEV1)
  • Decreased vital capacity
  • Arterial oxygen is less: the formula which adjusts for age is
    • PaO2 = 100.10 - 0 .323 x age
    • example, 60 yo average pa02 is about 82
slide6
GI
  • Diverticulosis occurs in over 1/2 of people over the age of 60
  • Decreased esophageal motility
  • Decreased saliva (by 2/3)
  • Less ability of liver to detoxify
renal
Renal
  • Nephron loss
  • Blood supply to kidneys decreases
  • Decreased creatinine clearance
musculo skeletal
Musculo-skeletal
  • Decreased muscle strength and mass
  • Cartilage deteriorates with narrowing of joint spaces
  • Bone mass decreased (osteoporosis)
neurology
Neurology
  • Parkinson’s disease seen in 10% of this population
  • Memory loss is NOT part of normal aging
  • Retention of new information decreases with aging
  • There is a slower processing time with aging
sensory
Sensory
  • Vision: trouble with glare and dim light; increased farsightedness, cataracts
  • Hearing: decreased universally by age 85; high frequency sounds harder to hear
  • Taste buds: ½ are non-functional
  • Smell decreased
  • Decreased proprioception
not normal aging
NOT normal aging
  • Fatigue is not part of normal aging
  • Anemia is not part of normal aging
  • Incontinence is not part of normal aging
  • Depression is not part of normal aging
  • DESPITE what patients themselves tell you – “I guess I am just getting old”
interviewing skills
Interviewing skills
  • Speak to the patient, not the caregiver
  • Speak distinctly and where the person can see your lips
  • Take your time
  • Avoid age-ist remarks, EVEN if the patient themselves makes them; don’t agree
  • Older patients tend to be more conservative in their dress and expect you to be also
examination skills
Examination skills
  • Deafness: speak in front of the patient, not to the side or behind them; do not shout
  • Attend to their comfort realizing that they may have arthritis
  • Warm your hands
  • Realize that they may respond slower; this does not indicate dementia
covering the geriatric issues the screening geriatric assessment
Covering the geriatric issues: The screening geriatric assessment
  • Medication, mentation, mobility
  • Activities of daily living
  • Social Support
  • Advance directives
  • Hearing and Vision
  • Incontinence
  • Nutrition
  • Depression
candy time
CANDY TIME
  • Today’s mneumonic: You will be quizzed on this at the end of the hour! MMM
    • MEDICATION
    • MENTATION
    • MOBILITY
medication
Medication
  • The list is NOT enough
  • Do they need each medication ?
  • Are there any medications that interact?
  • What is their renal function?
  • What drugs are potentially inappropriate in the elderly?
  • What is the average number of medications taken by an elderly person – at home, in the nursing home?
medications 2
Medications - #2
  • The list: must include over the counter, doses, as needed (“prn”), how often taken
  • Major interactions: Software programs help
  • Renal function: if you are a 90 yo man with a creatinine of 1.0 (“normal”), a weight of 72 kg, your clearance is--------?
  • Average number of meds: 4.5 for community dwelling, 7-9 for nursing homes
medications 3
Medications #3
  • Clearance is 50cc/hr (nearly half normal)
  • Potentially inappropriate medications
    • Anti-cholinergics
    • Benzodiazepines
    • Tricyclics (ex: anti-depressants, muscle relaxers)
    • Quinolones
    • Meperidine
    • Indomethacin
mentation
Mentation
  • Common sense approach: look at the patient’s dress, observe way questions are answered
  • Need a baseline: from records or family
  • Tests confirm your common sense and allow you to not be fooled by the socially adept but demented patient
  • Prevalence of dementia is about 50% in those over the age of 85
mentation 2
Mentation #2
  • You must distinguish between dementia, delirium and depression
  • Dementia: gradual onset, progressive
  • Delirium: acute onset, fluctuation, patient is inattentive
  • Depression: sad affect, sees future as no better or even worse than the present
tests for dementia
Tests for dementia
  • MMSE: developed 1975; educationally dependent; poor specificity and sensitivity but extensively used for screening
  • Questions: Orientation, Registration, Attention, Recall, Language
  • How to score: no half credit for being close
  • Traditionally, less than 24 = cognitive impairment
tips for doing mmse
Tips for doing MMSE
  • Use spelling WORLD backwards rather than serial 7s: easier for patient and for you
  • Overcoming resistance (yours and theirs)
    • “I do these tests on ALL over age 65”
    • “Some of the questions may seem silly - just bear with me”
    • If patient upset by not doing well, skip to the easier items
other tests
Other tests
  • Animal naming: Name all the animals you can in one minute
  • Lab: Thyroid stimulating hormone (TSH), B12, (VDRL only with appropriate history), CBC, Chemistry (renal and hepatic function). It is rare that a lab test shows you a problem that is responsible for the dementia.
  • X-ray: one time MRI or CT scan - especially to check for subdural hematoma
mobility
Mobility
  • Why might this be a problem?
    • Arthritis
    • Muscle atrophy (remember more fat than lean)
    • Sedentary life style
    • May contribute to incontinence
    • May contribute to depression
exam for mobility balance
Exam for mobility/balance
  • The Get Up and Go test : person sitting in chair, gets up, walks 10 feet, turns and walks back to chair and sits down
  • The Functional Reach: standing, not moving legs, reach with outstretched hand about 6 inches
  • One leg balance: should be able to stand a few seconds on each leg independently
activities of daily living
Activities of daily living
  • This is part of the geriatric history
  • ADLs versus IADLs
    • ADLs are basic, I =Independent or Instrumental

like using public transportation, using a phone

  • Mneumonic for ADLs: DEATH
    • Dressing, eating, ambulating, toileting, hygeine
social support
Social Support
  • This is a variation of the “social history” that you have been doing
  • Ask who would be able to help if the patient became sick
  • Ask where the children live; do not assume that if they live next door they help out
advance directives
Advance Directives
  • ASK what the patient wants
  • Difference between the living will and the durable power of attorney for health care
  • Offer the patient some concrete scenarios
  • Listen
  • Document
hearing vision
Hearing/Vision
  • Whisper test:” Boxcar” or several numbers, or finger rubbing
  • 20/40 is functional vision (glasses on); it is the equivalent of newspaper print
incontinence
Incontinence
  • There are 2 main types of incontinence
    • Stress: the history question here is “Do you pass urine if you cough or sneeze, or other times involuntarily?”
    • Urge: “Do you have to rush to get to the bathroom?”
nutrition
Nutrition
  • Ask if they have lost more than 10 pounds in the last 6 months
  • The cause is likely to be not a disease, but a situation
    • Medications
    • Depression/Loneliness
    • Finances
    • If a disease, hyperthyroidism, cancer
depression
Depression
  • Single question approach;
    • “How do you see your future?”
    • “Are you often sad or depressed?”
    • “What do you do for fun?”
depression 2
Depression #2
  • Distinguish between grief, minor depression and major depression
  • Depression in the elderly CAN be treated successfully
  • Grief: look at it functionally – not in terms of time
  • Major depression: the janitor can recognize; the excellent clinician can recognize “minor” depression and greatly benefit their patient
mmm what are they
MMM - what are they?
  • Medication
  • Mentation
  • Mobility
conclusion
Conclusion
  • You are now ready to do an excellent history and physical with your elderly patient
  • You know that it takes a different knowledge base, a different set of skills, and above all, a non-ageist attitude
  • If you remember nothing else, remember THE THREE M approach