Post on 17-Dec-2015
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 – With emphasis on mental status, mobility and
medication
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
• 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 • 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
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
• Nephron loss
• Blood supply to kidneys decreases
• Decreased creatinine clearance
Musculo-skeletal
• Decreased muscle strength and mass
• Cartilage deteriorates with narrowing of joint spaces
• Bone mass decreased (osteoporosis)
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
• 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
• 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
• 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
• 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
• Medication, mentation, mobility• Activities of daily living • Social Support • Advance directives • Hearing and Vision • Incontinence • Nutrition • Depression
CANDY TIME
• Today’s mneumonic: You will be quizzed on this at the end of the hour! MMM
– MEDICATION
– MENTATION
– MOBILITY
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
• 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
• Clearance is 50cc/hr (nearly half normal) • Potentially inappropriate medications
– Anti-cholinergics
– Benzodiazepines
– Tricyclics (ex: anti-depressants, muscle relaxers)
– Quinolones
– Meperidine
– Indomethacin
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
• 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
• 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 • 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
• 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
• 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
• 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 • 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
• 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
• 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
• Whisper test:” Boxcar” or several numbers, or finger rubbing
• 20/40 is functional vision (glasses on); it is the equivalent of newspaper print
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
• 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
• Single question approach; – “How do you see your future?”
– “Are you often sad or depressed?”
– “What do you do for fun?”
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?
• Medication
• Mentation
• Mobility
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