Geriatrics Presentation

8/12/2019 Geriatrics Presentation

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M3 SeminarSeptember 2006 1

Geriatrics

in a Nutshell

Karen E. Hall, M.D., Ph.D.

Clinical Associate Professor of Internal MedicineUniversity of Michigan, Ann Arbor VA Health Systems

Research Scientist,Geriatric Research, Education and Clinical Center


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Learning Outcomes

Review common Geriatric

Syndromes

In Coursetoolshtps://ctools.umich.edu/portal

Review geriatric assessment


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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


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Geriatric Syndromes (hospital)

Dementia, delerium, depression common, not documented

Inappropriate medications

anticholinergic Gait and mobility impairment

not documented

Incontinence

Iatrogenic complications constipation, pressure ulcers


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Geriatric Syndromes

(outpatient) Dementia, Depression, Delerium

Incontinence

Osteoporosis Falls

Hearing and vision impairment

Sleep disorders

Failure to thrive Iatrogenic (medications)


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Geriatric Syndromes

Dementia, Depression, Delerium Cognitive screen, ask about depression, check

orientation and concentration (serial 7s)

Delerium has variable orientation/concentration,

dementia doesnt

Incontinence Stress, urge, overflow

Stresssmall volume; urgelarger volume

Check for UTI with incontinence Ditropan can cause overflow


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Geriatric Syndromes

Osteoporosis Riskasian > 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 happenedtrip, slip, drop

Injury?

Mandatory: test sensation, balance, GAIT (TUG test)


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Geriatric Syndromes

Hearing and vision impairment Whisper test, check with glasses on

Sleep disorders

Normal agingsleep cycles only 3-5 hours max Going to bed too early?

ETOH; Tylenol PM?

Depression/anxiety?

Hot milk, read outside of bed, consider trazodone


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Geriatric Syndromes

Failure to thrive Dwindling

Weight loss

Increased frailty

Not able to live independently (without humanassistance)

Check for cognition, mobility, medication side effects

Cancer?

Consider hospice for refractory situation (sometimespeople get better with hospice!)


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Geriatric Syndromes

Iatrogenic

Medications Anticholinergics

Narcotics - dont forget the laxative

Stool softener alone will not be enough Antiarrhythmics

Dilantin (nausea; vertigo)

Neuroleptics

PPIsnausea, diarrhea; Aricept (diarrhea)

Bed Rest (hospitalization) Rapid loss of muscle strength (>80 years: lose 1 ADL

in 3-5 d)


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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,Pagets)

Renal (HTN, fluid/lyte abnormalities)

Infections (pneumonia, UTI, TB)

Gastrointestinal (dysphagia, constipation, tics)

Oncologic (colon, breast, prostate, hematologic)

Psychiatric (depression, psychosis)


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Documentation/Skills

First rule of history and physical exam

To treat the problem, you have todocument the problem


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Documentation

First rule of geriatrics (similar to first rule of

real estate sales)

Function, Function, Function

Patients dont care about their diagnoses,they care about their function


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Ask about.

ADLs (Activities of Daily Living)

IADLs (Independent Activities of

Daily Living)

Mobility

Incontinence

Affect/Mood

Cognition (Memory)


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These items go into the history

Either Social History or

Functional History

Or

In the HPI!


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Physical Exam

Test the following:

MobilityTimed Up and Go test- stand, walk,

turn, sitCognitionMini-Cog (3 item recall) or MMSE

(Mini Mental Status Exam)

AffectTwo question Depression screen


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The results go in the Physical

ExamTimed 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


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Documentation does not

necessarily mean DiagnosisDiagnosis belongs in the Impression/Plan

section

BUT.Rule #1:Avoid the trap of premature labeling

Problem 1. Falls (list the differential here)

NotProblem 1. Probable spinal stenosis

OrProblem 1. Musculoskeletal System


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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


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Prevention = Screening

Back to First rule of History and PhysicalExamination .

To prevent it, you have to document it

Learn about primary and secondary preventionscreening that maximizes function and minimizesfuture impairment

Keep current about age-associatedrecommendations for tertiary prevention(treatment)


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Social, Ethical, CulturalLearn 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, AreaAgency on Aging, 3 day inpatient requirement

for Medicare payment of CNH!


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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 otherintervention!

Geriatrics Presentation

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