The Stealth Geriatrician: How to learn what you need to know from your patients Tiffany Shubert,...
Transcript of The Stealth Geriatrician: How to learn what you need to know from your patients Tiffany Shubert,...
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The Stealth Geriatrician:How to learn what you need to know from your patients
Tiffany Shubert, Ph.D., MPTTony Caprio, MD
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Course Objectives
Identify four key risk factors for falling in older adults
Perform a comprehensive geriatric functional assessment
Evaluate the need for referral “Build a Team” – Determine
disciplines and community resources to aid in patient health management
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Why Falls?
AAMC Minimum Competency All adults over 65 years should be
asked about falls All adults should be observed and
assessed rising from a chair and walking
All patients who have fallen should have a differential diagnosis and evaluation plan to address the fall and potential risk of falls
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Why Falls?
Medicare PQRI Program Incentive pay for falls screening!
Good Practice Facilitates successful aging Opportunity for health promotion
Collaboration with other disciplines Collaboration with community
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Who is going to fall?
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How will you identify who will fall?
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A comprehensive geriatric assessment uncovers falls risk
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What you can find in your comprehensive exam
If you take their shoes off!
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Introducing Mrs. Jones
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Chief Complaint
It depends on who you ask:
Patient: “No complaints, I feel fine”
Daughter: “Difficulty getting around the house, I am afraid she may fall”
MD: “Blood pressure should be better controlled”
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History of Present Illness
What do you want to know? Changes in medications Trips to the opthamologist Trips to the ER Changes in mood/activity levels Previous falls
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Past Medical History
HypertensionParoxysmal Atrial FibrillationChronic Renal InsufficiencyAnxiety/Depression“Dizziness”Osteoporosis
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Medication List
Metoprolol Hydrochlorothiazid
e Digoxin Warfarin Sertraline
Diazepam Zolpidem Meclizine Fosinopril Alendronate
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Medication Review > 4 Drugs = Increased risk of falls Red Flags – Classes that increase falls risk
Benzodiazepines (short and long-acting agents)
Antidepressants (tricyclics and SSRIs) Antipsychotics Anticonvulsants Opioids Antispasmodics Over the counter medications
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Social History
What do you want to know? Living Situation
Type of house? Stairs? ADLs, IADLs Social Supports Economic Status Smoke/Drink Current Activity Level Fear of Falling
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Activities of Daily Living:Ask or Observe
ADLs Transferring Toileting Bathing Dressing Continence Feeding
IADLS Transportation Use the phone Buy groceries Meal preparation Housework Medication Pay bills
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Review of Systems Systems vs. Syndromes
Organ-based review may give you limited information
Geriatric syndromes encompass multiple organ systems
Falls Dizziness, Vision, hearing Cardiovascular Orthopedic problems, arthritis,
neuropathy Depression, cognitive impairment
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Physical Exam Findings General Impression Vital Signs
BP sitting 140/90, HR 88 BP standing 110/80, HR 100 Pain
HEENT Bilateral cataracts, difficulty reading magazine
and wall poster CV
Grade II/VI systolic murmur (right upper sternal border)
MS Neuro
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Functional Assessment:Timed Up and Go
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Functional Assessment: Walking Speed
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Functional Assessment:Timed Chair Rise
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Functional Assessment:Chair Rise Mrs. Jones
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Functional Assessment:Balance
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Mrs. JonesWhat Happens at Home
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Functional Assessment
What Do You Learn?
How Do You Assess?
Referral
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Cognitive Assessment
Clock Draw Test
Mini-Cog
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Mrs. Jones Clock
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Clock Draw Example
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Home Safety Evaluation
Use an environmental assessment sheet
Occupational therapy
Financial difficulties may be culprit
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Assessment: Mrs. Jones
What are the problems? History of falls 3 of the 4 risk factors for falls
Leg muscle weakness, poor walking, polypharmacy
Orthostatic Hypotension Osteoporosis
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Plan: Mrs. Jones What will you do about it?
Fix orthostasis Address osteoporosis Modify medications
Who will you refer to? Occupational Therapy - home safety eval Physical Therapy - leg strengthening, gait
training, and assessment for assistive device Consult with pharmacy about current
medication list and insurance coverage Community Services for behavior change
programs, wellness and socialization activities
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Synthesis Evaluating major risk factors for falls
is fundamental to a geriatric assessment
A functional assessment will identify individuals at risk for falls
A functional assessment can (and should) be done with your older patients
Refer to other disciplines to best manage complex older adults
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Practice Practice Practice
Practice with volunteers Physical, Cognitive, and Medication
Assessment On the wards
Perform at least one mini-Mental and clock draw
Shadow a physical therapist and perform 1-2 functional assessments
Identify which of your patients are at risk for falls