The Stealth Geriatrician: How to learn what you need to know from your patients Tiffany Shubert, Ph.D., MPT Zeke Zamora, MD Anthony Caprio, MD

Course Objectives Define “geriatric syndrome” Define “geriatric syndrome” Identify key risk factors for falling Identify key risk factors for falling Perform a comprehensive geriatric functional assessment Perform a comprehensive geriatric functional assessment Identify appropriate interventions Identify appropriate interventions “Build a Team” – Determine disciplines, community resources, and evidence-based programs to manage patient health “Build a Team” – Determine disciplines, community resources, and evidence-based programs to manage patient health

Why falls? > 35% of your patients fall annually AAMC Minimum Competency All adults over 65 years should be asked a falls history All adults over 65 years should be asked a falls history All adults should be observed and assessed rising from a chair and walking All adults should be observed and assessed rising from a chair and walking All patients who have fallen or at risk of falling should have a differential diagnosis and evaluation plan All patients who have fallen or at risk of falling should have a differential diagnosis and evaluation plan

4 Standard of Care AGS/BMJ Practice Guidelines All older adults screened for falls by health care provider Key questions Two or more falls in prior 12 months Presents with acute fall Difficulty with walking or balance If yes to any question, then comprehensive falls assessment

Who is going to fall?

How do you identify fallers?

Comprehensive Falls Risk = Comprehensive Geriatric Assessment History of falls Medications Gait, balance, mobility Visual acuity Other neurological impairments Muscle strength Heart rate/rhythm Postural hypotension Feet and footware Environmental hazards

Comprehensive geriatric assessment = falls risk

A comprehensive exam: A standard review of systems = limited information Functional assessment and a comprehensive exam will identify multiple factors contributing to falls

Geriatric Syndromes Multiple underlying factors (interacting causes) affecting multiple systems Multiple underlying factors (interacting causes) affecting multiple systems Delirium, Incontinence, Frailty, Falls Delirium, Incontinence, Frailty, Falls Shared risk factors such as older age, cognitive impairment, functional impairment Shared risk factors such as older age, cognitive impairment, functional impairment Falls as a geriatric syndrome Falls as a geriatric syndrome Dizziness, auditory, hearing Dizziness, auditory, hearing Cardiovascular Cardiovascular Orthopedic, arthritis, neuropathy Orthopedic, arthritis, neuropathy Depression, cognitive impairment Depression, cognitive impairment

Introducing Mrs. Jones

Chief Complaint It depends on who you ask: It depends on who you ask: Patient: “No complaints, I feel fine” Patient: “No complaints, I feel fine” Daughter: “Difficulty getting around the house, I am afraid she may fall” Daughter: “Difficulty getting around the house, I am afraid she may fall” MD: “Blood pressure should be better controlled” MD: “Blood pressure should be better controlled”

History of Present Illness What do you want to know? What do you want to know? Previous Falls Previous Falls Changes in medications Changes in medications Trips to the opthamologist Trips to the opthamologist Trips to the ER Trips to the ER Changes in mood/activity levels Changes in mood/activity levels

Past Medical History Hypertension Hypertension Paroxysmal Atrial Fibrillation Paroxysmal Atrial Fibrillation Chronic Renal Insufficiency Chronic Renal Insufficiency Anxiety/Depression Anxiety/Depression “Dizziness” “Dizziness” Osteoporosis Osteoporosis

Medication List Metoprolol Metoprolol Hydrochlorothiazide Hydrochlorothiazide Digoxin Digoxin Warfarin Warfarin Sertraline Sertraline Diazepam Diazepam Zolpidem Zolpidem Meclizine Meclizine Fosinopril Fosinopril Alendronate Alendronate

Medication Review > 4 Drugs = Increased risk of falls > 4 Drugs = Increased risk of falls Red Flags – Classes that increase falls risk Red Flags – Classes that increase falls risk Benzodiazepines (short and long-acting agents) Benzodiazepines (short and long-acting agents) Antidepressants (tricyclics and SSRIs) Antidepressants (tricyclics and SSRIs) Antipsychotics Antipsychotics Anticonvulsants Anticonvulsants Opioids Opioids Antispasmodics Antispasmodics Over the counter medications Over the counter medications

Social History What do you want to know? What do you want to know? Living Situation Living Situation Type of house? Stairs? ADLs, IADLs Type of house? Stairs? ADLs, IADLs Social Supports Social Supports Economic Status Economic Status Smoke/Drink Smoke/Drink Current Activity Level Current Activity Level Fear of Falling Fear of Falling

Activities of Daily Living: Ask or Observe ADLs ADLs Transferring Transferring Toileting Toileting Bathing Bathing Dressing Dressing Continence Continence Feeding Feeding IADLS IADLS Transportation Use the phone Buy groceries Meal preparation Housework Medication Pay bills

Physical Exam Findings General Impression General Impression Vital Signs Vital Signs BP sitting 140/90, HR 88 BP sitting 140/90, HR 88 BP standing 110/80, HR 100 BP standing 110/80, HR 100 Pain Pain HEENT HEENT Bilateral cataracts, difficulty reading magazine and wall poster Bilateral cataracts, difficulty reading magazine and wall poster CV CV Grade II/VI systolic murmur (right upper sternal border) Grade II/VI systolic murmur (right upper sternal border) MS MS Neuro Neuro

Functional Assessment: Timed Up and Go

Functional Assessment: Walking Speed

Functional Assessment: Timed Chair Rise

Functional Assessment: Chair Rise Mrs. Jones

Functional Assessment: Balance

Mrs. Jones What Happens at Home

Cognitive Screening Cognitive Impairment Cognitive assessment should be performed in all adults > 65 years Cognitive assessment should be performed in all adults > 65 years 23.4% community dwelling elderly have some level of cognitive impairment 23.4% community dwelling elderly have some level of cognitive impairment Mild – moderate cognitive impairment increases risk of falls and hip fracture Mild – moderate cognitive impairment increases risk of falls and hip fracture *Neurology 2001 Nov 13; 57(9): *Neurology 2001 Nov 13; 57(9):

Screening Tools: MMSE Screens for Alzheimer’s Disease Screens for Alzheimer’s Disease  Orientation  Registration  Attention/Calculation  Recall  Language  Copy Pentagons Limitations Limitations Age, education, cultural, socioeconomic, English proficiency affects scores Age, education, cultural, socioeconomic, English proficiency affects scores Length to administer Length to administer

Screening Tools: Mini-Cog General screen for cognitive impairment 1. Dictate three items, ask to repeat 2. Clock Drawing Test 3. Ask to recall the three items

Screening Tools: Mini-Cog Score 1 point for each recalled word Score 1 point for each recalled word Score normal/abnormal clock draw Score normal/abnormal clock draw  Score of 0 positive screen for dementia  Score of 1 or 2 with abnormal clock draw positive screen for dementia  Score of 1 or 2 with normal clock negative for screen for dementia  Score of 3 negative screen for dementia

Mrs. Jones Clock

Clock Draw Example

Home Safety Evaluation Use an environmental assessment sheet Use an environmental assessment sheet Must utilize occupational therapy, social work, etc to have an effect Must utilize occupational therapy, social work, etc to have an effect Financial difficulties may be culprit Financial difficulties may be culprit

Comprehensive Geriatric Assessment: Ms. Jones History of falls Medications Gait, balance, mobility Visual acuity Other neurological impairments Muscle strength Heart rate/rhythm Postural hypotension Feet and footware Environmental hazards

Assessment: Mrs. Jones What are the risk factors? What are the risk factors? History of falls Leg muscle weakness Polypharmacy Orthostatic Hypotension Osteoporosis ? Cognition

Plan: Mrs. Jones What will you do about it? What will you do about it? Fix orthostasis Fix orthostasis Address osteoporosis Address osteoporosis Modify medications Modify medications Interventions? Interventions? Occupational Therapy - home safety evaluation Occupational Therapy - home safety evaluation Physical Therapy - leg strengthening, gait training, and assessment for assistive device Physical Therapy - leg strengthening, gait training, and assessment for assistive device Consult with pharmacy about current medication list and insurance coverage Consult with pharmacy about current medication list and insurance coverage Community Services for behavior change programs, wellness and socialization activities Community Services for behavior change programs, wellness and socialization activities

Community Resources North Carolina Roadmap for Healthy Aging Locates evidence-based programs in your area NC Division of Aging and Adult Services For every county: health promotion, long term care, in-home care, caregiver resources, meals on wheels, etc

Synthesis Evaluating major risk factors for falls is fundamental to a geriatric assessment 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 will identify individuals at risk for falls A functional assessment can (and should) be done with your older patients A functional assessment can (and should) be done with your older patients Refer to other disciplines to best manage complex older adults Refer to other disciplines to best manage complex older adults

Key Physical Findings in Older Adults I HATE FALLING I HATE FALLING I Inflammation of joints or joint deformity H Hypotension (orthostatic) A Auditory/visual problems T Tremor (Parkinson’s disease) E Equilibrium (balance problems) F Foot problems A Arrhythmia, heart block L Leg length discrepancy L Lack of conditioning

Practice Practice Practice Practice with volunteers Practice with volunteers Physical, Cognitive, and Medication Assessment Physical, Cognitive, and Medication Assessment On the wards On the wards Perform at least one mini-Cog Perform at least one mini-Cog Shadow a physical therapist and perform 1-2 functional assessments Shadow a physical therapist and perform 1-2 functional assessments Identify which of your patients are at risk for falls Identify which of your patients are at risk for falls