Evaluation of The Elder Patient David V. Espino, M.D. Vice Chair & Director, Div. Of Community Geriatrics Dept. of Family & Community Medicine University of Texas Health Science Cntr-San Antonio

Elder Evaluation Introduction Evaluation Review Summary

Aging Is Not A Disease Occurs at Different Rates Among Individuals Within Individuals Increases Susceptibility to Specific Conditions

Characteristics of Geriatric Medical Conditions Chronic with Superimposed Acute Illness Multiple and Coexisting

Iatrogenesis Medication Misuse Hospitalization Falls, Delirium, Immobility Diagnostic/ Therapeutic Procedures

Presentation of Geriatric Patient Typically “Atypical” Nonspecific “Cascade Phenomenon”

Goals of Geriatric Care Care vs. Cure Iatrogenesis Function Quality of Life Prevention Palliation

Geriatric “Money Balls” Small Changes In Function = Big QOL Gains Taking Things Away Can Make Things Really Better or Really Worse!

Elder Evaluation Introduction Evaluation Orientation Summary

Geriatric Evaluation Geriatric H&P Functional Cognitive/Affective Medications Nutritional Bone Integrity/Falls Strength/Sarcopenia Continence Eyes/Ears ETOH/Tobacco/Sex EnviroSocial Capacity

History: {Communication & Rapport} Impaired Communication? Eye Contact, Physical Contact Use Last Name Speak Directly to Elder Establish Decision Maker Address CC Make Only One Change/Visit

Geriatric History Avoid Open Ended Questions Focus On Current Medical Problems Address Families Concerns Focus On Medications

Physical Exam: Blood Pressure 24% of Elders have Orthostasis Pseudohypertension Trial of Hypertensives? 25% Normotensive

Physical Exam: Height/Weight/Skin Serial Heights Serial Weights Essential Skin Senile Lentigines, Skin Tags Physical Abuse Signs? Decubs? Examine at Annual Exam

Physical Exam Areas to Focus On Cardiovascular Musculoskeletal Neurological Thyroid?

Functional Evaluation Instrumental Activities of Daily Living (IADL’s) Activities of Daily Living (ADL’s) Executive Functioning Gait & Balance

Gait & Balance Get Up and Go ! Tinetti Gait & Balance

Cognitive/Affective Status Folstein’s MiniMental State Exam (MMSE) Clock Drawing Geriatric Depression Scale (GDS)

Mini Mental State Exam [ General Information ] Developed by Marshall Folstein in 1975 Estimate Severity of Cognitive Impairment NOT Designed To Make Specific Diagnoses

MMSE [Cognitive Domains] Orientation/Time 5 points Orientation/Place 5 points Registration 3 points Attention/Calculation 5 points Recall of Three Words 3 points Language 8 points Visual Construction 1 point

MMSE [Scoring / Cutoffs] Total Number of Correct Answers 24-30 Correct No Cognitive Imp. 18-23 Correct Mild Cognitive Imp. 0-17 Correct Severe Cog. Imp.

MMSE [Influences] Educational Level Race / Ethnicity Socioeconomic Status?

Clock Drawing Test Different Versions 4 Point Scale Most Useful 1 Point- Circle 1 Point-Numbers 1 Point-Hands/Arrows 1 Point-Right Time

Geriatric Depression Scale [ General Information ] Total Number of Questions Long Version = 30 Short Version = 15 Administered in about 5 Minutes Count the Missed Questions

Geriatric Depression Scale [ Error Cut-Offs ] Long Version < 11 Not Depressed 11-14 Possible Depression ≥14 Depression Short Version <11 Not Depressed ≥11 Probable Depression

Geriatric Depression Scale [ Clinical Utility ] Use As Screener Only Utilize Suggested Cut-Offs Recognized Ethnicity or Language Influence GDS Interpretation

Medications Only Use When Life, Function or Comfort Threatened Medications Must Be Reviewed On Each Visit

Medication Review Prescription Shared OTC OTB Alternative

Nutritional Status Often Overlooked Oral Screening Poor Dentures? “Weigh All Of The Elders, All Of The Time” BMI

Bone Integrity Risk Factors DEXA Falls Risk

Strength/Sarcopenia Strength Decreased Immobility Issues

Continence Major Cause of Morbidity Urinary & Fecal Incontinence

Eyes/Ears Eyeglasses Hearing Aids Alternative Aids Screen With Snellen Chart Hearing Aids Ask About Hearing Alternative Aids $55 Radio Shack

ETOH/Tobacco/Sex Alcohol and Smoking Common Sex Also Common CAGE? Smoking Cessation Sex Also Common Major QOL

Enviro-Social Status Does The Elder Live Alone? Who Functionally Assists? Home Assessment, If Necessary

Enviro-Social Status Social Activity, Relationships and Resources Caregiver Burden Quality Of Life Issues Advance Directives Capacity

Determining Capacity Describe Illness and Course Explain Proposed Treatment Understand Treatment Consequences Understand Risks and Benefits

Develop Plan Set Goals Discuss With Family, If Appropriate Realistic, Measurable, Achievable Discuss With Family, If Appropriate Develop Stepwise Approach

Approach To Evaluation Visit 1 Address CC, Initial Hx Visit 2 PX and Labs Visit 3 Cognitive/Functional Eval Visit 4 Social, QOL, and Plan

Elder Evaluation Introduction Evaluation Orientation Summary

Geriatrics Clinic South Module-FHC Both Frail Elder & CDC Be Prompt 8:AM 1:PM Unexcused Absences

Process White Board Put Initials See Patient Present Patient Fill Out Orders Finish Note

Other Required Activities Keep Problem List Current Keep Meds List Current Fill Out Prescriptions Check Out before you leave

Final Points Learning and Knowledge Content Are Different Things Just Because You Complete A Task Does Not Imply That You Completed It Well

SUMMARY Chronic Problems With Acute Events Interspersed Communication Essential Expect the Unexpected Iatrogenesis Rules!