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 w Introduction w Evaluation w Review w Summary

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

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

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

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

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

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

Elder Evaluation w Introduction w Evaluation w Orientation w Summary

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

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

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

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

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

Physical Exam w Areas to Focus On Cardiovascular Musculoskeletal Neurological Thyroid?

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

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

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

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

MMSE [Cognitive Domains] w Orientation/Time5 points w Orientation/Place5 points w Registration3 points w Attention/Calculation5 points w Recall of Three Words3 points w Language8 points w Visual Construction1 point

MMSE [Scoring / Cutoffs] w Total Number of Correct Answers w CorrectNo Cognitive Imp. w CorrectMild Cognitive Imp. w 0-17 CorrectSevere Cog. Imp.

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

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

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

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

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

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

Medication Review w Prescription Shared w OTC w OTB w Alternative

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

Bone Integrity w Risk Factors w DEXA w Falls Risk

Strength/Sarcopenia w Strength Decreased w Immobility Issues

Continence w Major Cause of Morbidity w Urinary & Fecal Incontinence

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

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

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

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

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

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

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

Elder Evaluation w Introduction w Evaluation w Orientation w Summary

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

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

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

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

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