1. 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

2. Elder Evaluation
Introduction
Evaluation
Review
Summary

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

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

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

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

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

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

9. Elder Evaluation
Introduction
Evaluation
Orientation
Summary

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

11. 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

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

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

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

15. Physical Exam Areas to Focus On Cardiovascular Musculoskeletal
Neurological
Thyroid?

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

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

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

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

20. 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

21. 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.

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

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

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

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

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

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

28. Medication Review
Prescription
Shared
OTC
OTB
Alternative

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

30. Bone Integrity
Risk Factors
DEXA
Falls Risk

31. Strength/Sarcopenia
Strength Decreased
Immobility Issues

32. Continence
Major Cause of Morbidity
Urinary & Fecal Incontinence

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

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

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

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

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

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

39. 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

40. Elder Evaluation
Introduction
Evaluation
Orientation
Summary

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

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

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

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

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