2. 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

3. Elder Evaluation w Introduction w Evaluation w Review w Summary

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

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

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

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

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

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

10. Elder Evaluation w Introduction w Evaluation w Orientation w Summary

11. 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

12. 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

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

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

15. 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

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

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

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

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

20. 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

21. 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

22. MMSE [Scoring / Cutoffs] w Total Number of Correct Answers w 24-30 CorrectNo Cognitive Imp. w 18-23 CorrectMild Cognitive Imp. w 0-17 CorrectSevere Cog. Imp.

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

24. 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

25. 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

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

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

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

29. Medication Review w Prescription Shared w OTC w OTB w Alternative

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

31. Bone Integrity w Risk Factors w DEXA w Falls Risk

32. Strength/Sarcopenia w Strength Decreased w Immobility Issues

33. Continence w Major Cause of Morbidity w Urinary & Fecal Incontinence

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

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

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

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

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

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

40. 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

41. Elder Evaluation w Introduction w Evaluation w Orientation w Summary

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

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

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

45. 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

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