2. Functional Disability Screening Brenda K. Keller, M..D. Section of Geriatrics, Dept. of Internal Medicine University of Nebraska Medical Center

7. Disability Screening Two realms of Abilities: Activities of Daily Living Instrumental Activities of Daily Living

8. Activities of Daily Living Activities needed to prepare for the day Toileting Dressing Bathing Feeding Grooming Ambulation

9. Activities of Daily Living

10. Instrumental Activities of Daily Living Shopping Transportation Housekeeping Telephone Use Food preparation Laundry Medications Finances

11. Instrumental Activities of Daily Living

13. Disability Screening:Who Needs It? All asymptomatic elderly outpatients Initial VisitAnnual H&P Not done during acute illness

14. Disability Screening: What do we Want? Incorporate into General Exam Target Common problems Keep it simple Screens should be of high yield Clear next step to treatment

15. Disability Screening:Target Areas Vision Hearing Arm & Leg function Urinary Incontinence Mental Status Nutrition Depression Home Safety Social Support

16. Vision Visual impairment, particularly from decreased accommodation and cataracts, is more common with age. Role of the primary care MD is identification of vision loss and f/u of care plan outlined by eye specialist

17. Vision Screening Jaeger card 14 inches from face Well lit room, minimize glare If unable to read 20/40 or better refer to ophthalmologist

18. Hearing Hearing Loss is prevalent among elderly. Associated with: isolation, confusion, depression High frequency hearing loss common Affects conversation

19. Hearing Screening Whisper Test: consistent with a 30 Db. Loss. Validated against audiometry Stand 2 feet behind patient and whisper a series of 3 numbers into each ear

20. Hearing Screening If unable to respond: check for wax Wax in ears: remove and repeat test If still fails -- refer for audiogram

21. Hearing Loss Options for Treatment Prosthesis: hearing aides Assistive listening devices Environmental Changes

22. Hearing Aides

26. Improving Communication with hearing impaired elderly Be certain to have the person’s attention Speak face-to-face Repeat by paraphrasing Speak at normal level to slightly louder Speak a little more slowly Stand within 2 - 3 feet

27. Improving Communication with hearing impaired elderly Reduce background noise Pause at end of sentences Avoid appearing frustrated Write down key words if the person can read Have the person repeat to be certain message was understood

28. Arm Function Decrease in arm function leads to difficulty Gross tasks such as dressing, Fine tasks such as writing and eating Community dwelling elderly, this increases reliance on family, formal services

29. Arm Function Screening Proximal Function“Touch the back of your head with both hands.” Distal Function“Pick up a pen.”

30. Arm Function Evaluation If difficulties, then full neuromuscular exam: pain Range of motion weakness

31. Arm Function Disability Options for Treatment Treat underlying medical condition Occupational therapy consultation Assistive devices

35. Leg Function Screening Get Up and Go Patient arises from chair, walks 10 ft., turns & returns to chair

36. Leg Function Evaluation If unable to walk or transfer: full neuromuscular exam, focus on pain Range of motion Balance and Gait

37. Leg Function Disability Options for Treatment Initiation of exercise program Physical Therapy consult for: Gait Training, Strengthening Assistive Devices

41. Mental Status Dementia is the most common important disturbance in mental status in elderly persons Older people compensate well for the problem, so it may be missed if not specifically tested Short term memory and calculations are sensitive indicators of cognitive decline

42. Mental Status Screening Three item recall Names of three items presented to pt. Pt. asked to repeat 3 items immediately and remember them for later Recall at 1 minute If unable to recall any at 1 minute, then MMSE

43. Mental Status Further Evaluation Folstein MMSE < 24 Ascertain onset, duration, and fluctuation of overt symptoms Complete Neuro Exam Assess Affect, level of consciousness Med review, appropriate lab, x-ray

44. Depression Affects over 1 million over age 65 13% of community dwelling elderly 25% of all suicides committed by old

45. Depression Screening Do you often feel sad or depressed? If yes, then: Geriatric Depression Scale Score > 10 Check meds, labs. Consider counseling or antidepressant Rx.

46. Urinary Incontinence Ten million Americans suffer from urinary incontinence 30% of community dwelling elderly 50% of people in Nursing Facilities Over half of those afflicted have had no treatment or evaluation 75-90% of individuals can be helped

47. Urinary Incontinence Screening Ask “Do you ever lose urine and get wet? If yes, then: Ascertain frequency, amount, circumstances, time of day Look for acute reversible causes for incontinence

48. Nutrition Poor nutrition in the elderly can be a reflection of: Concurrent Illness Depression Poor dentition Financial Hardship Inability to shop or cook Inability to feed oneself

49. Nutrition Screening Have you lost more than 10 lbs in the past year.? If yes, or if appears of low body weight, then: Evaluate intake with food diaries If inadequate, dietitian to see If adequate, evaluate for medical cause

50. Food Pyramid for the Elderly

51. Nutrition Evaluation of Weight Loss H & P Investigate Abnormalities Lab evaluation for occult malignancy and metabolic disturbances

52. Home Safety Environmental hazards lead to increased risk of falls Hip Fx in 1% of falls in community dwellers and 5% of NH residents Falls cause 70% of accidental deaths Stairs and bathrooms are likely sites for falls.

53. Home Safety Screening Have you had any falls at home? Identify potential fall hazards: # StairsThrow RugsBath rails

54. Home Safety Evaluation OT or PT Home visit to identify and change hazards Supply patient or family with safety checklist

55. Social Support Degree of social support has been associated with survival, morbidity and quality of life Breadth and depth of social circle are important factors in determining need for formal support ID of potential caregivers in the medical record facilitates interactions

56. Social Support Screening Who would be able to help you in case of illness or emergency? Who would make health decisions for you if you were unable to make them for yourself? Inquire about current advanced directives Document these individuals in the medical record Become familiar with community services for the elderly

57. Helping the Elderly Stay Active Conclusions Functional Disability is common in the elderly Search of Target areas for disability can lead to early identification and Rx Screens can be easily incorporated into H & P or can be done by office personnel prior to MD visit