1. M3 Seminar September 2006 1 “Geriatrics” in a Nutshell Karen E. Hall, M.D., Ph.D. Clinical Associate Professor of Internal Medicine University of Michigan, Ann Arbor VA Health Systems Research Scientist, Geriatric Research, Education and Clinical Center

2. M3 Seminar September 2006 2 Learning Outcomes Review common Geriatric Syndromes In Coursetools htps://ctools.umich.edu/portal Review geriatric assessment

3. M3 Seminar September 2006 3 M3 Clinical Competencies (from CourseTools) Geriatric syndromes and conditions Diseases more common in older patients Psychosocial issues Disease prevention Ethical Issues Health Care Financing (Medicare) Cultural aspects of aging

4. M3 Seminar September 2006 4 Geriatric Syndromes (hospital) Dementia, delerium, depression m common, not documented Inappropriate medications m anticholinergic Gait and mobility impairment m not documented Incontinence Iatrogenic complications m constipation, pressure ulcers

5. M3 Seminar September 2006 5 Geriatric Syndromes (outpatient) Dementia, Depression, Delerium Incontinence Osteoporosis Falls Hearing and vision impairment Sleep disorders Failure to thrive Iatrogenic (medications)

6. M3 Seminar September 2006 6 Geriatric Syndromes Dementia, Depression, Delerium m Cognitive screen, ask about depression, check orientation and concentration (serial 7’s) m Delerium has variable orientation/concentration, dementia doesn’t Incontinence m Stress, urge, overflow m Stress – small volume; urge – larger volume m Check for UTI with incontinence m Ditropan can cause overflow

7. M3 Seminar September 2006 7 Geriatric Syndromes Osteoporosis m Risk – asian > caucasian > AA/black m Kyphosis on physical exam m Dexa scan (femoral neck; L spine) m Everyone gets 1000-1500 mg Ca + 400-800 IU Vit D m Treatment: Alendronate > calcitonin; estrogen/reloxifene; weight lifting Falls m How many “Any in past 6 months?” m What happened – “trip, slip, drop” m Injury? m Mandatory: test sensation, balance, GAIT (TUG test)

8. M3 Seminar September 2006 8 Geriatric Syndromes Hearing and vision impairment m Whisper test, check with glasses on Sleep disorders m Normal aging – sleep cycles only 3-5 hours max m Going to bed too early? m ETOH; Tylenol PM? m Depression/anxiety? m Hot milk, read outside of bed, consider trazodone

9. M3 Seminar September 2006 9 Geriatric Syndromes Failure to thrive m “Dwindling” m Weight loss m Increased frailty m Not able to live independently (without human assistance) m Check for cognition, mobility, medication side effects m Cancer? m Consider hospice for refractory situation (sometimes people get better with hospice!)

10. M3 Seminar September 2006 10 Geriatric Syndromes Iatrogenic Medications m Anticholinergics m Narcotics - don’t forget the laxative Stool softener alone will not be enough m Antiarrhythmics m Dilantin (nausea; vertigo) m Neuroleptics m PPIs – nausea, diarrhea; Aricept (diarrhea) Bed Rest (hospitalization) m Rapid loss of muscle strength (>80 years: lose 1 ADL in 3-5 d)

11. M3 Seminar September 2006 11 Common Diseases in Elderly Neurologic (Parkinsons, stroke, TIA) Rheumatologic (RA, PMR, vasculitis) Genitourinary (BPH, sexual dysfunction) Cardiovascular (afib, CAD, CHF, HTN) Endocrine (hypothyroid, diabetes type II, Paget’s) Renal (HTN, fluid/lyte abnormalities) Infections (pneumonia, UTI, TB) Gastrointestinal (dysphagia, constipation, ‘tics) Oncologic (colon, breast, prostate, hematologic) Psychiatric (depression, psychosis)

12. M3 Seminar September 2006 12 Documentation/Skills First rule of history and physical exam “To treat the problem, you have to document the problem”

13. M3 Seminar September 2006 13 Documentation First rule of geriatrics (similar to first rule of real estate sales) “Function, Function, Function” Patients don’t care about their diagnoses, they care about their function

14. M3 Seminar September 2006 14 Ask about…. ADLs (Activities of Daily Living) IADLs (Independent Activities of Daily Living) Mobility Incontinence Affect/Mood Cognition (Memory)

15. M3 Seminar September 2006 15 These items go into the history Either “Social History” or “Functional History” Or In the HPI!

16. M3 Seminar September 2006 16 Physical Exam Test the following: Mobility – Timed Up and Go test- stand, walk, turn, sit Cognition – Mini-Cog (3 item recall) or MMSE (Mini Mental Status Exam) Affect – Two question Depression screen

17. M3 Seminar September 2006 17 The results go in the Physical Exam “Timed Up and Go was 15 seconds, patient walked slowly, unsteady, had to hold rail for support” “Two question depression screen positive” “Patient only remembered 2 of 3 items on Mini- Cog”

18. M3 Seminar September 2006 18 Documentation does not necessarily mean “Diagnosis” Diagnosis belongs in the “Impression/Plan” section BUT…. Rule #1: Avoid the trap of “premature labeling” Problem 1. “Falls” – (list the differential here) Not Problem 1. “Probable spinal stenosis” Or Problem 1. “Musculoskeletal System”

19. M3 Seminar September 2006 19 Develop a Plan rather than a Diagnosis Rule #2: You can start addressing functional impairments without having a specific diagnosis Patients appreciate a practical plan Home safety, mobility aids, social supports

20. M3 Seminar September 2006 20 Prevention = “Screening” Back to First rule of History and Physical Examination …. “To prevent it, you have to document it” Learn about primary and secondary prevention screening that maximizes function and minimizes future impairment Keep current about age-associated recommendations for tertiary prevention (“treatment”)

21. M3 Seminar September 2006 21 Social, Ethical, Cultural Learn about cultural influences on health behavior DNR, family involvement Learn about stressors that affect patients and families Caregiver stress, finances Know what resources are out there to help Social work (Turner clinic + other), types of assisted living, medication assistance, Area Agency on Aging, 3 day inpatient requirement for Medicare payment of CNH!

22. M3 Seminar September 2006 22 Social, Ethical, Cultural Ask the patient what THEY WANT TO DO about their problem “Do not assume your preference is their preference!” This will avoid more lawsuits than any other intervention!