INTRODUCTION TO GERIATRIC INTRODUCTION TO GERIATRIC ASSESSMENTASSESSMENT

Marcos Milanez, MDMarcos Milanez, MD

Rose van Zuilen, PhDRose van Zuilen, PhD

University of Miami University of Miami Division of Gerontology & Geriatric MedicineDivision of Gerontology & Geriatric Medicine

ObjectivesObjectives

• Appreciate the importance of a Appreciate the importance of a multidimensional assessment in the elderlymultidimensional assessment in the elderly

• List the common screening tests used in List the common screening tests used in Geriatric assessmentGeriatric assessment

• Understand the available options for patients Understand the available options for patients with self care deficits.with self care deficits.

DemographicsDemographics

• By 2030 there will be 65.6 million elderly or 22% By 2030 there will be 65.6 million elderly or 22% of the total population of the total population

• 80% of health care costs are incurred by 20% of 80% of health care costs are incurred by 20% of the older age groupthe older age group

• A generalist will spend about 50% of practice time A generalist will spend about 50% of practice time caring for older adultscaring for older adults

Challenges in caring for the elderly Challenges in caring for the elderly populationpopulation

• FrailtyFrailty

• DisabilityDisability

• Multiple comorbiditesMultiple comorbidites

• Underreporting of symptomsUnderreporting of symptoms

Clinical Presentation of Illness in Clinical Presentation of Illness in the Elderlythe Elderly

• Non-specific presentationNon-specific presentation• Atypical or uncommon presentationAtypical or uncommon presentation• Multiple pathologies and diagnosesMultiple pathologies and diagnoses• ““I’m just getting old"I’m just getting old"

Why focus on function?Why focus on function?

• Impaired function is often the Impaired function is often the first indicationfirst indication of of diseasedisease

• A systematic A systematic assessmentassessment of function is a valuable of function is a valuable tool for tool for identifyingidentifying disease disease

• Provides a means for evaluating the extent or Provides a means for evaluating the extent or severityseverity of diseases of diseases

• Helpful for selecting among treatment optionsHelpful for selecting among treatment options• Allows effective Allows effective monitoringmonitoring of response to of response to

treatmenttreatment

What is Geriatric Assessment?What is Geriatric Assessment?

• An evaluation that addresses the functional, An evaluation that addresses the functional, physical, psychological and social limitations physical, psychological and social limitations that can impact the life of an elderthat can impact the life of an elder

• Can be performed in many locations and health Can be performed in many locations and health care contextscare contexts

• Usually performed by an interdisciplinary Usually performed by an interdisciplinary healthcare teamhealthcare team

Goal:Maintain & improvefunctionalindependence Physical

PsychologicalFunctionalEconomical

Social

Geriatric AssessmentGeriatric Assessment

Functional AssessmentFunctional Assessment

• 10% of elderly people in the community need 10% of elderly people in the community need help with an ADLhelp with an ADL– 1/3 of people over 85 years old1/3 of people over 85 years old

• Progressive disabilities related to:Progressive disabilities related to:– DementiaDementia– Cardiovascular diseaseCardiovascular disease– StrokeStroke– Musculoskeletal diseasesMusculoskeletal diseases

Basic Activities of Daily Living Basic Activities of Daily Living (ADLs)(ADLs)

• BathingBathing• DressingDressing• ToiletingToileting• TransferringTransferring• ContinenceContinence• FeedingFeeding

Instrumental Activities of Daily Instrumental Activities of Daily Living (IADLs)Living (IADLs)

• Using the telephoneUsing the telephone• ShoppingShopping• Preparing mealsPreparing meals• HousekeepingHousekeeping• Doing laundryDoing laundry• Doing handyman workDoing handyman work• Using public transportationUsing public transportation• Managing medicationsManaging medications• Handling financesHandling finances

Physical AssessmentPhysical Assessment• Routine components of a history and physical Routine components of a history and physical

exam plus screening for geriatric syndromesexam plus screening for geriatric syndromes– Sensory impairmentsSensory impairments– Nutritional compromiseNutritional compromise– Urinary incontinenceUrinary incontinence– Optimal drug useOptimal drug use– Falls and/or immobilityFalls and/or immobility– Dementia, delirium, depressionDementia, delirium, depression– Chronic painChronic pain– Pressure ulcersPressure ulcers

Visual ImpairmentVisual Impairment

• Persons 65 to 75 years old:Persons 65 to 75 years old:– 5% rate of visual impairment (acuity 20/40 or 5% rate of visual impairment (acuity 20/40 or

worse) worse) – 10% to 21% after age 7510% to 21% after age 75

• Black Americans > White AmericansBlack Americans > White Americans

Vision ScreeningVision Screening

• Visual acuity charts: Snellen (20/40 or Visual acuity charts: Snellen (20/40 or worse)worse)

• Reading a headline and a sentence from a Reading a headline and a sentence from a news papernews paper– normal: both headline and sentencenormal: both headline and sentence– severe: neither headline or sentencesevere: neither headline or sentence

Hearing ImpairmentHearing Impairment• Affects 33% of people over 65Affects 33% of people over 65

– two thirds of those over 70 two thirds of those over 70 – 3/4 of those over 80 years old are affected3/4 of those over 80 years old are affected

• What is the most common form of hearing loss?What is the most common form of hearing loss?– Presbycusis is the most common type of hearing loss.Presbycusis is the most common type of hearing loss.

• Otoscopic exam necessary to evaluate cerumen, Otoscopic exam necessary to evaluate cerumen, otitisotitis

Hearing ImpairmentHearing Impairment

• Whisper testWhisper test– Examiner stands 12 inches behind the patient, covers Examiner stands 12 inches behind the patient, covers

one ear and whispers 3 words into the uncovered ear one ear and whispers 3 words into the uncovered ear which are repeated by the patient.which are repeated by the patient.

• Ticking of watchTicking of watch• Presence of two fingers rubbing togetherPresence of two fingers rubbing together

Nutritional DeficiencyNutritional Deficiency• 17% of older adults in U.S. consume less than 17% of older adults in U.S. consume less than

1,000 calories/day1,000 calories/day

• What are the consequences of nutritional What are the consequences of nutritional deficiency?deficiency?– Increased morbidity, prolonged hospital stays, more Increased morbidity, prolonged hospital stays, more

frequent readmissions, susceptibility to pressure frequent readmissions, susceptibility to pressure ulcers and increased mortalityulcers and increased mortality

Nutritional DeficiencyNutritional Deficiency

• Weight loss > 5% of total body weight in one Weight loss > 5% of total body weight in one month, or > 10% in 6 monthsmonth, or > 10% in 6 months

• Physical examPhysical exam

• No reliable lab testsNo reliable lab tests

Urinary IncontinenceUrinary Incontinence

• The involuntary loss of urine of sufficient The involuntary loss of urine of sufficient severity to be a social or health problemseverity to be a social or health problem

• 10 to 15% in women over 6510 to 15% in women over 65

• > 25% in men and women 85 years old > 25% in men and women 85 years old and olderand older

Urinary IncontinenceUrinary Incontinence

• Simple questions to ask elderly patients:Simple questions to ask elderly patients:

– do you ever leak urine?do you ever leak urine?– Do you have trouble holding your urine?Do you have trouble holding your urine?– Do you wear protective pads or diapers?Do you wear protective pads or diapers?

Optimal Drug UseOptimal Drug Use• ““Medicine cabinet biopsy” or “Brown Bag” Medicine cabinet biopsy” or “Brown Bag”

approach – review all medications including approach – review all medications including – OTCs, herbal medicines, shared medicinesOTCs, herbal medicines, shared medicines

• Also assessAlso assess– Who prescribes? – Are there different doctors?Who prescribes? – Are there different doctors?– Pt understanding of their meds (why and how Pt understanding of their meds (why and how

to take meds, side effects)to take meds, side effects)– Adherence – Does the pt take the medication as Adherence – Does the pt take the medication as

prescribed? How often does the pt miss a dose prescribed? How often does the pt miss a dose (either purposely or accidentally)?(either purposely or accidentally)?

Optimal Drug UseOptimal Drug Use• Also assess (continued)Also assess (continued)

– Problems with taking medications (vision, Problems with taking medications (vision, arthritis, swallowing)arthritis, swallowing)

– Need for assistance with medications and use of Need for assistance with medications and use of aids (pill box, reminders).aids (pill box, reminders).

– Beneficial effects and side effectsBeneficial effects and side effects– New medications and dose adjustments (in New medications and dose adjustments (in

relation to new Sxs)?relation to new Sxs)?– Ability to pay for medicationsAbility to pay for medications

• Adverse drug effects can cause decline of Adverse drug effects can cause decline of cognition or function!cognition or function!

Falls and immobilityFalls and immobility• Which chronic medical conditions could Which chronic medical conditions could

lead to falls?lead to falls?– Musculoskeletal and neurologic disorders, Musculoskeletal and neurologic disorders,

polypharmacypolypharmacy

• 30% of community-residing elderly 30% of community-residing elderly Americans fall each yearAmericans fall each year

• As high as 50% among 80 year olds & As high as 50% among 80 year olds & institutionalizedinstitutionalized

Falls and immobilityFalls and immobility• Ask “Ask “Have you accidentally fallen to the Have you accidentally fallen to the

ground in the last 6 months?”ground in the last 6 months?”

• Perform a gait assessment – Timed Up and Perform a gait assessment – Timed Up and GoGo

Mobility upper extremityMobility upper extremity

• Touch the back of your headTouch the back of your head

• Place both hands together in back of the Place both hands together in back of the waistwaist

• Any pain or limitations in shoulder Any pain or limitations in shoulder mobility should prompt a more complex mobility should prompt a more complex examinationexamination

Psychological AssessmentPsychological Assessment

• Mood Mood

• CognitionCognition

Depression Depression

• 10-27% of adults10-27% of adults– 12% in hospitalized and institutionalized 12% in hospitalized and institutionalized – 20-40% of pts with Alzheimer’s have major depression!20-40% of pts with Alzheimer’s have major depression!

• What are some risk factors in older patients?What are some risk factors in older patients?– Physical illness like recent CVA, CABG, MI, cognitive Physical illness like recent CVA, CABG, MI, cognitive

impairment and psychosocial lossesimpairment and psychosocial losses

• Be aware of somatic depressive symptomsBe aware of somatic depressive symptoms

DepressionDepression

• Ask: “Do you feel sad or depressed.”Ask: “Do you feel sad or depressed.”• Geriatric Depression ScaleGeriatric Depression Scale• SIGECAPSSIGECAPS

DementiaDementia• 1% of 60 year olds1% of 60 year olds• 50% of 90 year olds50% of 90 year olds

• What are some complications related to having What are some complications related to having dementia?dementia?

– Increased risk for delirium and functional losses from Increased risk for delirium and functional losses from illnesses, medications or operative proceduresillnesses, medications or operative procedures

– Increased use of health services and increased Increased use of health services and increased mortalitymortality

DementiaDementia

• One minute recall of 3 itemsOne minute recall of 3 items• Mini-CogMini-Cog• Mini-Mental State Exam (MMSE)Mini-Mental State Exam (MMSE)

DeliriumDelirium

• Confusion Assessment MethodConfusion Assessment Method

Socio-economic DomainSocio-economic Domain

• Informal support Informal support • Formal support (paid services)Formal support (paid services)• Environment (home safety)Environment (home safety)• Advance care planningAdvance care planning• Hobbies and habitsHobbies and habits• Religion/spiritualityReligion/spirituality• Caregiver burden and elder abuseCaregiver burden and elder abuse• Sources of income/insuranceSources of income/insurance

Formal SupportsFormal SupportsPaid services such as:Paid services such as:• HousekeeperHousekeeper• HandymanHandyman• In home caregiversIn home caregivers• Home health servicesHome health services• Assisted living facility (ALF)Assisted living facility (ALF)• Adult day careAdult day care• Respite careRespite care• Meals on wheelsMeals on wheels

DocumentationDocumentation

• MedicalMedical• PsychologicalPsychological• FunctionalFunctional• SocioeconomicSocioeconomic

SMALLSMALL changes in function can changes in function can makemake

BIGBIG differences in the quality of differences in the quality of life for patients.life for patients.