1. The Stealth Geriatrician: How to learn what you need to know from your patients Tiffany Shubert, Ph.D., MPT Tony Caprio, MD

2. Course Objectives Identify four key risk factors for falling in older adults Identify four key risk factors for falling in older adults Perform a comprehensive geriatric functional assessment Perform a comprehensive geriatric functional assessment Evaluate the need for referral Evaluate the need for referral “Build a Team” – Determine disciplines and community resources to aid in patient health management “Build a Team” – Determine disciplines and community resources to aid in patient health management

3. Why Falls? AAMC Minimum Competency All adults over 65 years should be asked about falls All adults over 65 years should be asked about falls All adults should be observed and assessed rising from a chair and walking All adults should be observed and assessed rising from a chair and walking All patients who have fallen should have a differential diagnosis and evaluation plan to address the fall and potential risk of falls All patients who have fallen should have a differential diagnosis and evaluation plan to address the fall and potential risk of falls

4. Why Falls? Medicare PQRI Program Medicare PQRI Program Incentive pay for falls screening! Incentive pay for falls screening! Good Practice Good Practice Facilitates successful aging Facilitates successful aging Opportunity for health promotion Opportunity for health promotion Collaboration with other disciplines Collaboration with other disciplines Collaboration with community Collaboration with community

5. Who is going to fall?

6. How will you identify who will fall?

7. A comprehensive geriatric assessment uncovers falls risk

8. What you can find in your comprehensive exam What you can find in your comprehensive exam If you take their shoes off!

9. Introducing Mrs. Jones

10. Chief Complaint It depends on who you ask: It depends on who you ask: Patient: “No complaints, I feel fine” Patient: “No complaints, I feel fine” Daughter: “Difficulty getting around the house, I am afraid she may fall” Daughter: “Difficulty getting around the house, I am afraid she may fall” MD: “Blood pressure should be better controlled” MD: “Blood pressure should be better controlled”

11. History of Present Illness What do you want to know? What do you want to know? Changes in medications Changes in medications Trips to the opthamologist Trips to the opthamologist Trips to the ER Trips to the ER Changes in mood/activity levels Changes in mood/activity levels Previous falls Previous falls

12. Past Medical History Hypertension Paroxysmal Atrial Fibrillation Chronic Renal Insufficiency Anxiety/Depression“Dizziness”Osteoporosis

13. Medication List Metoprolol Metoprolol Hydrochlorothiazide Hydrochlorothiazide Digoxin Digoxin Warfarin Warfarin Sertraline Sertraline Diazepam Diazepam Zolpidem Zolpidem Meclizine Meclizine Fosinopril Fosinopril Alendronate Alendronate

14. Medication Review > 4 Drugs = Increased risk of falls > 4 Drugs = Increased risk of falls Red Flags – Classes that increase falls risk Red Flags – Classes that increase falls risk Benzodiazepines (short and long-acting agents) Benzodiazepines (short and long-acting agents) Antidepressants (tricyclics and SSRIs) Antidepressants (tricyclics and SSRIs) Antipsychotics Antipsychotics Anticonvulsants Anticonvulsants Opioids Opioids Antispasmodics Antispasmodics Over the counter medications Over the counter medications

15. Social History What do you want to know? What do you want to know? Living Situation Living Situation Type of house? Stairs? ADLs, IADLs Type of house? Stairs? ADLs, IADLs Social Supports Social Supports Economic Status Economic Status Smoke/Drink Smoke/Drink Current Activity Level Current Activity Level Fear of Falling Fear of Falling

16. Activities of Daily Living: Ask or Observe ADLs ADLs Transferring Transferring Toileting Toileting Bathing Bathing Dressing Dressing Continence Continence Feeding Feeding IADLS IADLS Transportation Use the phone Buy groceries Meal preparation Housework Medication Pay bills

17. Review of Systems Systems vs. Syndromes Systems vs. Syndromes Organ-based review may give you limited information Organ-based review may give you limited information Geriatric syndromes encompass multiple organ systems Geriatric syndromes encompass multiple organ systems Falls Falls Dizziness, Vision, hearing Dizziness, Vision, hearing Cardiovascular Cardiovascular Orthopedic problems, arthritis, neuropathy Orthopedic problems, arthritis, neuropathy Depression, cognitive impairment Depression, cognitive impairment

18. Physical Exam Findings General Impression General Impression Vital Signs Vital Signs BP sitting 140/90, HR 88 BP sitting 140/90, HR 88 BP standing 110/80, HR 100 BP standing 110/80, HR 100 Pain Pain HEENT HEENT Bilateral cataracts, difficulty reading magazine and wall poster Bilateral cataracts, difficulty reading magazine and wall poster CV CV Grade II/VI systolic murmur (right upper sternal border) Grade II/VI systolic murmur (right upper sternal border) MS MS Neuro Neuro

19. Functional Assessment: Timed Up and Go

20. Functional Assessment: Walking Speed

21. Functional Assessment: Timed Chair Rise

22. Functional Assessment: Chair Rise Mrs. Jones

23. Functional Assessment: Balance

24. Mrs. Jones What Happens at Home

25. Functional Assessment What Do You Learn? What Do You Learn? How Do You Assess? How Do You Assess? Referral Referral

26. Cognitive Assessment Clock Draw Test Clock Draw Test Mini-Cog Mini-Cog

27. Mrs. Jones Clock

28. Clock Draw Example

29. Home Safety Evaluation Use an environmental assessment sheet Use an environmental assessment sheet Occupational therapy Occupational therapy Financial difficulties may be culprit Financial difficulties may be culprit

30. Assessment: Mrs. Jones What are the problems? What are the problems? History of falls History of falls 3 of the 4 risk factors for falls 3 of the 4 risk factors for falls Leg muscle weakness, poor walking, polypharmacy Leg muscle weakness, poor walking, polypharmacy Orthostatic Hypotension Orthostatic Hypotension Osteoporosis Osteoporosis

31. Plan: Mrs. Jones What will you do about it? What will you do about it? Fix orthostasis Fix orthostasis Address osteoporosis Address osteoporosis Modify medications Modify medications Who will you refer to? Who will you refer to? Occupational Therapy - home safety eval Occupational Therapy - home safety eval Physical Therapy - leg strengthening, gait training, and assessment for assistive device Physical Therapy - leg strengthening, gait training, and assessment for assistive device Consult with pharmacy about current medication list and insurance coverage Consult with pharmacy about current medication list and insurance coverage Community Services for behavior change programs, wellness and socialization activities Community Services for behavior change programs, wellness and socialization activities

32. Synthesis Evaluating major risk factors for falls is fundamental to a geriatric assessment Evaluating major risk factors for falls is fundamental to a geriatric assessment A functional assessment will identify individuals at risk for falls A functional assessment will identify individuals at risk for falls A functional assessment can (and should) be done with your older patients A functional assessment can (and should) be done with your older patients Refer to other disciplines to best manage complex older adults Refer to other disciplines to best manage complex older adults

33. Practice Practice Practice Practice with volunteers Practice with volunteers Physical, Cognitive, and Medication Assessment Physical, Cognitive, and Medication Assessment On the wards On the wards Perform at least one mini-Mental and clock draw Perform at least one mini-Mental and clock draw Shadow a physical therapist and perform 1-2 functional assessments Shadow a physical therapist and perform 1-2 functional assessments Identify which of your patients are at risk for falls Identify which of your patients are at risk for falls