Doç. Dr. Nurver Turfaner Department Of Family Medicine
Activities of daily living( ADL) Basic ADLs: Mobility,bathing,dressing,grooming, transferring, toileting,continence,eating Instrumental ADLs:Using telephone, driving, using public transportation, shopping, preparing meals, housework,taking medicine, managing money
Ability: Physical assessment 6 maneuvers task ( function tested ) 1. Both hands behind head ( hair combing, washing back, etc) 2.Both hands together in back of waist ( lower extremity dressing, hygiene) 3.Sitting, touch great toe with opposite hand (lower extremity dressing, hygiene)
Ability: Physical assessment 4.Squeeze examiner’s two fingers with each hand (opening jars, doors, etc) 5.Hold paper between thumb and lateral side of index finger while examiner tries to pull out ( picking up objects) 6. Stand from chair with hands crossed over chest (transferability)
Ability: Cognitive assessment Mini-mental state Orientation:What is the (year)(season)(date)(day)(month) 5 Where are we?(state)(city)(town)(hospital)(floor) 5 Registration:Name 3 unrelated objects. Ask for all 3. Repeat until patient learns all 3. Record number of trials Attention and calculation: Serial 7’s (93,86,79,72,65).Stop after 5. OR spell WORLD backwars. D L R O W 5 Recall: Ask 3 subjects above 3
Language: Naming: pencil and watch 2 Repetition: No ifs, ands or buts 1 3-stage command: Take paper in your right hand, fold it in half,and put it on th e floor 3 Reading: Close your eyes. 1 Writing: Write a sentence. 1 Copying: Intersecting pentagons 1 Scoring ≤ 20 = dementia
Motivation: Assess depression-Single question:’’Do you often feel sad or depressed’’ Short geriatric depression scale Choose the best answer for how you felt over past week ( Yes or No ) 1.Are you basically satisfied with your life Y 2.Have you dropped many of your activities or interests N 3.Do you feel your life is empty N 4.Do you often get bored N 5.Are you in good spirits most of the time Y
Motivation: Assess depression-Single question:’’Do you often feel sad or depressed’’ 6.Are you afraid that something bad is going to happen to you N 7.Do you feel happy most of the time Y 8.Do you often feel helpless N 9.Do you prefer to stay home rather than going out and doing new things N 10.Do you feel you have more problems with memory than most N
Motivation: Assess depression-Single question:’’Do you often feel sad or depressed ’’ 11.Do you think it is wonderful to be alive Y 12.Do you feel pretty worthless the way you are now N 13.Do you feel full of energy Y 14.Do you feel your situation is hopeless N 15.Do you think most people are better off than you N ‘’ Normal’’ answers indicated in bold (Y / N)- › 5 ‘’ Depressed’’ answers= positive screen
FALLS KEY POINTS Falls are common in the elderly and can result in serious, even fatal, injury. Most falls are multifactorial in nature. Physicians should ask about falls periodically, because many elders consider falling normal and may not report it.
FALLS Falling is preventible, and there are well recognized risk factors. A thorough evalution of falls, targeted treatment, and management of risk factors can reduce the risk of future falls. Physical restraints are not necessary to reduce the risk of future falls. They are likely to increase the risk of injury and should be avoided.
FALLS In a patient who falls, sedating medications should be minimized or eliminated. All patients who fall but who are able to participate in an exercise program should pursue a program of balance training and strengthening.
Initial Evaluation of Falls History Circumstances of fall Vision or hearing deficits Medical conditions Medications( especially sedatives, psycotropics, antihypertansives, narcotics, anticonvulsants) Functional abilities
Initial Evaluation of Falls Physical examination Postural blood pressure Heart rhythm ‘’ Get up and go’’ test Visual acuity Targeted neurologic examination Targeted musculoskelatal examination Hemodynamic response to carotid sinus massage ( in appropriate patients)
Initial Evaluation of Falls Diagnostic Studies None required routinely If indicated in the appropriate patient: complete blood count, blood urea nitrogen (BUN) level, creatinine, electrolytes, glucose, thyroid function, vit. B 12, Holter monitor
Risk Factors for Falls in Older People Age-related changes in Vision Hearing Proprioception Muscle activation (delayed onset of compensatory activation in response to postural changes) Blood pressure (reduced compensatory response to postural changes)
Risk Factors for Falls in Older People Age › 80 years Cognitive impairment Depression Functional impairment (measured by changes in activities of daily living) Visual impairment History of falls Gait or balance deficit
Risk Factors for Falls in Older People Use of assistive device Arthritis Leg weakness Orthostatic hypotension Psychotropic or sedative drug use Female gender Frequent fear of falling
Urinary Incontinence In the elderly, urinary incontinence affects up to 30% of women and up to 15% of men. Maintaining continence requires more than intact urinary function; it also requires mobility, motivation, proper access to facilities and relatively intact function. Acute changes in continence are often caused by underlying medical conditions (e.g, infection, hypoglycemia), and the incontinence may be reversible
Men are more likely to have overflow and urge incontinence. Women are more likely to have urge and stress incontinence. History, examination, urinalysis, and post-void residual bladder volumes usually lead to the proper categorization of incontinence, with no further testing needed. Kegel exercises, bladder training exercises, and use of an incontinence diary are effective for managing urge and stress incontinence.
Urinary Incontinence Stress incontinence is poorly treated with drug therapy but successfully treated with surgery; urge incontinence is poorly treated with surgery but successfully treated with drugs. Drugs used to treat urge incontinence are all anti-cholinergics, and side- effects may limit their use in the elderly..
Urinary Incontinence Functional incontinence is common in frail or demented elders and is treated with environmental adjustments and with scheduled and prompted voiding.. Incontinence and asymptomatic bacteriuria may coexist in nursing home patients, but incontinence does not improve with eradication of bacteria.
RATIONAL DRUG PRESCRIBING KEY POINTS Certain medications should be avoided in the elderly. Age alone should not be a criterion for avoiding the use of drugs with appropriate indications (e.g.,β-blocker after myocardial infarction) A certain degree of polypharmacy (use of numerous drugs) may unavoidable in the elderly, but each drug should be associated with an appropriate indication
RATIONAL DRUG PRESCRIBING Avoid using one drug to treat the adverse effect of another. The effects and toxicities of some drugs change with aging, resulting in more narrow indices. Renal function declines with aging and has an impact on the dosing of many drugs, whereas liver function generally does not.